Health Care Reform and People with Special Needs

Health Care Reform in America

We've come across a terrific article that we are running in the next issue of the “Senior Sunshine Times. ” The following breaks down the new health care reform policy as it pertains to people with special needs, including seniors. The article and more information can be found at the Special Needs Answers website. Health Care Reform Offers Something Old, Something New for People With Special Needs Although it took more than a year of back and forth, a comprehensive health care reform bill and an associated reconciliation bill finally passed both houses of Congress and were signed into law by President Obama. People from both sides of the aisle have complaints about various portions of the legislation, but it is clear that the new law will have far-reaching consequences for people with special needs. Since the size of the law is staggering, we have highlighted some of the most important features of health care reform as it pertains to people with special needs. 

Solutions – Funds to Move People from Institutions into the Community 

The Community First Choice Program will offer states that develop community support programs for people with disabilities partial Medicaid reimbursement from the federal government. States that participate in the program would have to create specialized programs that specifically help people with special needs who require an institutional level of care move into the community. Most of the suggested programs will focus on providing in-home support and attendants. The program is funded for five years, but can be extended in the future if necessary.

Insurers Will Not Be Able to Refuse Coverage to People With Pre-Existing Conditions

One of the most talked-about provisions of the new law prevents health insurance companies from denying coverage to people with pre-existing medical conditions. People with special needs who do not receive comprehensive health insurance coverage through government programs or a relative's health insurance have routinely been denied private coverage because of their special needs. The new law prevents insurance companies from denying coverage based on these pre-existing conditions. This portion of the law will not apply to coverage for adults until 2014, but children with pre-existing conditions should be covered under the new law this year.

No Lifetime Limits on Coverage No matter the amount of care an insured receives, she will be able to keep her insurance coverage.

Children Can Remain on Parents Policies until Age 26

Parents will be able to keep children on their medical insurance until their children reach age 26, whether or not they are in school. Insurance policies differ considerably on coverage they provide the children of insured beneficiaries. Extension of Mental Health Parity The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 recently took effect for group insurance plans covering more than 50 people. This law requires plans that include coverage for mental illness to provide that coverage on an equal footing with coverage for other medical conditions. For instance, insurers are no longer allowed to charge higher co-pays for visits to mental health professionals than they would for visits to medical doctors. The health care reform law eventually extends mental health parity to all plans, regardless of the number of participants, and it goes one step further by including mental health care as “essential” care that plans are required to cover. CLASS Plan Allows Voluntary Purchase of Long-Term Care Insurance Despite the best efforts of insurance industry lobbyists to kill it, the new health care reform law includes the CLASS (Community Living Assistance Services and Supports) Plan, a program that allows individuals to purchase long-term care insurance from the government. Those who wish to participate would pay a modest premium (yet to be determined, although originally estimated to be $65 a month). After they had contributed for at least five years, participants would be eligible for a benefit that would vary depending on functional ability but that would average at least $50 a day. While the benefit would be modest compared to the average cost of nursing home care, it could be used instead to pay for a range of services that would help people stay in their homes. The CLASS program could be of greatest use for those people with special needs who do not require full-time nursing home care, but who will need additional in-home care as they get older. New Office Will Help Integrate Medicaid and Medicare Benefits A sizable number of people with special needs, known as “dual eligible” beneficiaries, receive both Medicaid and Medicare. As anyone with a dual eligible family member knows all too well, coordinating the various benefits offered by Medicaid and Medicare is next to impossible. What makes matters worse is that some provisions of Medicare law, especially prescription drug coverage, can directly contradict and cancel out better coverage offered by Medicaid. The health care reform law will create the Federal Coordinated Health Care Office to coordinate between the two programs and encourage the states to provide a higher level of care to dual eligible beneficiaries. Dramatic Expansion of Medicaid Current federal regulations require states participating in the Medicaid program to provide coverage for children in families living under the federal poverty level, and to extend coverage to their parents in certain situations. Although people who qualify for Supplemental Security Income (SSI) often obtain Medicaid benefits, for the most part adults who do not have severe disabilities and who do not have children have a hard time getting Medicaid. Under the health care reform law, states must offer Medicaid to all adults making less than 133 percent of the poverty level by 2014. This dramatic expansion of Medicaid could provide benefits to many people with special needs who do not otherwise qualify for the program because they are able to work, albeit in low-paying jobs. States that want to begin offering these benefits immediately can apply for federal funding of Medicaid expansion beginning this week. Higher Medicaid Payments to Doctors It can often be difficult to find doctors who accept Medicaid because of the program's low reimbursements, which average only 72 percent of rates paid by Medicare. In 2013 and 2014, Medicaid's reimbursements to doctors will rise to the same level as Medicare, making it more likely that a doctor will participate in the program. Additional Training For Workers Who Assist People With Disabilities and Funding for Research The new law also designates funds for the training of behavioral health workers who assist people with special needs. Funds are also set aside for private research institutes devoted to researching mental illness.

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