Understanding Your Health Insurance Options: A Practical Overview of Public and Private Resources by Abby Nash Edited by Robin Owen, Managing Editor Summary For individuals with epilepsy, receiving affordable treatment on an ongoing basis from qualified epileptologists and/or neurologists is a major concern. While in today’s economy, more people are uninsured then ever before, there are many programs available to help those with epilepsy receive the appropriate treatment. President Obama has identified healthcare reform as one of his top priorities, and he appears to recognize the importance of making highquality health care affordable for more Americans. While it’s too early to know exactly how our healthcare system will be reformed, many of the proposed changes would require both coverage of preexisting conditions and premium limitations that would make coverage for those with epilepsy more accessible. In the meantime, navigating the world of health insurance and health-care resources is anything but simple, especially for those managing chronic conditions. This article identifies many of the available programs, public and private, and describes their benefits and limitations. The specific programs mentioned in this article apply mainly to people in the United States, where health-care coverage is not available to a substantial number of people. The goal is to help you plot a course, depending upon your situation and resources, to choose the best health-care options available to you. Throughout the article, there are “What this means for you” summaries which indicate how you can or cannot expect to use the potential benefits available through the programs. At the end of the article is a listing of helpful resources. Topics covered include: • • • • • • Child Health Insurance Plan Reauthorization Act of 2009 (CHIPRA) Medicaid and Medicare Prescription Drug Coverage COBRA (Consolidated Omnibus Budget Reconciliation Act) Coverage for the Uninsured Private Health Insurance for the Uninsured Health Insurance Portability and Accountability Act (HIPAA) Introduction The number of individuals facing both unemployment and lack of health insurance has been increasing steadily since the recession began in December 2007. From 2007 to the present, 5.7 million jobs have been lost with private sector employment decreasing by 611,000 in the month of April 2009 alone.1 As of January 2009, the unemployment rate was the highest it had been in twenty-six years and has continued to grow steadily from 7.6 percent to 9.5 percent. While many individuals with epilepsy lead highly productive lives, for others epilepsy is a struggle and maintaining a job is difficult at best. Unfortunately, job loss is all too often linked to becoming uninsured or underinsured. Most people recognize the need for change in the way health care is provided in the United States. President Obama campaigned on the need for reform, but knowing there would be much debate and controversy before anything is implemented, one of the first things he did as president was sign into law the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA). In addition to compelling Congress to work toward revamping the health-care system, he strongly encouraged the insertion and enactment of various provisions in the American Recovery and Reinvestment Act August 2009 Epilepsy: Insights & Strategies 25 Understanding Your Health Insurance Nash (ARRA—the economic stimulus package) that attempt to immediately expand access to health insurance for many Americans. Until substantial changes are made to our health-care system, it’s important to be familiar with the rights individuals have as a result of previously enacted legislation such as CHIPRA, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Consolidated Omnibus Budget Reconciliation Act (COBRA). Knowledge of these programs—CHIPRA, COBRA and ARRA—along with Medicare and Medicaid, can be critical to ensuring that you receive proper health care. Child Health Insurance Plan Reauthorization Act of 2009 (CHIPRA) The State Children’s Health Insurance Program (SCHIP, or CHIP for the federal program) was established in 1997 to help provide coverage for uninsured children in families whose incomes are too high to qualify for Medicaid but too low to afford private health insurance. Federal law does not require that families seeking coverage for their children under CHIP or Medicaid provide paperwork to document their income; however, states are permitted to request it. On February 4, 2009, President Obama signed a reauthorization of this program (CHIPRA) into law. This reauthorization of the plan is important because there is no individual entitlement to medical care under CHIP (unlike Medicaid which has an openended entitlement for eligible applicants). CHIP funding has always been capped both nationally and by the states. If money runs out, eligible applicants can be placed on a waiting list until new funding becomes available. Coverage for existing participants can be canceled if adequate funding is not provided. As a result of the reauthorization of CHIP, an additional $32.8 billion will be available for this program over the next four and a half years. In addition to continuing to cover those currently enrolled, CHIPRA allocated $100 million for outreach, allowing CHIP representatives to go out into communities to find the millions of eligible children who are not currently enrolled. States will also receive a performance bonus if they exceed enrollment expectations and implement specific policies aimed at making enrollment easier. In addition, ARRA requires coverage for dental care under CHIP (as of October 31, 2009) and while mental health coverage is not mandatory, if it is provided, it may not be more limited in scope or duration than coverage for surgery and hospital stays or medical benefits 26 Epilepsy: Insights & Strategies August 2009 such as office visits, outpatient testing and durable medical equipment—such as a wheelchair. CHIPRA also enables states to provide immediate insurance coverage to pregnant women who meet the state criteria and to legal immigrant children. Without insurance, illnesses that go untreated may result in the need for high cost emergency room care and long term treatment. Medicaid and SCHIP have improved access to preventive and primary care as well as treatment for chronic conditions such as epilepsy. A study of participants for at least two years in California‘s SCHIP program revealed that even those children in the poorest health showed noticeable and sustained improvement both physically and socially after becoming enrolled.2 Because epilepsy typically requires continuous monitoring and medication, parents of uninsured children with epilepsy should take advantage of the opportunity to obtain the appropriate care for their children. Such care may make the difference between seizure control and a normal life, versus uncontrolled seizures and a difficult time learning and making friends. What this means for you Your children may be eligible for coverage under your state’s CHIP program if you are uninsured but your income and assets cause you to be ineligible for Medicaid. In order to determine whether your children (including infants) qualify and what benefits would be provided, you should contact the agency that runs this program in your state. If you have questions, would like additional information or are searching for your state’s contact information, please see http://www.insurekidsnow.gov/states.asp or call the US Department of Health and Human Services at 1-877-KIDS NOW (1-877-543-7669). Also, if you are an eligible employee, and either you or your dependents lose eligibility for Medicaid Understanding Your Health Insurance Nash or CHIP coverage, then your employer must permit you and/or your dependents to enroll in the employer’s health plan. However this only applies if you request this special enrollment within sixty days after you or your dependents lose Medicaid or CHIP eligibility. The same is true if you become eligible to participate in a premium assistance program. You must be permitted to enroll in your employer’s health plan, as long as you request enrollment within sixty days of becoming qualified for the premium assistance. (Premium assistance is a health insurance purchasing strategy in which a state uses public funds to pay for a portion of the premium costs of employer-sponsored insurance for eligible populations.) Medicaid and Medicare Medicaid was designed to help people with limited incomes afford medical care. The federal government established minimum Medicaid guidelines but the states have great latitude in determining both benefits and eligibility. While Medicaid is helpful for some, only sixteen states define eligibility in terms of the federally-defined poverty level, and Medicaid income eligibility criteria in forty-three states currently does not cover adults without children even if they have no income.3 Most individuals age sixty-five and older are automatically enrolled in Medicare Part A, which covers inpatient services and hospitalization at no cost as long as the individual or his/her spouse has worked at least forty quarters (which is equivalent to ten years). Those individuals who are found to be disabled by the Social Security Administration also become entitled to Medicare Part A, twenty-four months after receiving their determination. While waiting for Medicare coverage to begin, individuals with epilepsy or any other disability, whose income is extremely low or who spend a high percentage of their income on health care may be eligible for Medicaid. Medicare Part B pays for various outpatient medical services such as doctor’s appointments and other medically necessary procedures that are not covered under Part A such as outpatient testing (including MRIs or scans), physical and occupational therapy and some home health care visits. Some well-care services are also covered, but annual physicals are not. Unlike Medicare Part A, almost everyone pays a premium for Part B. However, individuals whose income is at or below the poverty level and whose resources do not exceed twice that permitted in order to receive Social Security Income (SSI) will not be obligated to pay any Medicare premiums, copayments or deductibles. Individuals whose income is slightly higher may be subject to copayments and deductibles but not the Medicare Part B premium. A penalty will be imposed “for each full twelve-month period” that people fail to enroll in Medicare Part B when eligible to do so, unless they are covered under a group health insurance plan sponsored by their (or their spouses’) employer. If the delay in enrolling is less than twelve full months after enrollment in Medicare Part A, the penalty does not apply. The penalty clock starts to run at the beginning of the month following the participant’s seven-month initial enrollment period (IEP), and ends on the final day of the annual open enrollment period (OEP) in which he/ she enrolls in Medicare Part B. If an individual fails to sign up during the initial seven months allotted, he/she must wait until the next OEP to enroll unless he/she loses current group coverage and is entitled to a special enrollment. The OEP is from January 1 through March 31 of each year. If one’s IEP terminates at the end of March and he/she signs up for Part B the following January during the first month of the OEP, the actual enrollment delay is only ten months. However, according to the Social Security rules, the clock continues to tick until the last day of the OEP in which the participant enrolls (i.e., March 31); thus, the delay is considered to be a full twelve months (April 1 through March 31) and the individual would be required to pay a 10 percent late penalty on all future Medicare Part B premiums. If he/she waited three years, he/she would be required to pay a 30 percent penalty on all future Part B premiums. Individuals who are eligible for both Medicare and Medicaid, referred to as “dual eligibles,” are often entitled to receive a portion of the costs of Medicare paid by Medicaid. The varying programs have similar names but provide different benefits. Eligibility for these programs is contingent upon income and assets and the benefits are often referred to as “Medicare Savings Programs.” Medicaid acts as supplemental insurance to Medicare; thus, services covered by both programs are reimbursed first by Medicare with the balance paid by Medicaid, not exceeding August 2009 Epilepsy: Insights & Strategies 27 Understanding Your Health Insurance Nash the state’s limit. Also, for those benefits not covered by Medicare but covered by Medicaid, dual eligibles shall receive the full amount of the Medicaid reimbursement. Medicare Part D is the prescription drug coverage option for everyone who receives Medicare. In some states, failing to elect Medicare Part D coverage will result in a loss of all Medicaid benefits. Others who fail to elect Part D during their initial enrollment period will incur a penalty on all future payments. While there is a minimum benefit that all insurance companies offering Part D coverage must provide, companies offering this coverage have substantial leeway in how they structure the benefit. Thus, those eligible for Medicare Part D should spend time searching to find a plan that meets their needs at a price they can afford. Medicare Part D participants should be aware that if they do not choose a prescription drug plan, in many situations they will be automatically assigned to one. This plan may or may not provide coverage for the seizure medications currently being used. Dual eligibles may choose a different plan at any time if the new plan does not meet their needs; however, Medicare Part D participants who are not dual eligibles are subject to penalties for switching plans unless they do so during open enrollment. Thus, it is important that Medicare participants choose their plan wisely and if their seizures are not fully controlled at the time they select their option, they should select an option which covers both their current drugs and the drugs their neurologist is considering for use in the future. Currently, barbiturates such as phenobarbital and benzodiazepines such as Valium (whose generic name is diazepam) are not covered under Medicare Part D. Beginning in 2013, benzodiazepines will become Medicare Part D covered drugs irrespective of the condition being treated with these drugs; whereas, barbiturates will be permitted to be reimbursable as Medicare Part D covered drugs, if used for epilepsy, chronic mental health disorders and cancer. Medigap Medigap policies are sold by private insurance companies. Their aim is to fill the “gaps” in Medicare coverage. Medigap policies, which range in price and degree of benefits, provide covered individuals age sixty-five and older with assistance in paying Medicare copayments, and perhaps premiums and 28 Epilepsy: Insights & Strategies August 2009 deductibles. In some states, Medigap may also be available for those enrolled in Medicare due to a disability. There are no limits on out-of-pocket costs under Medicare; therefore, supplemental insurance is helpful to many Medicare beneficiaries. Comparisons of different plans are available at the following government site: http://www.medicare.gov/MPPF/ Include/DataSection/Questions/SearchOptions.asp Medicare Advantage Plans Medicare Advantage plans are private health plans that may provide coverage for all benefits available under Medicare in addition to services and other benefits not covered under Medicare Part A or B. In addition, some plans may also include prescription drug coverage. These plans are referred to as Medicare Advantage with Prescription Drug (MAPD) coverage. Finally, Medicare Advantage plans may offer lower copayments than those required under Medicare. To join a Medicare Advantage Plan, an applicant must have Medicare Part A and Part B. Once approved (enrolled in the plan), the participant will have to pay his/her monthly Medicare Part B premium to Medicare. In addition, it is likely that he/ she will be required to pay a monthly premium to his Medicare Advantage Plan in order to help cover the cost of the extra benefits offered (by the plan). If any individual, in particular one who requires treatment by a particular specialist, is interested in a Medicare Advantage Plan, he/she should carefully review the list of providers covered under the plan. What this means for you Medicare In order to gain some insight regarding Medicare eligibility based upon your age or disability, please see the following websites: http://www.medicare.gov/MedicareEligibility/home.asp http://www.medicare.gov/MedicareEligibility/Static/ EligibilityHelp.asp Since Medicare eligibility and benefits are subject to change, in order to obtain a final determination regarding eligibility, you should contact or go to your local social security office or call 1-800-7721213. If you have questions pertaining to your Medicare benefits, you should call 1-800-633-4227. Understanding Your Health Insurance Nash As a reminder, it is important to select a Medicare Part D option that covers the medicines you are currently using or may switch to in the near future. If you are dissatisfied with your current Medicare Part D prescription drug coverage, you may select a different Part D plan without penalty if you do so during open enrollment, which is between November 15 and December 31 each year. Also during this time period, if you are unhappy with your Medicare benefits, you may change Medicare Advantage plans, return to original Medicare, or enroll in a Medicare Advantage plan for the first time. Enrollment changes take effect on January 1. If you did not enroll in Part B when you first became eligible for Medicare, you may elect Part B coverage during the General Enrollment Period, which extends from January 1 through March 31 each year. Enrollment becomes effective on July 1 of the same year. For those of you who may soon be eligible for Medicare, you should research all your options regarding Medicare Plans. Because there are so many factors to consider before selecting a Medicare Plan, it may be helpful for you to speak with a Medicare expert. Each state has a State Health Insurance Counseling and Assistance Program (SHIP) which may provide guidance regarding choosing a health-care plan and determining whether a supplemental insurance (Medigap) or long-term care policy should be purchased. The following website provides links which may assist you in making your final decisions: http://www.medicare.gov/contacts/ staticpages/learn-more.aspx. The SHIP link on this website refers you to each state’s SHIP offices which may be instrumental in helping you to reach a decision as to what Medicare elections you should choose. Medicaid As the Medicaid requirements vary from state to state, you should contact the office that regulates Medicaid in your state. The following link will provide you information about Medicaid in your state along with telephone numbers you may call to discuss eligibility and benefits in your state: http:// www.northeastcenter.com/links_medicaid_offices_ by_state.htm. Prescription Drug Coverage While many benefits are required to be provided under Health Maintenance Organizations (HMOs) and commercial health plans, in all states except Massachusetts, prescription drug coverage is not a mandated benefit and laws pertaining to prescription drug coverage vary from state to state. If an insured individual has questions after speaking to the insurer, they should contact the appropriate State Insurance Commission. The National Association of Insurance Commissioners (NAIC) provides access to all State agencies that regulate insurance by clicking on the map on the following website: http://www.naic.org/state_web_map.htm Typically, covered brand name drugs require higher copayments than do generic drugs. Furthermore, as “step therapy” is now being used by many insurance companies, the insurers will often not cover a nonpreferred drug—usually a new or more expensive drug—without knowing the generic or less expensive drug was unsuccessful in treating the insured. Also, generic drug riders are now being introduced by many insurers; thus, individuals are either being denied coverage for brand-name drugs or charged the difference in price between a generic and its brand-name equivalent, in addition to any other copayments or coinsurance required under the plan. Therefore, even those who are insured may find they cannot afford their epilepsy medication. While generic drugs are acceptable for many patients, switching from brand name to generic, generic to brand name or one form of generic to another may be dangerous and detrimental. In some instances, an insured or his neurologist may file an appeal if coverage is denied but an insured should review his certificate in order to determine any grievance and appeal rights and procedures. The decision as to whether a new generic drug should be tried must be discussed and ultimately decided by the individual with epilepsy and his/her neurologist. For those who cannot afford a required medication, Needy Meds provides a wealth of information and August 2009 Epilepsy: Insights & Strategies 29 Understanding Your Health Insurance Nash sources to contact regarding prescription drug assistance. The best place to contact first is the drug company that produces the medicine needed and the Needy Meds website (http://www.needymeds.org) refers you to prescription drug assistance programs, many of which are run by the drug companies. For those individuals who wish to speak with someone, organizations are listed at the end of this article that may be of assistance in obtaining prescription drugs at little or no cost, based on the applicant’s financial situation. Many websites imply that their assistance programs only apply to people who are uninsured; however, sometimes there is a program to assist those with insurance but no prescription drug coverage or those with prescription drug plans, such as but not limited to generic drug plans or those which require step therapy; all of which may result in exceedingly high and thus unaffordable copayments for brand-name epilepsy medications. Programs available through Needy Meds, which will refer individuals to the appropriate organizations or pharmaceutical companies, provide assistance at no cost; yet others charge a one-time fee or a fee per each prescription needed. In addition, some states have low-cost prescription drug programs either for individuals above a certain age or for low-income families. Information regarding these programs and coverage for the uninsured should be available from either the State Department of Health or the State Insurance Commission. Also, for more information about extra help with prescription drug costs for those on Medicare and how to apply, visit http:// www.socialsecurity.gov or call Social Security at 1-800-772-1213. What this means for you Both those who are uninsured and insured may have difficulty obtaining the seizure medicine their neurologist believes is best for them. If you require assistance, you should contact the drug company that produces your medication and inquire about their prescription assistance programs. Needy Meds (http://www.needymeds.org) can provide you with the websites for the assistance programs you should contact. If you are still having difficulty obtaining the medications you require, you should contact either your neurologist’s office or one of the organizations listed at the end of this article. COBRA Coverage for the Uninsured COBRA was passed in 1986 in order to provide individuals who lost their group health insurance, as a result of a “qualifying event,” with premium assistance. The following circumstances are considered qualifying events for the employee or their dependents: • Voluntary or involuntary termination of employment for reasons other than gross misconduct, Bankruptcy of the employer, Reduction in the hours worked by the covered employee, The covered employee’s becoming entitled to Medicare, Divorce or legal separation from the covered employee, Loss of dependent status, and The death of the covered employee. • • • • • • In order for employees or their dependents to be eligible for COBRA, employees must have worked for an employer with twenty or more employees or for a smaller employer in those states which have “state continuation” or “mini-COBRA” laws. COBRA payments usually equal 102 percent of the cost of the group policy which includes a 2 percent administrative fee. This can be a substantial amount of money, especially for individuals whose employers had paid the majority of the cost of health insurance premiums. Most COBRA-eligible beneficiaries are entitled to eighteen months of continuous coverage. If a current spouse loses coverage due to divorce or legal separation, or if a dependent loses coverage due to age, these individuals may elect COBRA coverage under the plan for a maximum of thirty-six months. Additionally, if an employee is determined to be disabled prior to or during the first sixty days after becoming COBRA eligible, he/she will be eligible for twenty-nine months of COBRA coverage. However, during this extended eleven-month period of time, plans are permitted to charge additional premium rates of up to 50 percent of the total cost. 30 Epilepsy: Insights & Strategies August 2009 Understanding Your Health Insurance Nash Until the qualified employee is no longer entitled to COBRA benefits, the prior employer cannot attempt to reduce existing benefits any more than it reduces benefits for those employees still actively participating in the plan. While COBRA coverage has been an option since 1986, very few eligible individuals elected to participate because while the cost was often lower than other options available for individual coverage, it was far too expensive for most people who qualified.4 COBRA subsidy under ARRA In an attempt to encourage more unemployed and uninsured individuals to elect COBRA coverage, ARRA created a premium assistance program which provides a 65 percent premium subsidy for many individuals who have lost group health insurance coverage as a result of INVOLUNTARY termination from employment occurring anytime between September 1, 2008 and December 31, 2009. Eligible workers who were terminated after September 1, 2008 but before February 17, 2009, and failed to elect COBRA coverage, perhaps because it was too expensive, should have been given an additional sixty days to elect coverage and receive the subsidy. Retirees or individuals, who lose coverage because of divorce or legal separation, are not eligible for the subsidy. Those who lose their benefits due to a reduced work schedule are also not entitled to the subsidy unless this reduction in hours indirectly causes an employee to change jobs/employers. Workers who are single and earn more than $125,000 or are married filing jointly and earn more than $250,000 shall not be eligible for the subsidy. Finally, those who are or become eligible for health insurance under Medicare or another group health plan shall also no longer be eligible for the COBRA subsidy. Recipients of the subsidy shall be entitled to up to nine months of continuation coverage for 35 percent of the coverage payment previously required; the subsidy covers 65 percent of the premium payment. In order to be eligible for this program, “assistance eligible individuals” (AEIs) must have worked for an employer with twenty or more employees, or for a smaller employer in those states which have “state continuation” or “mini-COBRA” laws that are comparable to federal COBRA. States were advised to create or amend mini-COBRA laws in order to ensure that their benefits are in fact “comparable” to federal COBRA. Provisions in these laws should provide individuals with a second chance to elect for continuation coverage either because they originally chose not to opt for continuation of coverage or because they opted for it and lost that coverage perhaps due to inability to pay. These state laws should also ensure that individuals with preexisting conditions such as epilepsy, who choose to accept their second chance to enroll, will not be subject to an exclusion of coverage of their preexisting condition even if they have a gap exceeding sixtythree days from the time they lost their insurance to the time they opted to purchase continuation coverage as a result of the subsidy. In order to obtain additional information and determine each state’s policy regarding mini-COBRA benefits as of April 14, 2009, please see the following website: http://www. familiesusa.org/assets/pdfs/state-mini-cobra-laws.pdf.5 For updated information, individuals should check the websites for their States’ Insurance Commissions. What this means for you The cost of individual insurance for someone with uncontrolled seizures is likely to be extremely high and in many cases unaffordable. If someone had family coverage and only one of the family members has epilepsy, he/she could opt to purchase COBRA coverage for just that family member and the COBRA subsidy may still be used. She or he could then purchase individual coverage for herself/himself at a lower price and if applicable she/he may consider the various options, such as CHIP, which may be available for some other dependents. This would ensure continuation of coverage for a period of time. By only covering one party under COBRA, the cost should be substantially less. Once COBRA expires, individuals may still have the right to be insured based on HIPAA provisions. If you were covered under a large group plan—or small group plan in a state which provides comparable coverage to small groups—you are entitled to continue your insurance through COBRA for eighteen months or potentially longer depending upon the reason you lose coverage, generally for 102 percent of the cost. At this point you should also be searching for insurance that would cover all your necessary medical expenses. If you find a policy that fits your needs at a lower price than your COBRA premium, you should purchase that policy and terminate your continuation coverage. August 2009 Epilepsy: Insights & Strategies 31 Understanding Your Health Insurance Nash If not, you should continue COBRA at the required price and continue to search for a policy that will be acceptable to you once you are no longer eligible for COBRA. While some states require insurers to convert your COBRA policy into an individual policy, many do not and the ones that do require it do not prohibit a substantial increase in price from a group policy to your new individual policy. Private Health Insurance for the Uninsured There are some reputable insurers who offer lower cost policies for those with preexisting conditions, but when deciding what type of policy to purchase, individuals must carefully review the benefits covered under the contract and the providers included in the network. If an individual’s prescription drugs are not covered or his or her doctors are out-of network, this plan is usually not a viable option for someone with epilepsy. However, if the necessary medications are covered under an HMO, but the necessary specialists (such as an epileptologist) are not available within the network, then in some states it is possible to obtain the services of the specialist at the same copayments as charged for in-network services, provided that a primary care physician can explain why it’s necessary for the patient to see a specialist. If the insurance premium sounds too good to be true, it may be. If the company is requesting money before it will provide something in writing, individuals seeking coverage should proceed cautiously. If the company name is not familiar, one should contact the Better Business Bureau or Insurance Commission in the state in which it’s being sold to determine whether it is a legitimate company and if any complaints have been submitted. Uninsured individuals seeking coverage may benefit by contacting a reputable broker. Also, the individuals at the Foundation for Health Coverage Education (FHCE), http://www.coverageforall.org, and the Cover Me Foundation (CMF), http://covermefoundation.org, provide guidance as to what options are most suitable to their callers whether it be a state run program or a private insurance policy.6 The eHealthInsurance website enables individuals to insert their information and obtain the lowest private insurance premiums available for them; see https://www.ehealthinsurance.com.7 FHCE and eHealthInsurance employees are knowledgeable about state and federal insurance laws and the policies being sold and are willing to provide advice over the telephone at 1-800-234-1317 (for FHCE) and 1-877- 678-7631 (for eHealthInsurance). Health Insurance Portability and Accountability Act (HIPAA, P.L. 104-191) While HIPAA made great strides to protect people with epilepsy, there are limitations. HIPAA does not require any employer to provide health insurance. If an individual’s last employer provided health insurance, HIPAA does not require his/her new insurance plan to match coverage on everything that was reimbursed under his/her previous plan. For example, even if the prior insurance plan covered prescription drugs, the new plan is not required to do so. In fact, his/her new plan may only cover generics or it may require the use of step-therapy (requiring evidence that the generic or less expensive drug was unsuccessful in treating the insured before agreeing to cover a non-preferred—possibly newer and/or more expensive—drug). In addition, if the old plan covered physical therapy or any other benefit not mandated by law, the new plan would not be required to cover this benefit. Finally, HIPAA does not prevent the rising cost of health insurance. More importantly, a preexisting condition exclusion may still prevent coverage of epilepsy for a limited time if an individual had received any treatment, including prescription drugs within the past six months. However, for those with epilepsy or other preexisting conditions, HIPAA prohibits the use of such exclusions which exceed twelve months. 32 Epilepsy: Insights & Strategies August 2009 Understanding Your Health Insurance Nash What this means for you If you were without insurance for less than sixtythree days (or longer, depending on laws in your state), the amount of time you were previously covered will diminish or eliminate your preexisting condition exclusion period. Based on HIPAA, if you had continuous coverage for eight months before switching employers, then your new health plan cannot impose a preexisting condition waiting period on you for longer than four months. If your new employer imposes a waiting period, this waiting period is not considered creditable coverage. However, neither will it be considered a break in coverage; therefore, while it will not shorten your waiting period, it cannot prevent you from receiving new insurance. And, the waiting period time will reduce the period of exclusion for your preexisting condition. If you lose or leave your job or if your COBRA coverage ends, you should receive a certificate of creditable coverage within sixty days. If you lose your certificate, you may request another one, free of charge, for up to twenty-four months after your coverage ends. This certificate provides proof to your next insurer that you were covered during that time period. Conclusion Currently those with epilepsy must choose their insurance wisely to ensure all necessary services and medication will be provided. While health insurance reform has been one of the administration’s main focuses since President Obama took office, the final outcome is still unclear. Representatives of consumers, insurers, physicians, hospitals and pharmacies have expressed an interest in helping foster a new health insurance system; however there are varying viewpoints on what reforms are necessary. The president’s messages regarding health care have outlined the major elements he is seeking in a health-care plan: cost reduction, patient choice of doctors and available benefits, and universal access to health care. His proposal requires coverage of all individuals with preexisting conditions and prohibits insurers from issuing higher rates for those individuals. It’s too early to predict the outcome, but if these ultimately become law, essential health-care services will then be available to all individuals suffering from epilepsy. Un- til that time, your best strategy is to be equipped with knowledge of how to best utilize existing programs. Dedication This article is dedicated in memory of Dr. Susan S. Spencer, whose compassion and devotion to her family, friends, students, colleagues and patients touched the hearts of so many people. For her patients whose refractory seizures remained uncontrolled, she worked tirelessly when others may have given up and equally as important, without making false promises, she instilled hope and self respect within many of them. For those of her patients who were ultimately controlled, Dr. Spencer rejoiced with them and instilled within them a level of self-confidence which was not previously possible. She encouraged her patients to dream like she did. She left an indelible mark on the lives of so many. Her attention to detail and perseverance, her wit, smile, demeanor, warmth and caring nature shall never be forgotten. Abby Nash is a wife and mother to two fun loving and supportive individuals. She is an attorney whose job entails reviewing insurance products and pending legislation and responding to questions and concerns (inquiries) regarding health insurance. Abby is also an agency representative on the Early Intervention Coordination Council and the Interagency Autism Task Force. Additional Resources More detailed information regarding CHIP http://www.familiesusa.org/assets/pdfs/chipra/chipra101-overview.pdf http://www.statehealthfacts.org/comparetable. jsp?ind=229&cat=4 Chart pertaining to presumptive eligibility for CHIP. On the left, there are several charts pertaining to CHIP, Medicaid and Medicare eligibility and enrollment practices, and the Medicare drug benefit. http://ccf.georgetown.edu/index/cms-filesystemaction?file=statistics/2009 federal poverty guidelines.pdf Federal Poverty Level Guidelines. http://ccf.georgetown.edu/index/chip-law Articles, issue briefs and Centers for Medicare and Medicaid Services (CMS) Guidance. August 2009 Epilepsy: Insights & Strategies 33 Understanding Your Health Insurance Nash More detailed information regarding Medicaid http://medicaidbenefits.kff.org/state_main.jsp There is a lot of valuable information on this website; however, please be aware it is only up to date as of 2006. Thus, while it is a good resource, you should contact your state Medicaid office to confirm its accuracy. http://medicaidbenefits.kff.org/st_foot.jsp Likewise, this website is only current to 2006. You will need to confirm its present-day accuracy. More detailed information and contacts regarding prescription drug assistance http://www.needymeds.com email: info@needymeds.com 1-978 865-4115 http://www.medicare.gov/pdphome.asp (800) MEDICARE 1-800 633-4227 http://pfizerhelpfulanswers.com/pages/Find/FindAll.aspx (866) 706-2400 http://www.pparx.org (888) 4PPA-NOW - (888) 477-2669 http://www.freemedicineprogram.org/how_it_works.html (573) 996-3333 http://www.patientassistance.com 1-888-788-7921 http://www.rxassist.org/default.cfm (401) 729-3284, info@rxassist.org http://www.rxhope.com/ (732) 507-7400, email: CustomerService@RxHope.com http://www.riteaid.com/pharmacy/rx_savings.jsf 800-RITEAID (800) 748-3243 There are not many anti-seizure medications on this list; however carbamazepine 100 mg chewable tablets and 200 mg tablets are included on the list of $8.99 per thirty-day and $15.99 per ninety-day prescriptions. Also, please be aware that the price for the pills received is based upon the number of pills determined by Rite Aid to be most common, which may be less than the amount of medicine a doctor has prescribed. http://i.walmartimages.com/i/if/hmp/fusion/ customer_list.pdf (800)Wal-Mart (800) 925-6278 for customer service questions or (800) 273-3455 for pharmacy mail order questions. A few anti-seizure medications appear on this list, one of which is carbamazepine 200 mg tablets at $4 per thirty-day and $10 per ninety-day prescriptions. The price is based upon the number of pills determined to be the most common dosage which may not be the dose your doctor has prescribed for you. Notes and Citations 1. “The Employment Situation” (2009). U.S. Bureau of Labor Statistics, Department of Labor. http://www.bls. gov/news.release/pdf/empsit.pdf (accessed April 2009 and June 2009). 2. “Medicaid and the Uninsured - The Impact of Medicaid and SCHIP on Low-Income Children’s Health” (2009). Kaiser Commission. http://www.kff.org/medicaid/upload/7645-02.pdf (accessed February 2009). 3. “Families USA, PhRMA Propose National Income Eligibility Floor for Medicaid” (2009). Medical News Today. http://www.medicalnewstoday.com/articles/147218. php (accessed April 23, 2009). 4. “Squeezed! Caught between Unemployment Benefits And Health Care Costs” (2009). Families USA, the voice for health care consumers. http://www.familiesusa. org/assets/pdfs/cobra-2009.pdf (accessed January 2009). 5. “States Act to Help People Laid Off from Small Firms: More Needs to Be Done” (2009). Families USA, the voice for health care consumers. http://www.familiesusa.org/assets/pdfs/state-mini-cobra-laws.pdf (accessed April 2009). 6. http://www.coverageforall.org or by telephone at 1-800-234-1317 and http://www.covermefoundation. org or by telephone at 1-877-NSURME1, 1-877- 6787631 or 1-877-828-2736. 7. https://www.ehealthinsurance.com or by telephone at (800) 977-8860. 34 Epilepsy: Insights & Strategies August 2009