1. Healthcare Coverage for Adults with Autism January 20, 2018
Amy Weinstock
Autism Insurance Resource Center UMass Medical School/Shriver
Joanne Bayliss
Massachusetts Department of Developmental Services

2. Introduction Overview Types of Insurance What is ARICA?
Types of MassHealth
MassHealth Premium Assistance
Keeping a Dependent on a Parent’s Policy
Medicare
How Social Security affects coverage
Resources
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3. Healthcare - It’s Complicated!!!
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4. The Autism Insurance Resource Center UMass Medical School, E. K
The Autism Insurance Resource Center UMass Medical School, E.K. Shriver Center
A Resource for Consumers, Providers, Employers, and Educators on Issues Related to Medical Insurance for Autism Treatment
Information and technical assistance by phone/
Assistance with issues related to accessing coverage for treatment, including MassHealth questions and issues.
Access to documents including Legislation, FAQ’s, Agency Bulletins, etc.
Webinars and Trainings on Insurance Laws and Related Topics
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5. Types of Insurance Private Self Funded Public Fully Funded
aka “ERISA plans”
MassHealth plans, including
MassHealth Standard
MassHealth CommonHealth
Medicare
includes UNSUBSIDIZED Health Connector Plans aka “QHP’s”
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6. What is ARICA
ARICA (An Act Relative to Insurance Coverage for Autism), is a law enacted in 2010 requiring private insurance to cover medically necessary treatment for autism.
Provides coverage for habilitative and rehabilitative care, including, but not limited to, Applied Behavior Analysis (ABA) therapy.
Provides coverage for Pharmacy, Psychiatric, Psychological, and Therapeutic Care.
No Age Limits, Visit Limitations, or Dollar Caps.
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7. Coverage Under ARICA Private Self Funded Public Fully Funded
Not subject to ARICA, but may include benefits
Not subject to ARICA, but covers many of the same benefits. ABA is only covered until age 21.
Subject to ARICA
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8. Frequently Asked Questions
Can my child receive MassHealth and also have private insurance? If so, which plan will be primary? Yes, Private insurance is primary.
Does ARICA cover autism treatments for adults? Yes
Can I purchase a policy from the Health Connector that will provide access to ARICA benefits for my child? Yes, but it has to be an UNSUBSIDIZED plan - called a QHP.
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9. MassHealth Standard Adults age 19-64 who;
Have a disability determined by the Social Security Administration (SSA), Massachusetts Commission for the Blind (MCB) or MassHealth and;
Have total household income either at or below 138% of the Federal Poverty Level (FPL).
There is no monthly premium for MassHealth Standard
Income level is roughly $17,000/year or $1,400/month
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10. MassHealth CommonHealth for Working Individuals
Adults age 19 or older, and;
Have a disability determined by SSA, MCB or MassHealth and;
Have total household income more than 138% of the FPL.
Is employed at least 40 hours per month, or have been employed at least 240 hours in the six months
Charges a sliding scale monthly premium
FPL comes to about $17,000/yr or about $1,400/month
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11. MassHealth CommonHealth for Non-Working Individuals
Adults age who;
Have a disability determined by SSA, MCB or MassHealth and;
Have total household income more than 138% of the FPL
A one time deductible will apply
MassHealth gives six months to meet the deductible with paid or unpaid medical bills.
There is a sliding scale monthly premium
138% of FPL in 2015 is $1,355.
Deductible applied by by calculating one month’s total income - $542.00, then multiplying the remainder by 6.
for members with household income at or above 150% of FPL
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12. MassHealth Premium Assistance
Premium Assistance is a program within MassHealth, and is available for people who are covered under Standard or CommonHealth.
For people with Employer Sponsored Insurance and MassHealth, Premium Assistance may reimburse the cost of the Employer’s insurance. This can be a valuable benefit for a disabled adult who receives MassHealth, but remains on their family’s policy.
Policies have to meet certain criteria, and disabled adult has to live with the policy holder.
PA is not provided for policies with Deductibles over $2,000 individual $4,000 family, or where an employer contributes to an HSA. There are also other requirements.
PA doesn’t notify people if their policy is determined not to be eligible.
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13. Frequently Asked Questions
Will MassHealth provide Premium Assistance for private insurance purchased through the Connector (versus Employer Sponsored Insurance)?
What happens when a parent gets Medicare?
What steps should I be taking now?
If you are eligible for PA, call the office to apply.
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14. Keeping a Dependent on a Parent’s Policy
Under the ACA, children can remain under a parent’s policy until age 26.
Disabled dependents can usually remain on a parent’s policy after age 26.
Parents need to apply to their employer for this coverage – advised to do so well before dependent turns 26.
After a dependent turns 26 they are not able to be added back to a parent’s policy, regardless of disability.
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15. Frequently Asked Questions
Does this just apply to people with ASD? – No, it applies to all disabilities
If my child has a job that provides, insurance, can I put them back on my policy if they lose their job? – Not if they are over 26
My child is older than 26 – what are my options? – Check with your employer.
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16. Medicare For individuals age 65 or older, or;
Under age 65 and disabled
Medicare benefits are provided in four parts
Beneficiaries don’t have to take coverage under all parts.
Some parts have premiums, co-pays and deductibles.
If individuals have MassHealth and Medicare, MassHealth will cover those premiums, co- pays and deductibles.
Part A: helps pay for inpatient hospital care. There are no premiums, but co-pays an deductibles apply
Part Part C: Medicare Managed Care. It allows HMO’s, PPO’s, etc. to offer health insurance to Medicare beneficiaries. Dental and vision may be included in Part C.
Part D: Provides prescription drug benefits through private insurance companies. Monthly premiums apply and vary by state, company and the amount of coverage offered.
B: helps pay for doctor visits, outpatient hospital care, PT/OT (what’s not covered in Part A). There is a premium, as well as co-pays and deductibles. The Part B premium is deducted from the SSDI benefit.
MassHealth will not provide PA for a private insurance policy if a person (or parent) has Medicare – even if the parent declines certain parts of Medicare.
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17. Social Security - SSDI vs. SSI
How can I tell which Benefit I can get?
SSI vs SSDI
Financial need Eligibility Basis Work-History
YES Resource Limits? NO
Medicaid/
MassHealth Health Insurance Medicare
1st of the month Payment Details Any day but the 1st
SSI= income max amount of the Federal supplement is $735 (some of you get more, but it comes directly from the state-state supplement)
SSDI=insurance temporary-not supposed to be permanent until you turn 65 (Medicare)
A disabled child can also get SSDI as a Disabled Adult Child based on their parent’s work history (Only after the parent starts getting Social Security). Many disabled adults get SSI first, and then get SSDI when their parents retire. SSDI is a higher amount, but doesn’t come with MassHealth.
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18. Can I Work and Keep my Health Insurance when I have SSI?
MassHealth Standard (free) eligibility is automatic when you apply for SSI
MassHealth Standard is protected when beneficiaries work
If work causes a loss of SSI cash benefits you can keep MassHealth for one year
You can keep MassHealth for one year under what is called 1619(b)
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19. Can I Work and Keep my Health Insurance when I have SSDI?
Most individuals apply for MassHealth during the 2 year wait time for Medicare eligibility
You are eligible for Medicare once you have received SSDI benefits for a full 24 months
MassHealth coverage and assistance may change if your income increases
Medicare is protected (for over 7 years), even if you go back to work.
The Social Security Administration determines when eligibility will stop.
93 months because of the Extended Period of Medicare Coverage (EPMC).
Substantial gainful activity for 2017 is $1,170.
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20. How Can I Verify My Benefits?
My Social Security (
Social Security Benefits Planning Query (BPQY)
DTA Connect (DTA benefits)
Virtual Gateway (DTA benefits and MassHealth
MyMedicare.gov (Medicare Parts A-D)
VERIFY YOUR BENEFITS BEFORE WORKING!
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21. Can I ever get my benefits back?
YES!
There is a safety net that former SSI and SSDI recipients may use to get benefits reinstated.
Important:
Case closure must be due to work activity
Only available within 5 years of case closure
You can receive temporary cash benefits until the final decision is made
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22. What must I do when I work?
You must report any work activity to Social Security and any other public agencies you receive benefits from (like MassHealth).
It is critical you report consistently and on time to avoid any under or overpayments.
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23. Where Can I Get Benefits Counseling?
Two program in Massachusetts provide FREE and confidential counseling to those working and those actively seeking work.
1. BenePLAN
2. Project IMPACT
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24. Other Resources Health Care for All Helpline: 1.800.272.4232
SHINE (Serving Health Information Needs of Everyone): FREE health insurance information to Massachusetts residents on Medicare
, press 3.
Medicare Advocacy Project (MAP): provides legal aid for Massachusetts residents with Medicare and Medicare-related health insurance coverage.
Boston:
Worcester:
South Coast:
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25. The Autism Insurance Resource Center UMass Medical School Shriver Center
Contact Information
Acknowledgments
MA Developmental Disabilities Council
Nancy Lurie Marks Family Foundation
Doug Flutie Jr. Foundation for Autism
MA Department of Developmental Services (DDS), Department of Public Health (DPH), Department of Elementary and Secondary Education (DESE)
UMassMedical School
Copyright © 2018 Autism Insurance Resource Center – All Rights Reserved