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Insurance Information for Adult Congential Heart Patients

Insurance Information for Adult Congential Heart Patients

What is health insurance?

Health insurance covers medical expenses for illnesses, injuries and conditions. Not all insurance plans will be accepted everywhere.

How does health insurance work?

Let’s say you develop a serious illness, need surgery and spend several days in the hospital. The costs of your covered medical expenses add up to $50,000. Without health insurance, you would be responsible for paying all $50,000. But with insurance, your financial responsibility is much smaller.

For this example, we’ll say these are the terms of your health insurance:

  • Your deductible is $5,000.
  • Your co-insurance is 20 percent.
  • Your maximum out-of-pocket is $7,000.
  • In this case, you are responsible for the first $5,000 in charges. This is your deductible. After you’ve paid your deductible, there are $45,000 of expenses left. You are responsible for 20 percent co-insurance — that is 20 percent of the remaining cost, or $9,000. This is more than your maximum out-of-pocket of $7,000. So you pay $5,000 toward the deductible and only $2,000 of the co-insurance. Your insurance plan pays the rest of the covered expenses.
    Here’s how it breaks down:
    • Your payments come to $7,000.
    • Your health insurance pays $43,000.
    • In addition, since you’ve reached your maximum out-of-pocket limit for the year, you won’t have to pay anything for the rest of the year for covered medical expenses.

Key terms

Deductible: The amount you’re responsible for paying for covered medical expenses before your health insurance plan begins to pay for covered medical expenses each year.

Co-insurance: Shared costs between you and the health insurance plan. For example, you pay 20 percent and your plan pays 80 percent.

Co-payment: The payment you make each time you visit the doctor or fill a prescription medication. This is usually a fixed-dollar amount.

Out-of-Pocket Maximum: The most you will have to pay for covered medical expenses in a plan year through deductible and co-insurance before your plan begins to pay 100 percent of your covered medical expenses.

Preauthorization: A decision by your health insurer or plan that a healthcare service, treatment plan, prescription drug or medical equipment is medically necessary.

Types of insurance

Private health insurance

This is usually offered through employers or other organizations. It can also can be bought on your own, but that costs more.

  • Some insurance plans work with certain healthcare providers and facilities, which are part of the plan’s network, to provide care at lower costs. This is called managed care. There are different kinds of managed care plans:
    • Health Maintenance Organizations (HMOs): These plans usually pay only for medical care within their network of healthcare providers. HMOs generally cost less than plans that offer a greater choice of providers.
    • Preferred Provider Organizations (PPOs): These plans cover more of your medical costs if you get care within the network of care providers. But they still pay some costs for care outside the network.
    • Point of service: You can choose between an HMO or a PPO each time you get medical care. These plans offer more flexibility in choosing doctors and hospitals.
  • Indemnity (fee-for-service) plans are different from managed care plans. The choice of doctors or hospitals you can use for your care is not restricted. Your healthcare provider is paid a fee each time you get medical care covered by the plan. The costs you have to pay on your own (out-of-pocket) could be higher than they are with some managed care plans.

Public insurance (government)

Medicaid

  • Medicaid is a state-run, government insurance program that helps some people with lower incomes pay for medical care. Medicaid pays your healthcare provider. You may have to pay a small amount for certain medical care.
  • Medicaid is available only to certain low-income people and families who are eligible. Rules about who is eligible and what services are covered vary from state to state. Learn more at cms.gov.

Medicare

  • Medicare is health insurance provided by the government for people age 65 or older. People who have certain disabilities or health problems, such as long-term (chronic) kidney failure treated with dialysis or a transplant, also may get insurance through Medicare. It covers some, but not all, medical costs for people who qualify.

Obtaining insurance as a congenital heart disease patient

If you are on your parents’ insurance, you will no longer be eligible to be on their plan once you turn 26. If you need health insurance, see if you are eligible to obtain insurance through:

  • Your employer
  • The Marketplace at healthcare.gov
  • Medicaid

If you lose your job-based insurance, you can consider the following options:

  • Buy a plan through the Marketplace at healthcare.gov
  • Sign up for COBRA coverage through your employer
  • See if you are eligible for Medicaid or the Children’s Health Insurance Program (CHIP)

Medicaid

Medicaid is a government program that provides health coverage to qualified low-income individuals, including families and children, pregnant women, the elderly, and people with disabilities. In some states, the program is available to all adults below a certain income level.

You could lose Medicaid if you:

  • earn too much
  • are no longer pregnant
  • are no longer under a certain age
  • inherit, win or are given assets that change your financial status
  • fail to report a household change like getting married or adopting/having a child

If you lose Medicaid, check to see if you are eligible for Social Security disability benefits or Supplemental Social Security Income (SSI).

Social Security

Disability benefits

Social Security pays benefits to people who can’t work because they have a medical condition that’s expected to last at least one year or result in death. Federal law requires this very strict definition of disability. While some programs give money to people with partial disability or short-term disability, Social Security does not.

In general, to get disability benefits, you must meet two different earnings tests:

  • A recent work test, based on your age at the time you became disabled
  • A duration of work test to show that you worked long enough under Social Security

Applying for disability benefits

You should apply for disability benefits as soon as you become disabled. Processing an application for disability benefits can take three to five months.

For more information on how to apply for disability benefits, visit socialsecurity.gov or call 1-800-722-1213.

Supplemental Social Security Income (SSI)

SSI is a program that Social Security administers that pays monthly benefits to people with limited income and resources who are disabled, blind or age 65 or older.

How is SSI different from Social Security benefits?

  • Social Security benefits may be paid to you if you are “insured,” meaning you worked long enough and paid Social Security taxes. Unlike Social Security benefits, SSI benefits are not based on your prior earnings.
  • In most states, SSI beneficiaries can also get Medicaid to pay for hospital stays, doctor bills, prescription drugs and other health costs.
  • SSI beneficiaries may also be eligible for food assistance in every state except California.
  • To get SSI, you must:
    • be disabled, blind or at least 65 years old;
    • have “limited” income and resources;
    • be a legal resident of the United States;
    • not be absent from the country for a full calendar month or more or for 30 consecutive days or more; and
    • be either a U.S. citizen or national, or in one of certain categories of qualified noncitizens .

How is SSI similar to Social Security benefits?

  • Both pay monthly benefits
  • The medical standards for disability are generally the same in both programs for individuals age 18 or older

Compassionate Allowances Initiative

The Social Security Administration’s (SSA) Compassionate Allowances (CAL) initiative speeds up the processing of disability claims for patients with certain severe medical conditions.

The following CHD diagnoses automatically quality for disability under the CAL initiative:

  • Aortic atresia
  • Eisenmenger syndrome
  • Hypoplastic left heart syndrome
  • Mitral valve atresia
  • Pulmonary atresia
  • Single ventricle
  • Tricuspid atresia

Applying for disability through the CAL initiative
If you have a CAL condition, you can apply for disability benefits using the standard SSDI/SSI application process. The SSA will fast-track your application and, in most cases, will let you know the status of your application in just a few weeks. If the SSA needs more information to make a decision about your claim, the process may take longer.

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