Transcript Health Care Self-Advocacy for People with Disabilities

Health Care Self-Advocacy
for People with Disabilities
Disability and Employment Rights
Advocacy
Spring 2008
Health Care Rights
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All people have a right to minimal health care
in California
People with health insurance have additional
rights
People with disabilities have some additional
access to health insurance others do not
have
Health care should be provided without
discrimination, but the rules in the health care
context are different
Access to minimal care in California
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The California Welfare and Institutions Code
requires every California county to provide minimal
health care to people with disabilities
Generally, this means that counties must pay for
medical treatment that is necessary to prevent death
or disability
Counties must also pay for health care that treats
communicable diseases like Tuberculosis
Care may be provided through hospitals, county
clinics or private providers through county medically
indigent programs
Why is access to minimal care important?
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People in need of emergency medical
attention cannot be refused treatment
Inability to pay is not a barrier to accessing
emergency medical care
Counties provide a health insurance program
that usually covers more than minimal care,
including care for chronic conditions
County medically indigent programs may be
the fastest way to get health insurance
coverage, even if it’s not the best coverage
Health Insurance
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Private Health Insurance
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Subject to underwriting rules – insurers can refuse
to issue a policy for a person who they deem to be
high risk
Cost regulated by the market
Provides 3 main benefits:
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Negotiated rates for care Full or partial payment for
care, services, prescriptions
Access to continued care
Types of Health Insurance
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Public Programs
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Require that you meet eligibility requirements
Usually there are income and resource/asset
limits
Not subject to underwriting – cannot refuse
coverage or care because of health condition or
disability
Provide extra “due process” protections
Major Public Programs
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Medicare
Medi-Cal
Healthy Families
County Medically Indigent Programs
Managed Risk Medical Insurance Program
(MRMIP)
Medicare
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Medical Insurance
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Eligibility
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A – Hospital
B – Out-patient & preventive
“C” – Medicare Advantage
D – Prescription Drugs
People 65 years old and older
People receiving Childhood Disability Benefits
People receiving Title II (SSDI) benefits for 25 months or
more
Covers medically necessary care within the scope of
covered benefits
Medi-Cal
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California’s Medicaid Program
Eligibility
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Coverage
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Links through other public programs
People with disabilities
People older than 65
People with specific health conditions
Medically necessary care within the scope of services
More broad than Medicare
Cost
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Can be free or with a share of cost (monthly deductible),
depending on income
Healthy Families
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Health insurance for families
Eligibility
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Cost
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Children that do not qualify for Medi-Cal, but are under 19
and cannot afford other health insurance
Families pay monthly premiums
Ordinary managed care costs like co-pays
Coverage – Broad
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Doctor’s visits, lab/xray, emergency care, DME, mental
health, skilled nursing, physical therapy, maternity care
Patient Tip
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If you have a managed care plan through
Medi-Cal or Healthy Families, you have 2
sets of protections
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Managed care rules
Medi-Cal/Health Families rules
Appeal Rights
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Rights with the Department of Managed Health
Care
Fair Hearing rights
County Medically Indigent Programs
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Eligibility
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Coverage for otherwise uninsured adults
Must meet income and asset limits
Coverage – services to protect “life and limb”
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Less than Medi-Cal
More than imminent death
Standard is whether or not a reasonable person
would believe it is an emergency
MRMIP
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What it is
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Subsidized health insurance for people who do
not qualify for Medi-Cal or Healthy Families and
who have been refused insurance policies from
private insurers because of medical conditions or
disability
Cost
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Premiums and other ordinary managed care
expenses
Patient Rights with Insurance Coverage
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Different laws apply depending on the type of
coverage
Private insurance and employer insurance
are governed by California law
Public programs each have their own
program rules
When you are denied a service or
treatment you need
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Insurer appeals processes
Independent Medical Reviews
Complaints/Grievances
Fair Hearing Requests (only with public
programs)
When your provider does not provide the
treatment you need
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Second Opinions
Medical or Dental Board complaints
When you are treated differently because of
your disability
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Civil Rights Complaints (applies to hospitals,
clinics, etc. that receive government funding)
When your privacy rights are violated
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Doctors can share information about your medical
conditions for purposes of treatment and billing
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Exceptions – psychotherapy notes, HIV/AIDS diagnosis,
substance abuse
Doctors and health plans cannot release health
information to your employer except in limited
situations
If you believe your doctor or health plan violated
your rights, you can make a complaint with:
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The insurance company’s privacy officer
Department of Health and Human Services’ Office of Civil
Rights
When you disagree with a statement in
your medical records
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You have a right to review your medical records
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Send a written request your doctor’s office to review
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Provider must respond within 30 days of request
You can be charged a reasonable amount for any copies
You have a right to amend to your medical records if
incomplete or incorrect
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Addendum can be up to 250 words per item
Provider must add to records within 60 days of receipt
Medical Debt
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Tips for avoiding medical debt
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Tell your doctor, hospital, or other provider about
all of the insurance coverage you have
Show your insurance cards to the provider
Make sure the treatment you receive is covered
by your health plan
Never use a credit card to pay a medical bill
If you already have medical debt
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Set up a payment plan
Apply debts to Medi-Cal share of cost
Resources for Help
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Private Insurance
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HMO Help Center – (888) 466-2219
Department of Insurance (PPOs) – (800) 927-4357
Health Consumer Alliance (www.healthconsumer.org)
Public Programs
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Legal Aid (www.lsc.gov to find the program serving your
area)
HMO Help Center - (888) 466-2219
Health Consumer Alliance (www.healthconsumer.org)
Fair Hearings
Sacramento County Department of
Human Services
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General Information and Referral Line
(916) 874-2072
Office Locations (not complete)
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2700 Fulton Avenue, Sacramento, CA
(916) 874-3800
1725 28th Street, Sacramento, CA
(916) 874-2072