According to Delaware Online, fewer than 40 Delawareans have enrolled in the plan thus far. Federal Officials have been visiting healthcare clinics in recent weeks to help promote the plan that an estimated 4 million people nationally are eligible for. According to HealthCare.gov, Delaware and 22 other states have opted to have the US Department of Health and Human Services administer the plan. For Delaware residents that means that you apply for coverage directly from the federal government.

It is important to note that there are criteria that must be met in order to be eligible to purchase the plan, and the monthly premiums can still be significant. To qualify you must:

1. Be a citizen or national of the United States or lawfully present in the United States.
2. Have been uninsured for at least the last six months before you apply.
3. Have a pre-existing condition or have been denied coverage because of your health condition.

If you qualify (and can afford the premiums), the plan covers a broad range of benefits including primary care, hospital care, prescription medications, testing, and specialty care. Three types of plans are offered, the standard option, the extended option, and the HSA option. The difference between the plans are the monthly premium and the deductible before benefits begin. A detailed summary of the benefits is available from the Pre-Existing Condition Insurance Plan website.

The current monthly rates for the Pre-Existing Condition Insurance Plan for Delaware Residents are summarized below (please note that these rates may be adjusted in the future):

The standard and extended options both have separate deductibles for medical and prescription costs. Under the standard plan, the medical deductible for in-network care is $2,000 and the prescription deductible is $500. The extended plan has a $1,000 deductible for in-network care and a $250 deductible for prescription costs. The HSA option has a combined deductible of $2,500 for in-network medical and prescription costs. Copay and co-insurance benefits do not begin until after the calendar year deductible is spent. The maximum out-of-pocket medical costs under these plans is $5,950 for in-network care and $7,000 for out of network care.

Coverage under these plans begin based on when the application is completed. If your application is completed on or before the 15th of the month, coverage begins no later than the first day of the following month, if your application is completed after the 15th of the month, your coverage may not begin until the first day of the second calendar month after you apply.

To apply for benefits in States that the plan is administered by the US Department of Health and Human Services, you may complete and submit a paper application or apply online at https://www.pcip.gov/Apply.html. The following documentation is needed when applying for the federally administered program:

1. Denial letter from an insurance company licensed in your state that is dated within the past 12 months, or a letter in the past 12 months from an insurance agent or broker that shows that you are not eligible for one or more health insurance plans because of your medical condition; or,
2. Offer of individual insurance coverage within the past 12 months that you did not accept that has an exclusion for a pre-existing medical condition; or,
3. If you are under 19 (or you live in Massachusetts or Vermont), an offer of individual insurance coverage within the last 12 months that show a premium that is at least twice as much as the Pre-Existing Condition Plan premium for the Standard Option in your State.

To determine the Pre-Exisiting Condition Insurance Plan requirements for your State, visit http://www.pcip.gov or http://www.healthcare.gov.

No related posts.

Related posts brought to you by Yet Another Related Posts Plugin.

Social Security Disability Law Weekly, Episode 5, includes discussion of use of technology in disability claims; alcohol abuse and mental health claims; importance of trying work before applying for disability; problem of being disabled and uninsured; how to qualify for Social Security based on mental illness/bipolar disorder; improve your Social Security Reconsideration appeal; and, more reasons to file an appeal of your disability denial. Download Episode 5 or press play below to listen in your browser.

Show Notes: Social Security Disability Law Weekly Podcast Episode 5

• Subscribe in iTunes (subscribe in iTunes)

This Week’s Topics:

• Why Technology is Important to Social Security Disability Law
  • Discussion of my attendance at American Bar Association TechShow in Chicago
  • Discussion of how technology has improved Social Security’s processing of disability claim files
• Question from Last Week’s Podcast
  • Does Alcohol Dependence in Mental Health/Depression claims guarantee that your disability claim will be denied?
• Issues during my week in practice
  • Attempting to obtain disability benefits without ever attempting to work
    • Discussion of importance of trying work before applying for Supplemental Security Income Payments
    • Link to Delaware Division of Vocational Rehabilitation
  • Serious medical problems without medical insurance
    • Review of how lack of medical insurance limits options for individuals that have disabilities
    • Link to Delaware Division of Social Services Medicaid Information Page
• Social Security News (Discussion of Topics Reported in the News and Blogs this Week)
  • Bipolar Disorder and Social Security Disability by Aaron Rifkind of Illinois Social Security Blog
    • Explanation of the Medical Listing criteria for qualifying for disability benefits based on Bipolar Disorder
    • Important to also determine if you qualify based on your Residual Functional Capacity
  • Four Tips for Filing for Your Social Security Disability Reconsideration by Cavey Barrett, Attorneys at Law
    • Steps you can take to improve your reconsideration appeal
  • Another Reason to Appeal Your Denial by Gordon Gates of the Social Security Disability Lawyer Blog
    • Discussion of how high turnover at Disability Determination Services impacts denial rates at the initial application and reconsideration levels

Closing Credits:

• Contact Steve Butler to Discuss Social Security Disability Law Weekly
  • DelawareDisability.com Contact Form
  • Email: Steve@SSAlaw.us
  • Twitter: @DisabilityGuy
  • Facebook: http://facebook.com/SSALaw

I hope you enjoyed the fifth episode. Please feel free to give me any feedback for improving future episodes. If you enjoy the podcast, you can subscribe in iTunes.

Social Security Disability Law Weekly is a podcast devoted to issues in Social Security Disability Law. Discussion is focused on Social Security Disability Insurance and Supplemental Security Income payments. Social Security Disability Law Weekly is hosted by Steven Butler of Linarducci & Butler, PA.

No related posts.

Related posts brought to you by Yet Another Related Posts Plugin.

Why Change Anything, I Am Happy with My Health Insurance?

Most individuals I speak to regarding these issues are not worried about the healthcare debate because they are happy with the current coverage that they have. These individuals often ignore how easy it would be to lose this coverage. For the majority of Americans, healthcare coverage is linked to your job. If you lose your job, you also lose your medical coverage. Although this is not an issue for a healthy individual that is able to obtain a new job (and new coverage), if you have lost your job because of your medical condition, you may quickly find yourself without medical insurance coverage. Even if you are eligible for COBRA coverage, when the choice is paying your mortgage and buying groceries or paying for health insurance, most individuals choose the necessities. No one ever expects to be in a position that they will not have health insurance available to them.

Medical Coverage does not Begin Immediately with Social Security Disability

What is shocking to most people is that if they are found disabled by the Social Security Administration, they do not immediately qualify for healthcare coverage. Under the best-case scenario, an individual that is ultimately found disabled is not entitled to Medicare coverage until 29 months after they last worked. (This is assuming that the individual was found disabled on the first of the month that they stopped working, and that the Social Security Administration determined that the medical condition was severe enough that they were entitled to disability from the day that they stopped working.)

If you are found entitled to Supplemental Security Income payments, you are entitled to Medicaid coverage immediately. However in order to qualify for SSI, you must be able to establish that you have very little assets, and little or no income on a monthly basis. Your spouse’s income is considered when determining your eligibility for SSI. The majority of the time if you qualify for SSI, it is likely that you already had Medicaid coverage, because the Medicaid criteria are similar to SSI.

During the waiting period for Medicare, no assistance is provided for medical treatment. If you do not have health insurance, you are expected to pay for your treatment out-of-pocket. Due to the amount of your Social Security Disability Insurance, you normally do not qualify for any income-based assistance from your State. Although the government has determined that your condition is severe enough to prevent you from performing work, no help is provided to obtain the treatment you need. Once Medicare beings, these benefits are just extended to the disabled individual and are not available to a spouse or dependents.

The Importance of COBRA

The thing that surprises me about many of the uninsured people that I meet is that they had an opportunity to purchase COBRA. The individuals refused COBRA because of the cost of the coverage. These individuals were unaware of the wait time for Medicare coverage and did not realize that they would not qualify for Medicaid because of their household income. Their immediate concern was paying their existing bills. They rarely considered the impact that one hospitalization could have on them financially. Many of these individuals are later forced into bankruptcy because of the cost of required medical care.

Even though COBRA initially sounds like a expensive alternative, you must consider how much your treatment will cost without insurance coverage. I have several clients that have medications that would cost more than the monthly COBRA premium. They quickly find after they refuse COBRA coverage, that the cost of one hospitalization would have paid for 12 months of COBRA. These individuals also discover that when they are unable to pay for medical treatment, it becomes less likely that they can establish their eligibility for Social Security Disability. Since they are unable to work and they do not have medical coverage, their financial situation only becomes worse.

Alternatives for individuals without Healthcare Coverage

It is possible for individuals without healthcare coverage to purchase personal policies. However these policies are often expensive, and rates raise with age. Insurers are allowed to consider your pre-existing health conditions, and in certain situations even exclude coverage based on pre-existing conditions. Affordable personal healthcare policies for older individuals normally require high deductibles. A yearly deductible of $5000 or more may be enough to prevent an individual from obtaining treatment even though they have healthcare insurance.

Medicaid is available to individuals with financial need, but if you have any source of income or your spouse is employed, it unlikely that you will qualify for this program. If you do not qualify for Medicaid, Delaware Residents may qualify for the Community Healthcare Access Program (“CHAP”). CHAP is a network of physicians and healthcare centers in Delaware that agree to provide discounts for medical services. There are still financial eligibility guidelines, but CHAP extends medical coverage to an additional group of individuals that normally would not qualify for help.

If you do not qualify for Medicaid or CHAP, healthcare is also available through a sliding-scale healthcare center. These facilities determine your eligibility for their services based on financial criteria, and limit the number of patients that they can see. Households with higher incomes will still be required to pay out-of-pocket co-pays for healthcare treatment, but will receive a substantial discount off the normal cost.

Although all of these options are better than no treatment, you will still not receive the same level of care that you would with a traditional health insurance plan. It will be harder to obtain specialist treatment for your condition, and some tests and medications that are needed will be excluded. Since treatment will be limited, establishing disability will be harder.

Pay Attention to Healthcare Debate

The purpose of this post is not to advocate any specific plan for reform, but instead to raise awareness of unforeseen healthcare concerns. Most of the uninsured people that I meet never expected to find themselves uninsured. They are normally hard-workers that simply did not realize that if their job ended due to disability, they would also lose medical benefits. These are individuals that always had healthcare coverage, and now when the need it the most, no affordable option is available.

Because continuing treatment is important to the Social Security Disability determination, many of these people will be denied benefits that they deserve because they cannot obtain the medical treatment that they need. These people need to share their stories with elected officials, family, friends and the public. It is only through increased awareness of these problems that there will ever be support for meaningful reform.

Relevant Links:

• Delaware Low-Cost Healthcare
• Delaware Division of Medicaid & Medical Assistance Programs
• Community Healthcare Access Program (CHAP)
• Delaware Uninsured Resources
• Delaware Insurance Commissioner’s Health Insurance Guide

This article was written by Steven Butler. Steven is a partner at Linarducci & Butler, PA and his practice is limited to Social Security Disability/SSI claims. Steven offers free initial consultations for Social Security Disability/SSI claims to residents of Delaware, Maryland, New Jersey and Pennsylvania. To schedule a consultation with Steven, please use the Linarducci & Butler Contact Form or call 302-613-0707 to schedule an appointment.

No related posts.

Related posts brought to you by Yet Another Related Posts Plugin.

As a result of the hold harmless provision of the Social Security Act, CMS indicated in the 2010 fact sheet that 73% of beneficiaries are protected from an increase in 2010. The Part B premium provides beneficiaries with co-insurance for doctor visits. Individuals that first enroll in Medicare Part B after November 2009 will have to pay the increased monthly premium of $110.50. The majority of beneficiaries that will be required to pay a higher premium are those that currently do not have the Part B premiums withheld from monthly Social Security payments (including individuals with low incomes whose premiums are paid through state subsidies).

Beneficiaries that file an individual tax return and have a “modified adjusted gross income” greater than $85,000 in 2010, or individuals that file a joint return and have “modified adjusted gross income” of greater than $170,000, will also be responsible for higher Medicare Part B premiums for 2010. Medicare has published a Frequently Asked Question on its’ website to help individuals with “Higher Income Levels” determine their Medicare Part B premium for 2010.

Additionally, the Medicare Part B deductible for doctor visits will be increased from the current $135 per year to $155 per year for 2010. The Medicare Part A deductible (that is paid when an individual has an inpatient hospital, skilled nursing facility, hospice or other qualified home health care service of 1-60 days) will increase to $1100 for 2010. This is an increase of $32 from the 2009 deductible. (According to my reading of 42 U.S.C.S. S 1395l, there is no “hold harmless” provision for Medicare Part A and Part B deductibles). All beneficiaries enrolled in Medicare Part D prescription drug coverage will also experience increased monthly premiums in 2010.

As indicated above, the majority of individuals that are currently receiving Medicare benefits will not see an increase in monthly Medicare Part B premiums for 2010, but will experience a net increase in Medicare costs as deductibles and Part D premiums will increase. Individuals that are currently disabled, but will not qualify for Medicare coverage until after November 2009, will not only face the increased deductibles and Part D premiums, but will also be required to pay the increased Medicare Part B premium of at least $110.50 per month when their Medicare coverage begins. Medicare has updated its’ Frequently Asked Questions to help individuals determine if their Medicare Part B premium will increase.

Although the “hold harmless” provision has protected current Medicare beneficiaries from seeing a monthly Part B premium increase in 2010, the next time Social Security payments are increased for COLA, it is likely that Medicare beneficiaries will see a much more sizable jump in their monthly premium payment. Not only will the beneficiaries have to pay the increase that occurs in that current year, they will also be responsible for any increases that had previously occurred that had not impacted them because of the “hold harmless” provision. (For example, if there is an increase of Social Security Payments because of COLA in 2011 and Medicare premiums increase to $120 per month in 2011, the individual would have their monthly Medicare Part B premium increased from $96.40 per month to $120 per month).

President Barack Obama called for Congress to quickly pass an Economic Recovery Provision for 2010 that would extend a onetime payment of $250 to all individuals receiving Social Security Retirement, Disability and Supplemental Security Income Payments. If you are currently receiving Social Security benefits and eligible for Medicare Coverage, it is important that you contact your United States Senators and United States Representative(s) to encourage them to support President Obama’s Economic Recovery Payment for 2010 so that you can qualify for a onetime payment of $250 in 2010. Delaware Residents should contact Senator Thomas Carper, Senator Edward Kaufman, and Representative Michael Castle. Passage of this legislation would help offset the increased costs that will be incurred from the Medicare deductible increases and the increase in Medicare Part D premiums outlined above.

If you are currently a client of Linarducci & Butler and have additional questions about the Medicare premium increase, please contact our office.

This article was written by Steven Butler. Steven is a partner at Linarducci & Butler, PA and his practice is limited to Social Security Disability/SSI claims. Steven offers free initial consultations for Social Security Disability/SSI claims to residents of Delaware, Maryland, New Jersey and Pennsylvania. To schedule a consultation with Steven, please use the Linarducci & Butler Contact Form or call 302-613-0707 to schedule an appointment.

Relevant Links:

• Center for Medicare and Medicaid Services Releases the 2010 Medicare Fact Sheet
• Center for Medicare and Medicaid Services Announces Medicare Part D prescription Drug Coverage Premiums Will Increase in 2010
• Medicare.gov FAQ on Medicare Premiums and Coinsurance Rates for 2010
• Medicare.gov FAQ to Determine if Medicare Part B Premium Will Increase in 2010
• Medicare.gov FAQ to Determine Medicare Part B Premium for Individuals with “Higher Income Levels”
• President Barack Obama’s Statement in Support of Extending Economic Recovery Payment to Social Security Recipients
• Center for Medicare Advocacy Description of Hold Harmless Clause of US Code
• Contact Senator Tom Carper
• Contact Senator Edward Kaufman
• Contact Representative Michael Castle

No related posts.

Related posts brought to you by Yet Another Related Posts Plugin.

Effective March 1, 2001, Delaware extended Medicaid eligibility to certain individuals that were approved for SSDI. The program was named “Medical Assistance During Transition to Medicare” or “MAT” and was codified as part of the Delaware Administrative Code. (See Title 16 Sec. 17800 of Delaware Administrative Regulations).

Beginning March 1, 2001, individuals in Delaware who were already receiving Medicaid and were approved for at least one month of Supplemental Security Income payments (SSI is the Social Security Administration’s poverty based disability program) no longer lost their eligibility for Medicaid because of the receipt of SSDI. The only requirements were that 1) the individual lost Medicaid because of receipt of SSDI, and 2) they were not yet eligible for Medicare. This was an important change, because previously these same individuals would lose eligibility for Medicaid if their SSDI payments were above the State income limits. Since Medicare does not begin until 24 months after eligibility for the first SSDI payment, before MAT, it was common for individuals to lose Medicaid and have to go months or even as long as 2 years without government provided medical coverage, despite being found disabled by the Social Security Administration.

Unfortunately, MAT did not extend Medicaid coverage in every situation. Only individuals that were approved for SSDI and had at least one month of SSI eligibility qualified for this program. The result was that anyone in Delaware that was receiving Medicaid and approved for SSDI, but was not approved for SSI (or never applied for SSI), still lost their Medicaid eligibility and had no government provided medical insurance coverage until Medicare began.

Effective September 1, 2008, Delaware extended MAT to any individual that was 1) not yet eligible for Medicare and 2) lost eligibility for Medicaid on or after January 1, 2008 due to the receipt of SSDI. As a result, even if an individual never met the requirements for SSI, they became eligible to retain Medicaid as long as they were receiving Medicaid before their SSDI claim was approved. This change in the Administrative Regulations closed a loophole that was causing many individuals in Delaware to lose all government provided medical coverage once they were approved for SSDI until they were finally eligible for Medicare.

In effect, this now means that no Delaware resident who is receiving Medicaid should lose government provided medical insurance just because of being found disabled by the Social Security Administration. Unfortunately, the regulations are not being applied consistently by the Delaware Division of Social Services. Many of my clients have had Medicaid benefits terminated after being approved for SSDI benefits, even though they should still qualify under MAT. I have found that several employees of the Delaware Division of Social Services are still not aware of these changes, and need reminders on how to properly apply the MAT Regulations.

I recommend that individuals that receive a notice that their Medicaid coverage has been terminated because of receipt of SSDI (who are not yet eligible for Medicare), print out copies of the applicable regulations and provide them to their Social Worker. Additionally, the individual should provide the Social Worker with the Notice of Approval from the Social Security Administration to prove that the source of their new income is SSDI benefits.

In order to implement this Medicaid gap coverage, individuals that fall within these limited categories are made eligible for $5.00 in an optional Delaware SSI State Supplement program regardless of the amount of their earned or unearned income. A Medicaid redetermination may be necessary after qualifying for SSDI, but the Administrative Regulations provide that eligibility for Medicaid continue until Medicare eligibility begins.

Remember, both of these extensions of Medicaid only apply if you were already receiving Medicaid before you were approved for SSDI. If you did not qualify for Medicaid before being found disabled under the SSDI program, you will still need to wait 24 months from the date of your first SSDI payment until you are eligible for Medicare Coverage. If you have not yet been approved for SSDI, and do not have medical insurance, you can use the Delaware Division of Social Services online Application for Social Services and Internet Screening Tool to determine if you qualify for State Assistance while waiting for your disability determination.

If you were represented by an attorney for your Social Security disability claim, and your Medicaid is terminated before you are eligible for Medicare, I would recommend that you ask your attorney to write a letter to your Social Worker describing the applicable regulations and explaining why you should retain your eligibility. If you live outside of Delaware, it is important that you determine if your State has a similar MAT program.

Relevant Links

Applicable Medical Assistance during Transition to Medicare Regulations

• Delaware Administrative Code Title 16, Section 17800 Medical Assistance during Transition to Medicare
• Delaware Administrative Code Title 16, Section 17801 Status Eligibility
• Delaware Administrative Code Title 16, Section 17802 Financial Eligibility
• Delaware Administrative Code Title 16, Section 17803 Eligibility Determination
• Delaware Administrative Code Title 16, Section 13434 Recipients of Optional State Supplement Payments

Delaware Medicaid

• Delaware Division of Medicaid & Medical Assistance
• Work World/Delaware Benefit Information System
• Work World Section on Delaware Medicaid MAT Program
• Delaware Application for Social Services and Internet Screening Tool

Medicare

• United State Medicare

Sample Letter

• Sample Letter Requesting Redetermination of Medicaid Termination

This article was written by Steven Butler. Steven is a partner at Linarducci & Butler, PA and his practice is limited to Social Security Disability/SSI claims. Steven offers free initial consultations for Social Security Disability/SSI claims to residents of Delaware, Maryland, New Jersey and Pennsylvania. To schedule a consultation with Steven, please use the Linarducci & Butler Contact Form or call 302-613-0707 to schedule an appointment.

No related posts.

Related posts brought to you by Yet Another Related Posts Plugin.