1 Insurance Coverage: Issues, Strategies and Solutions. Presenter: Beth Sufian. >> JACQUIE: Good afternoon everybody. Welcome to today's webcast. The topic for today is insurance coverage: Issues, strategies and solutions. We're going to provide information about options for health insurance coverage and government benefits and we will also touch on COBRA, FMLA and issues faced by parents of children with disabilities. Our presenter today was my friend and one of the best lawyers in practice for these kind of issues, Beth Sufian, who is with the law firm of Sufian & Passamano. The webcast is sponsored by NIDRR, who funds your host for today's program, the DBTAC southwest ADA center. I'm your moderator, Jacquie Brennan and I'm with the ILRU project, Southwest ADA Center. I'll be assisting with today's presentation. When you clicked on the webcast link, you brought up a screen that probably doesn't look like it is what I just said our webcast today is on because of a problem with PowerPoint today. So to view the PowerPoint presentation, you'll need to click on the PowerPoint link itself at the web page where you access the webcast. And then you can watch the PowerPoint. So on the screen you should be seeing just captioning for today's PowerPoint -- I mean for today's presentation, but you won't see the PowerPoint unless you go and download the PowerPoint separately. 2 For those of you who are listening to the webcast today to submit your questions, click on the E-mail button on your screen or you can E-mail those questions directly to webcast@ilru.org. We have received a few comments about today's topic already, but they -- those comments did not include questions. So I will be sure to forward all comments to Beth after the webcast, but I won't read those comments as part of the webcast unless they include a question. I expect we're going to have a lot of questions on this topic and I want to ask as many of those as we can given our time constraints. If you have any technical difficulties today, please feel free to call us at (713)520-0232 and, again, thanks for joining us today. Now I'm pleased to introduce our speaker. Good afternoon, Beth. >> BETH: Thank you, Jacquie and thank you for that nice introduction and I'll also say Jacquie Brennan certainly is one of the experts in the field of helping people with disabilities, and I appreciate her inviting me to speak today. So if you're on the PowerPoint, I'm going to tell you the top of each slide so that you know which slide I'm speaking about. So the first slide is the introductory slide. We're going to talk about insurance coverage issues, strategies and solutions. And it tells you my E-mail and phone number. So if you do have questions after today, you can feel free to E-mail me as the quickest way to reach me. My practice over the past 17 years has encompassed representing many people with different disabilities in Social Security appeals, issues dealing with Medicare and Medicaid and insurance coverage. And that's what 3 I'm going to talk to you about today. So the next slide is insurance coverage basics and that just gives you kind of an idea why this issue is important. Certainly if you have a disability or even if you don't have a disability, health insurance is necessary to pay for medical costs. Often I think people don't realize how important health insurance is until they have a medical crisis. I think people who live with chronic illness are very familiar with the importance of having health insurance, but often may be unfamiliar with the different ways to obtain coverage. So we're going to talk about that today. The next slide, slide 3, says who is affected by these issues? Through our work around the country, we find that many people have anxiety related to obtaining health insurance coverage, getting it to pay for what they need and keeping that insurance coverage intact. And we find that regardless of income, people have these -- people are anxious about their insurance, especially if they are dealing with a chronic illness or a certain medical crisis. We found recently that many middle income families encounter difficulties in terms of paying for copays and increasing rates for premiums. So I think this isn't just an issue that affects people that may be low income, but also affects people who are middle income and upper middle income. We also find that some people who transition from having Medicaid benefits to private insurance experience problems when they have to deal with private insurance and encounter high copays and premiums. 4 So the next slide is lessons learned, from the work that we've done and that is slide 4. We've found that often low income families who have a situation where they get a razor they get a better job that kicks them out of Medicaid benefits or state benefits, those people often have a lot of difficulty paying copays and premiums on a private insurance policy. We also find that young adults who reach limiting ages on their parents' policies and may be are not able to work and have their own insurance also have significant coverage issues. We find across the board when we're talking about insurance and coverage, it's very good to plan ahead. So if you know that your child is going to be reaching a limiting age on your policy, if you're the parent, very good idea to find out how you're going to keep that child covered and you shouldn't be doing that the day before the child drops from your policy, but try to ascertain how that child is going to stay covered many months prior to the time they will lose their coverage. The next slide, slide 5, says issues for those with coverage. As I talked about a minute ago, a lot of people, especially recently, are having trouble paying for insurance coverage premiums and copays for medication. There is quite a few studies that have been done that show -- especially for people with chronic illness -- that they have difficulties paying insurance premiums and if they are on more than a few medications, they are having difficulty paying for copays. So, for example, if you're on five medications to treat a certain medical condition, and your copay is $100 per medication, you're looking at a 500-dollar out lay just to get medication because of increases in copays. 5 So certainly if you work for an employer that offers more than one health insurance policy, it's very important to review the policy and understand all the costs associated with that policy. Sometimes the premiums may be low, but the copays may be very high, and so in that situation, if you have a choice, you may want to take a policy that has higher premiums, but lower copays. So you definitely have to do a cost analysis if you are faced or you're lucky enough to have a choice of more than one policy. And typically large employers are the ones that offer a choice of policies. There is no law that requires employers to offer insurance at all, and there is certainly no law that requires they offer more than one choice. But most large employers do offer a choice of more than one policy, and so if that's your situation, you need to make sure you make the right choice and pick the policy that will best serve your needs. Slide No. 6, access to care, we found a lot through our work that people's access to medical treatment and care is narrowed if they have issues related to coverage and paying for that care. Slide 2 continues and says access to care and talks about things that health care providers should be asking their patients. So if you are the patient -- I know we have people on this call who are both people with chronic illness or disabilities and also we may have some health care providers on the call. So for health care providers, I think it's important to make sure that patients express to you if they are having trouble obtaining medication. If they stop taking medication due to high copays and if they are having trouble paying for their insurance premiums. 6 And certainly if you're on the receiving end, if you're the patient, you need to make sure you tell your health care providers if you're having trouble with these issues. There is limited assistance available for people who need assistance with copays, and your physician is going to be the best person to provide you with information on copay assistance. You can certainly also use the Internet to look for copay assistance for certain drugs. Certain drug companies offer assistance and certain drug companies give grants to nonprofit organizations to help with copay assistance. So either your physician will know about those programs or you might be able to find some of those programs on the web, but certainly your provider needs to know if you're having trouble with these issues. You shouldn't be embarrassed to discuss it with them because they may be able to offer you some assistance. The next slide, slide 8, talks about what I just told you about. It talks about prescription assistance programs and it also -- one of the bullet points says assess whether eligible for government programs that will not have copays. We're doing a project right now where we're taking people with very high premiums and very high copays, a select group of people, and we're trying to see if they would be eligible for cheaper coverage. And we found that many of them are eligible for government benefits, but just didn't know it. So certainly if you were going to talk about eligibility for government programs, I think it's important to make sure you're not eligible for one of those programs, especially if you're having trouble with copays and premium payments. So now I guess I'll see if there are any questions on that topic. 7 >> JACQUIE: Okay, I have one from a small business owner who says that the problem for her is that she also has trouble offering insurance because of the expense of it and wants to know if you have any tips for her on how to be able to offer her employees in this very small business insurance coverage. >> BETH: I think the best thing to do when searching for insurance, if you're a small business, is to try to find an independent insurance agent who will give you a variety of policies to choose from. Most insurance agents will give you maybe four different insurance companies and a variety of levels of policies. And so if you may not be able to afford the most comprehensive policy, but you still want to provide coverage for your employees, you may be able to find a policy that offers less benefits, but at least offers some coverage for your employees. I think it's also important to look and see if there are any associations that may offer insurance, for example, the American bar association offers insurance policies for lawyers or the state bar of Texas. I know there is a variety of Chamber of Commerce entities that offer insurance for certain cities or locations, and so that might be an available avenue. >> JACQUIE: And then one more: You mentioned that we should assess whether government programs are available to help. How do I find out if I'm eligible for government benefits? Do I have to apply in order to find out? >> BETH: We're going to talk about that in a few minutes about government benefit eligibility. And so let's save that and hopefully we'll answer. 8 >> JACQUIE: That's all I have for now then. >> BETH: So now I go to slide 9, and it has a III issues for those in need of insurance. So if you are in need of health insurance, how can you access private health insurance? Thanks to a law called HIPAA, the health insurance portability, accountability act, which went into effect in 1997, so it's almost about 11 years it's been in existence, there is a lot of protection for group plans. So that would be plans offered by an employer or an association or any type of group. Not individual plans, so nothing I'm going to say in the next few minutes applies to a plan that you purchase on your own, and that's very important for everyone to understand. The coverage under HIPAA is very good protection, especially for people with medical -- serious medical conditions or chronic illness, but it will not apply to people who go out and buy their own policy. So what does HIPAA say? Most of us are familiar with HIPAA because it says people have to be very careful in terms of disclosing your medical information to a third party. And I think most people, when I talk about HIPAA, tell me that's the only part they know about. And that's unfortunate because there are other parts of HIPAA that I think are much more significant and gives people much more protection in terms of access to coverage. So what is this section of HIPAA say? It says that there is no discrimination based on health by a group policy. And that means if an employer, like the small employer who just asked a question, goes to an agent and says I'd like to purchase a policy, the agent or the health 9 insurance company cannot say, we're not going to cover your group because you have an employee who has asthma or has cystic fibrosis or hemophilia or Spina Bifida or any medical condition. And they also can't say we'll cover your group, but we're not going to cover the person who has the medical condition. So that's a very nice protection because prior to HIPAA, the insurance companies could exclude whoever they wanted, even from group plans. But HIPAA now says you can't do that. Slide 10 says access to coverage. HIPAA solutions. Another great thing HIPAA does is says if you've been on a policy for 12 months and you lose your job or you change jobs, if you get another job and another policy within 63 days, you don't have to meet a new preexisting condition clause on your new policy. So especially for people who have chronic illness and disabilities, this is very important. So if you're at job A. and you find a better job, and you switch to that job, within 63 days you don't have a break of coverage of more than 63 days, on the new policy you don't have to meet a preexisting condition clause. And what is a preexist tipping condition clause for anyone who doesn't know? That's a clause that is in most insurance policies that says we won't cover any condition you had prior to getting on this policy. And so HIPAA says if you've been on another policy, then the preexisting condition clause doesn't apply. So that's very important. Very important then that if you have coverage and for some reason you lose it, that you try to get other coverage within 63 days. This also applies for people going from Medicaid or Medicare to 10 private insurance. If you're on Medicaid or Medicare, and you then become eligible for private insurance, you don't have to meet the preexisting condition clause on the new policy, on the new private policy. And what they do is give you a month by month credit. So if you've only been on Medicaid for three months, you're only going to get a three-month credit toward the preexisting condition clause. So you want to try to be on one policy for at least 12 months so that if you switch policies, you get creditable coverage. The next bullet point on this slide says small businesses, if you are 2 to 50 employees, you must be able to buy a group plan. So this is really important if you are a small employer, and you want to buy insurance prior to HIPAA, they could say we're not going to cover you. You're too small of a group and you have people with certain health conditions and we're not going to sell you a policy. But HIPAA says they must sell you a policy if you are a legitimate business. There are different rules as to how they can rate the policy, which means they can charge more if you do have people that are high risk, but for most people who have high medical costs, the price of the policy will not be more than the cost of paying for medical treatment out of pocket. The next slide, slide 11, says employment issues at the top. Employment-related issues certainly affect access to insurance. About 85 percent of the people in the U.S. get health insurance, private health insurance, through their employer. And so that's a very good way to get insurance. 11 If a parent loses their job or a person who has a spouse that has a serious medical condition loses their job, they want to make sure that they COBRA their benefits. We're going to talk about what COBRA is in about one second and how you can get it. But it's very important if you lose your job or if you have one of these COBRA events, that you have money to pay for COBRA because as you'll see on one of the next slides, you must pay your full premium under COBRA. So we always suggest that people who know they have a medical condition that requires them to have insurance, that you must have insurance in order to pay for your treatment, that you set aside some money in the event you may need COBRA. So that you're not shocked and surprised that you're going to have to pay the full premium if you need to go on COBRA. So let's go to slide 12, which says COBRA at the top. And COBRA stands for the consolidated omni bus budget reconciliation act which is quite a mouth full so most people just say COBRA. And COBRA says that in five situations if you have one of these things happen, you get to extend your health insurance coverage. The first one many of you are probably familiar with, you're terminated or laid off or you just decide to quit or leave your job, you get 18 months of COBRA. The other four people often don't know about. If the covered employee dies, his dependents get 36 months of COBRA. If the covered employee divorces or separates, the dependents get 36 months. If someone becomes eligible for Social Security disability, you get 29 months under COBRA. You'll see that this is very important because if you become eligible for Social Security disability, you have a 29 month waiting period before you 12 become eligible for Medicare. So it's very important to COBRA if you leave work to go on Social Security disability. And lastly, if you have a child that reaches a limiting age on your policy, you can extend under COBRA for 36 months. Most policies say your dependent children's coverage will stop at a certain age. There is not a set age. So you may have a neighbor that has a policy that covers his children until 25; but you may have a policy that only covers your children until 18. So it's very important to know when the coverage will stop and that you can COBRA the benefits if the child doesn't have another policy to go to. The next slide, slide 13, has COBRA again at the top. And tells you that the law COBRA only applies to employers with 20 or more employees. So if you only have 19 employees at your job, they do not have to offer you COBRA. Sometimes some employers will let people COBRA benefits even if they have under 20 employees, and that's because the employee pays the premium. And so the employer, if they have been paying the premium themselves, don't pay the premium under COBRA. If the employer decides to stop coverage for all employees, if you are on COBRA, your coverage will end as well. And as insurance costs go up, as premiums go up, there are increasing numbers of employers who are deciding they just can't afford to pay or have insurance for their employees. So if you're on COBRA, and your employer stops providing insurance for everybody else, your COBRA will stop as well. Slide 14 talks about employment issues and mainly talks about the family medical leave act. And some of you who know about family medical leave may not understand how this relates to insurance, but you'll find out 13 in about two seconds. The family medical leave act says that if you have 50 or more employees, and the employees have worked one year and worked 1250 hours in the year prior to asking for leave, then the employee can get up to 12 weeks of unpaid leave to care for themselves, their spouse, a parent or child. The important thing is that while you are on FMLA leave, your insurance continues. You don't have to go on COBRA while you're on FMLA leave. And so if your employer is paying the premiums for employees, if you're on FMLA leave, your employer continues to pay the premiums. So are there any questions? >> JACQUIE: Yes. I just got started on SSDI and they said Medicare would kick in in 24 months, but you said 29 months. >> BETH: Good point. >> JACQUIE: I really need this coverage. >> BETH: Okay, there is a five month waiting period for the initial Social Security benefits. So the first five months of being unable to work, you won't get a benefit and you'll start getting benefits on that sixth month of being unable to work. So you can either say 29 months from becoming unable to work or 24 months from the date you start getting your checks. So it's 24 months until you get Medicare from the date you get your checks, but if you add the five month waiting period, it's 29 months from the date you become unable to work and it's full months. So if you stopped work in the middle of a month, that month is not going to count. >> JACQUIE: I get it. Okay, if the employee pays the premium under COBRA anyway, then why does my company which has just 12 employees, get out 14 of providing COBRA to me? >> BETH: Could you say that again? >> JACQUIE: If the employee pays the premium under COBRA anyway, then why does my company, which has only 12 employees, get out of providing COBRA? I think that's -- >> BETH: That's just because did law says 20 or more employees. >> JACQUIE: Right. Nothing much to be done about that. Okay, one last one which I don't even know if you're going to get to this at all today, but it says maybe it's because I just watched the movie sicko, but do you think we'll ever have universal health care? >> BETH: I don't know. I wish I had that answer. I don't have that answer. You know, I do think that people if they are concerned about this issue should make sure that when they are voting they understand the positions of their local leaders, their congressmen, their senators, you know, when they are voting in November, that they make sure they understand what the people they are voting for -- what their stand is. >> JACQUIE: Right. Okay, that's all I have right now. >> BETH: Okay. So the next slide says government programs and it has a very light etching of what's supposed to be the capitol I think. I don't know if you guys can see that. So we'll go to the next slide which has IV and then government benefits. So government benefits certainly can increase access to care and treatment to those people who otherwise don't have insurance and meet the eligibility requirements. And so we're going to talk about how you become eligible for benefits and I'll just preface this section by saying that Social Security benefits are very complicated. 15 There are hundreds and hundreds of pages of rules that deal with Social Security and we're certainly not going to be able to talk about all of them. So I'm going to try to talk to you about some basic Social Security rules and some things that I think are important to know, but I do want you to know that I can't go into everything about Social Security in the next few minutes. So this is an abbreviated discussion hopefully to give you enough information so that if you need to find out more, you can. Okay, so slide 17 says change in situation. And I think we talked a few slides ago about our experience of seeing people who have their financial situation get better and end up losing Medicaid actually having more health care costs that's race any kind of benefit from a razor any kind of job with a higher salary. I think it's important if you're in that situation that if you decide you get a raise for $50 a month that sets you over the Medicaid income guidelines, that you assess whether you're going to have very high copays and premiums of more than $50 a month. It may be better not to take the 50-dollar raise and instead keep the Medicaid coverage. So that's again going to be what they talk about in law as a cost benefit analysis. If you're going to lose Medicaid, how much is it going to cost you to get the same care and treatment on a private policy? The next slide is 18, and it talks about the two programs that Social Security offers for people who cannot work due to a disability. And those are supplemental security income or SSI, and Social Security disability insurance or SSDI. Some people call that SSD. Some people call it S. S. I call it SSDI which talks about Social Security disability insurance. 16 Okay, so the next slide, slide 19, talks about the SSI nonmedical requirements. Very important for everybody to understand that SSI and SSDI have different eligibility requirements, meaning you may be eligible for one, but not eligible for the other. A lot of people get these two programs mixed up and they interchange the requirements. And so make sure you understand which program has which requirements. So under SSI, if you're under 18, your parents must meet certain low income guidelines and you can find those on SSA.gov. Those will tell you if you're a family of two how much your yearly income can be or a family of four. If you're over the income guidelines, then you cannot get SSI no matter how sick you are. You must meet the income guidelines. There are also asset guidelines, so you can't have more than a certain amount of assets. So, for example, you can't have $50,000 in the bank and be eligible for SSI. If you're over 18 and you're living with your parents, as long as you have an agreement to pay your share of household expenses once you receive benefits, they should not be considering the parents' income. So that's very important. Someone who is over 18 who has not worked will not be eligible for Social Security disability and may be eligible for SSI if they meet the income and medical guidelines. The next slide, slide 20, says SSDI, nonmedical requirements. So for SSDI, you do not have to be low income. There are no income guidelines in order to be eligible for SSDI. However, you must have worked and paid in to the Social Security system by paying Social Security taxes in order to 17 be eligible for Social Security disability. You can find out if you've paid in enough by calling the Social Security 800 number which is 1-800-772-1213. In addition, Social Security yearly should be sending you a benefit statement that would show you if you have enough time paid in to Social Security in order to get Social Security disability. And again, it says right here, eligible for Medicare after 29 months of eligibility, first five months are awaiting period plus the 24 months of receiving checks. Then you would be eligible for Medicare. This is different than SSI. SSI upon approval you are eligible for Medicaid. You don't have awaiting period under SSI to be eligible for Medicaid. But under SSDI, you do have awaiting period for becoming eligible for Medicare. Okay? So the next slide says government benefits, and it's slide 21. And it talks about what medical proof you need to show you're eligible for benefits. Just having a certain medical condition or a disability or chronic illness, whatever you want to call it, will not make you eligible. You have to meet certain medical eligibility that is set out in the Social Security rules. So it's real important for you to have your doctor help you to show that you meet those rules, getting a letter from the doctor that discusses your condition and that says why you're unable to work full time is very important. So Social Security disability and SSI are for people who cannot work full time. If you're able to work full time, you're not going to be eligible for either of those programs. The next slide, slide 22, talks about Social Security medical 18 eligibility, that's found at something called the Social Security Administration listing. If you go to www.SSA.gov, you'll find a long list of medical problems and the medical eligibility requirements that Social Security says will en title someone to benefits. So, for example, if you look for cystic fibrosis, that is found at 3.04 of the Social Security listing. You either have to have low pulmonary function or have three hospitalizations or six physician interventions or could you having up blood or pneumonia in the year prior to applying for benefits or you have to have been on home I.V.'s or inhaled medication. So if you don't have one of these requirements, you have to show you're as severe as a listed requirement. So just writing that you have muscular dystrophy or multiple sclerosis or asthma or any condition is not going to mean you get benefits. You also have to meet or equal the medical eligibility. So if you don't exactly meet the listed criteria, you have to be able to show that your condition is severe enough to keep you from working. And, again, you're going to need your medical team, your physician, to help you provide proof to Social Security that you meet their rules. And if you go to the next slide, slide 23, you see -- you need to show as severe as one of the listed criteria if you don't Mead the listed criteria. So why don't we stop here and see if people have questions. >> JACQUIE: Yes, we have -- >> BETH: I'm sure there is a lot. >> JACQUIE: We have a few now. One is I'm pregnant and I currently have insurance through my employer. If I were to leave my current job and get another job that offers insurance, would my pregnancy still be covered? 19 >> BETH: As a -- >> JACQUIE: A preexisting condition. >> BETH: It's going to depend if you get creditable coverage from a preexisting condition and also some policies exclude pregnancy and some policies put their own restrictions on pregnancy. So I think you'd have to check that actual policy. >> JACQUIE: Someone else wrote relative to COBRA, the information was helpful in explaining the coverage when children are involved. I would also like to know if one spouse retires and maintains coverage through COBRA, can the other spouse be added to the coverage? If so, is there a certain time frame during which this can be done? >> BETH: I guess the question is saying if they weren't initially on the coverage and you're on COBRA, I don't think you can add anybody once you've started COBRA. >> JACQUIE: I don't think so either. I always thought Medicare was better than Medicaid, but it sounds like maybe I was wrong. Which coverage is better? >> BETH: I don't think one is better than the other. I think the problem with Medicare is you have to wait the 29 months to be eligible for it; but in terms of actual coverage, certainly from Medicaid in most states there are no copays and there is no premium payments, although there are a few states that are now charging copays to Medicaid recipients. So I don't want anyone to start screaming well my state makes us pay copays. For the moment, Texas is not -- Texas Medicaid is not making people pay copays. So under Medicare, there are copays for prescription drugs and there is also a 20 deductible for hospital stays. So there are some additional costs involved with Medicare. Also you pay a Medicare premium. So I'm not sure if that makes it better or worse. I think overall they both provide coverage for treatment. Medicare, you're going to have a little bit more you're going to have to pay out of pocket than Medicaid. >> JACQUIE: Right. I have a client and her family is on SSI because she has two children who have disabilities, but when her husband works overtime, they love the extra money which is so desperately needed, but then they lose Medicaid for a month. They are constantly going on and off of Medicaid coverage. Is there anything that can be done about this kind of situation? >> BETH: They need to not go over the income limits. That's what I've been talking about. Families that go over the income limits and lose Medicaid and even if they like the extra money they've made, they've lost the coverage for their children. So they actually end up not making more money because I've never heard of anyone who makes more money in overtime than their child's medication if the child has a serious condition. So I think people really have to be made aware that if they go over the income limits, they lose benefits. And so it's just a choice that the people have to make. >> JACQUIE: Okay, this is the last one right now. If I have -- if I go to the Social Security website, will I be able to tell if I have a disability that will qualify me for SSI or SSDI? >> BETH: You should be able to decide if you meet the medical criteria. If you look for the Social Security listing, when you go to 21 www.SSA.gov, it gives you a very long list of links that you can read about a bunch of different things, and one of the things will be the Social Security listing, and in that, when you click on that, you'll see a whole bunch of different medical conditions listed. And then you'll be able to find what your criteria is for that medical condition. Now, in terms of finding out if you have enough credits to get Social Security disability, you're going to have to affirmatively call them. I don't think you can find that out online. >> JACQUIE: Right. Right. >> BETH: Does that answer that? >> JACQUIE: That's it for now. >> BETH: All right, so the next slide, slide 24, talks about SSI work programs. And these two programs not a lot of people know about, so I wanted to stick these in just in case they might help someone. One program is called section 1619b. That allows a person who is on SSI -- sorry, I left out that SSI right there. Allows a person on SSI to work making a certain amount by working part time and they keep their Medicaid, but they lose their monthly SSI cash payment. So, for example, someone who has a disability that makes them eligible for SSI will get $623 a month. If the person is able to work part time making $1,000 a month, but really needs the Medicaid because they are only going to work part time. They are probably not going to get private health insurance by just working part time, and so under 1619b, the person waives their $623. They are making $1,000 a month. So they are making more than the 623, but they get to keep their Medicaid. So you have to be enrolled in 1619b and would 22 you do that by going to your local office and asking to be enrolled in that program. Don't make over 623 and then say, oh, I thought I was on 1619b. Make sure that you affirmatively register with Social Security and tell them you want to be on 1619b and that's a way to make more money than the 623 and keep the Medicaid. But you still cannot work full time. Social Security benefits are not for people that work full time even if you're on 1619b. The next program is called the PASS program and that allows people to save money who are on SSI that they make from part-time work to save for a work goal. And you can do that for up to 36 months. So if you're on SSI and you can work part time, and you want to save the money in a savings account for work goals, you can do that. So, for example, you can save the money if you want to save it to go to college or to start your own business, you could do that under the PASS program, and again you have to enroll with Social Security and tell them that you want to do the PASS program. You come up with a plan of what your work goal will be. And certainly if you go to Social Security, the first person you talk to may not know about these programs. So did to talk too their supervisor because sometimes we find the initial people you talk to may not know about these programs. The next slide, slide 25, gives you the Social Security website and the phone number. Sometimes when people are applying for benefits, they make what I consider a mistake, and if they are 32 they get Social Security 32 years of medical records and what ends up happening is Social Security is just too overwhelmed by that much medical evidence. You only need to 23 show your medical condition the year prior to your application. So certainly it's a waste of trees and also a -- I think it kind of weighs down your application when you have more than a year of medical records. So you want to give the medical records for a year prior to your application. And you want to make sure you have a letter from your doctor that discusses your medical condition and discusses why you can't work full time. That's a very important -- very important to have a letter from your treating physician. And then if you get denied, if your application is denied, you only have 60 days to appeal. You want to appeal because you will accrue back benefits as your application is pending. So if you just start over, you're going to lose the time your application has been pending. For Social Security disability, as I said, the first full five months of being unable to work, you're never going to get a benefit for that time, but certainly if you apply and your application pends for five months and you get denied, if you start over and reapply, you have to start meeting the five month waiting period again. If you appeal, you've already met the five month waiting period and if you get approved on your appeal, you won't have to meet the five month waiting period because you've -- your application has been pending for five months. Do people have questions about that? >> JACQUIE: No, nothing yet. Sometimes it takes awhile sometimes for the question to get to me after you've covered a particular area. So there may be more about that. >> BETH: Okay. Let's see if there is anything I left out. All right, the next slide, slide 26, says transition to adulthood. Because as I said 24 in one of the earlier slides, one of the issues we see that people have are when children, especially with disabilities reach adulthood, there is a lot of insurance uncertainty. So as we said under COBRA, if the child reaches a limiting age, they can extend their insurance for 36 months. But again, those premiums will be paid for by the parents and so if the policy was costing $600 a month and the employer has been paying that premium under COBRA the parent is going to have to pay that premium. Another way to get coverage for the child, especially the child with a disability, is to use a state law extension of coverage. Most states have laws that say -- and this is the next slide on 27 -- the insurance company has to continue coverage even if the child reaches a limiting age if the child is incapable of self-support because of a physical or mental condition. In Texas, I'm not sure if most of the calls are from Texas -- most of the listeners are from Texas -- >> JACQUIE: Not usually. They are all over. >> BETH: So most states have such a law, your department of insurance should know about it and the insurance companies should also know about it. Some of them call it a disabled child and some of them call it an incapacitated child. And you have to get a form from the insurance company, and your doctor has to say -- the treating physician has to say this child is incapable of self-support because of their physical or mental condition. If your child is working, making $80,000 a year as a computer programmer, they are not going to be able to stay on as a disabled child, but for the child that has a disability that does not allow them to work 25 enough to self-support, this is a way to keep him on the policy. In addition, unlike COBRA, if your employer has been paying for dependent coverage, they will continue to do so. So that's very important. Slide 28 say that is this must be done before the child reaches the limiting age. So a year later you cannot say oh, now my child can't self-support, I want to put him back on my policy. It's got to be done before he reaches the limiting age. You request the form from the insurance company and you need the doctor's signature. So if your doctor says I think your child can self-support, he doesn't sign the form, then you're not going to be able to extend coverage. So if you and your child think he can't self-support, it's real important to explain to the physician why you think the child cannot self-support. And that doesn't mean they can't work part time, it just means that they can't make enough money to totally support themselves. The next slide, 29, continues to talk about this issue because we hear of a lot of people who have children who may think they can self-support and so they get off the parents' policy, and they work and then lo and behold they can't self-support and they can't go back on the parents' policy. So it's real important that you assess the ability of the child to self-support, especially for kids with chronic illness. And now we see a trend and it's a nice trend, everybody is doing -- a lot of people are doing better. They have chronic illness children and there is new immediate indication and new treatment and everybody is very optimistic, but many children with chronic illness have very high treatment burden demands. So they have to do a lot of medical treatment or they have times 26 when they wouldn't be able to work and so those children -- there really needs to be an assessment of whether they really can work full time. Let's see, I'm trying to think of -- I think that's it. I don't know, do we have any more questions? >> JACQUIE: Yes. Now we're going back to west about Social Security again. >> BETH: That's fine. >> JACQUIE: I have muscular dystrophy and I can't work any longer. I applied for SSDI -- SSD she calls it -- three months ago and just got denied. I will appeal that, but -- then she has three questions: The first one is should I get a lawyer? >> BETH: The first question, should I get a lawyer? On the first appeal, it's actually hard to find a lawyer. Lawyers get paid -- big surprise a lawyer is leaving out how lawyers get paid in Social Security cases. It's like very low on my list. Lawyers get paid in Social Security cases a set amount. They can only get up to 25 percent of the back money that is accruing up to $5,300. If your case has been pending for three months, there are no back benefits for an attorney to take a fee out of because again there is the first five months where you don't ever get any benefits. So there is very few lawyers who will take those cases. Typically, attorneys will not take the case until you've been denied again and you've requested a hearing before a judge. So you could certainly look for a lawyer, but I think -- I can't think of many who -- if any -- that take cases on the second appeal. >> JACQUIE: And then her second question is how long will it take to 27 get benefits if I have to have a hearing? >> BETH: It depends on where you live. Big cities right now -- >> JACQUIE: Wisconsin, but it doesn't say what city. >> BETH: Wisconsin you probably have -- we have a case in Wisconsin right now. I mean, it's going to take you at least a year to a year and a half to get a hearing. In some larger cities and larger -- states with higher populations, it could take up to two years. And that's why it's really important -- no one will tell you this at Social Security. When you make an application, make sure you understand the medical criteria and get something from your doctor that's detailed and your medical records that shows how you meet the requirements. Because you really want to do your best at your application because otherwise you're going to have quite a long time to wait through the appeal process. And there is not a way to skip your file ahead of other people. >> JACQUIE: And I see that as the biggest problem is just people getting letters from the doctor that just says this person is totally and permanently disabled and then that's all it says. And well I have a letter from a doctor that says I have a disability and so, okay, give me benefits. And that is not what Social Security is interested in seeing because I think what's important is that disability is really a legal term instead of a medical term. So, you know, the people who are reviewing that, they really want to see the medical backup for your application. And then the third question that she has actually ties in to what you were just saying which is how does Social Security think you can support yourself if you have to wait more than a year for benefits? 28 >> BETH:Unfortunately I don't think they care. I wish that they cared, but I think that they say they are under staffed and they have problems with applications and I just don't think that's really something that they are concerned about unfortunately. But what I would suggest to anyone who maybe did an application and they are doing an appeal and they didn't hear all the wisdom that Jacquie and I had to give them before they filed their application. You now know all the secrets now, which is you need to find out what the Social Security listing says about your specific medical condition and what the requirements are. Otherwise, I always tell people it's like you just are blind folded. You have no clue what you have to proof and all you're putting on there is I have cancer. I have multiple sclerosis. And I have this diagnosis and no one realizes or tells you that's not enough. You must tell them how your condition meets the criteria they set out or is as severe as the criteria. And not only do you need to tell them, but like Jacquie says, your doctor needs to do more than -- we always see the doctor's letters that go initially. Beth is a lovely young lady. I enjoy taking care of her which is nice and makes me feel good, but it has nothing to do with my ability to get benefits. What's going to make me or someone else gets benefits is a doctor who says that according to Social Security 3.04a, Beth has -- meets the criteria because she's been hospitalized three times in the past year. I've attached the hospitalization discharge summaries and she is not capable of working full time because one, two, three, four, five, six. Please let me know if you have other questions. The other really important thing to know about Social Security is you 29 need to keep a copy of anything you send to them. We have a case right now we're working on -- we've sent them as attorneys of course we kept copies, but we sent them a huge amount of stuff, maybe 100 pages, shows our clients meets the criteria and today they called to tell us they don't have any of it. And we send it Fed Ex and it was signed for and they should have it and they don't. So when you're sending in your own record, make sure that you keep a copy. Under the Social Security regulations, you're not supposed to be charged for medical records that you need to send to Social Security. So don't let a hospital or a doctor's office say we're going to charge you $400 to give you a copy of your record. You need to remind them that under the Social Security rules when it's for Social Security purposes, they are not supposed to be charging you for copies of the records. The other thing that we find -- I'll just tell you one of our secrets is we take and make charts. So if you've been to the toke tore seven times, make a little chart that shows the dates you went to the doctor and why you went to the doctor. Anything you can do to make it easier for Social Security to understand why you meet the criteria is going to help your case. >> JACQUIE: Okay, one more question right now that I see. If a private health insurance company simply refuses to cover me due to my disabling condition, what recourse do I have? >> BETH: If you are just applying for insurance to an insurance company, you don't have any recourse because they can say we don't like the color of your hair. You used a blue pen on this application. They can 30 give any reason they want to deny an application for an individual policy. Certainly if they are violating HIPAA by not giving a policy to someone who needs group coverage, that would be a violation of federal law and you certainly would have a claim under HIPAA for that violation. >> JACQUIE: Right. And I think maybe you covered this, but I says are there rules like maybe under state law that require a private insurance company to provide health coverage for a child with severe disabilities covered under the parents' plan through their employer beyond the age of 18 or 24? This may have been sent before you covered that. >> BETH: Right. That would be the disabled child law that says if the child reaches a limiting age and is incapable of self-support because of a physical or mental condition, they should be allowed to keep the coverage. Now, District of Columbia, Oregon and Oklahoma do not have such a law. So if you live in one of those three places, you're out of luck. But if you live anywhere else, there are state laws that say that a child incapable of self-support is able to continue. >> JACQUIE: All right. That's all the questions we have. >> BETH: Okay. I think we're pretty much at the end of the slides. I'm not sure, Jacquie, if you want to -- if there is anything you think was very important that we didn't cover. If anyone else wants to send some questions -- >> JACQUIE: I think it went really well. I really appreciate it. >> BETH: Any other questions that people have -- I don't know if you want to wait a minute or two. >> JACQUIE: If there are questions that come in later I'll let the 31 listeners know if there are questions that come in after this, we'll get them answered. If we don't answer them from here, then we'll send them to Beth and I will forward comments that didn't include questions, I'll forward those to Beth as well. So thanks so much, Beth, for doing this today. >> BETH: You're welcome. And thanks everyone for listening and hopefully it was helpful. >> JACQUIE: It was. And for our listeners, please feel free to share the archives of today's presentation with your colleagues. They will be available tomorrow at ilru.org and please don't forget to complete the evaluation on the webcast page. We are very interested in receiving your feedback. I do want to remind our listeners about the national ADA symposium which is a three day conference on the Americans with Disabilities Act and related disabilities laws. And that conference has earned a reputation as the most comprehensive event available on the ADA. The symposium will be held May 12th through 14th in St. Louis and you can get more information at adasymposium.org. Thanks to the National Institute on Disability Rehabilitation and Research, our sponsor for today. The opinions and views expressed today are those of the presenters and no endorsement of the sponsoring agency should be inferred. And finally, this webcast would not be possible without the efforts of our webcast team: Rob Dickehuth for his technical expertise and our wonderful captioner today Marie Bryant. Please join us on April 30th when Marilyn Golden will join me for the last part in her ADA transportation series. Thanks again so much, Beth. Thanks for joining us today everybody. Have a dazzling day. 32 >> BETH: Thank you.