This fact sheet is intended to be a document that navigators can provide to people with disabilities to assist them in using their new insurance coverage consistent with the CMS “Coverage to Care” initiative.*
Q1. What is the HHS-CMS Coverage to Care Initiative?
The Department of Health and Human Services (HHS) and its Centers for Medicare and Medicaid Services (CMS) has launched an initiative – to help people with new health insurance coverage understand their benefits. This initiative is termed “From Coverage to Care.” This NDNRC fact sheet is intended to supplement the CMS initiative and materials with a focus on persons with disabilities. This is basically a guide for consumers once they have insurance. Navigators and assisters use the CMS “From Coverage to Care” materials; this fact sheet offers applicability to persons with disabilities.1
Q2. What is the Health Status of Persons with Disabilities?
“A growing body of research has found that people with disabilities experience lower health status and an excess burden of disease relative to the general US population.”2 The AAHD website and Centers for Disease Control and Prevention (CDC) National Center on Birth Defects and Developmental Disabilities (NCBDDD) website document numerous studies on the health status and disparities facing persons with disabilities.
Q3. What are Related National Disability Navigator Resource Collaborative Resources?
The National Disability Navigator Resource Collaborative (NDNRC) has fact sheets on particular services and supports typically required by persons with disabilities and recently has added fact sheets on different types of disabilities and the challenges faced by persons with such disabilities.
Q4. What Are the HHS-CMS Coverage to Care Steps?
The HHS/CMS “From Coverage to Care” initiative contains 8 steps. They are:
- Put your health first
- Understand your health coverage
- Know where to go for care
- Pick a provider
- Make an appointment
- Be prepared for your visit
- Decide if the provider is right for you
- Next steps after your appointment
Put Your Health First – Persons with Disabilities
Like all persons, each of us should determine our current health status. For persons with disabilities, are there special health needs related to your disability? What ongoing supports and services do you require to maintain good health and wellness, including the ability to live in the residence and community of your choice?
Understand Your Health Coverage – Persons with Disabilities
Health insurance plans will typically not provide the full array of specialized services and supports a person with disability requires to meet all of their health-related needs. To fully understand your health insurance, the costs it will cover, and what the consumer will have to pay, examine the benefits, premiums, and out-of-pocket obligations for all health care services it covers, especially the types of services the individual uses now. Persons with disabilities should know if their health plans cover special health care needs related to their disability (such as durable medical equipment, certain medications, habilitation services, or home health care), and what their out of pocket obligations are for any services related to their disability.
Know Where To Go for Care and Pick a Provider – Persons with Disabilities
People with existing disabilities, hopefully, already have existing relationships with healthcare providers who specialize in the unique health care needs related to their disability. If you have these relationships, determine if these providers are in the health insurance plan’s provider network. If you do not have these relationships, to the best of your ability with the assistance of navigators, assisters, and advocates, determine if the health insurance plan provider network includes specialists experienced in assisting persons with your particular disability.
Make an Appointment – Persons with Disabilities
All individuals should make an appointment with a primary care physician to assess the current status of their health. When making an appointment, use the telephone, and ask the physician about their experience in serving persons with your particular disability. Ideally, primary care physicians should fully communicate with and integrate their services and supports with specialty providers with expertise in your particular disability. When you make an appointment, explicitly request the physical and/or programmatic accommodations that you need.
Be Prepared for Your Visit – Persons with Disabilities
Ideally, you should bring with you records of all previous doctor, hospital, and other provider visits related to your health status, including any medications you previously took or are now taking. If you do not have these, you should bring the name and contact information of those providers you have previously seen, particularly those who have helped with your specific disability. You may need the assistance of your family and/or advocates to help you document your history.
Decide If The Provider Is Right For You – Persons with Disabilities
If you have difficulty communicating with and understanding the provider, you should seek another one. If the provider does not understand your disability and the life situation you face because of your disability, you should seek another provider. You may need the assistance of your family and/or advocates to help you change providers.
Next Steps After Your Appointment – Persons with Disabilities
If you agree with the services and support plan that you and your provider developed together, you should attempt to fully implement the services and support plan. Be sure to document any problems you experience implementing the services and support plan. If you disagree with the services and support plan and the provider does not modify it to meet your concerns and objectives, you should seek another provider. You may need the assistance of your family and/or advocates to help you change providers.
Important issues on how to get the most out of your Medicare/Medicaid/ACA health plan are “continuity of care” (keeping the existing providers and integrating and coordinating their services and supports) and the previously discussed “provider network adequacy.”
If you have an existing relationship with a provider who is not a member of your new health plan’s network, the health plan may permit the enrollee to continue an ongoing course of treatment by the non-participating provider during a transitional period of up to sixty days from the effective date of enrollment if the enrollee has a life-threatening disease or condition or a degenerative and disabling disease or condition. The non-participating provider must agree to accept the health plan’s payment rates and adhere to the plan’s policies and procedures.
Plans must provide accurate information about providers, timely access to care, adequate numbers of providers, adequate types of providers, inclusion of Essential Community Providers adequate geographic distribution of providers, access to out-of-state providers, accessible hours, language-accessible and culturally-competent care, and the right to go out of network when no plan provider is available to provide medically necessary services.
NDNRC fact sheets and Disability Guide address these important issues facing persons with disabilities. The NDNRC population-specific fact sheets attempt to provide examples of questions that persons with disabilities should ask of any health plan.
- We have not examined the accessibility of the CMS videos and materials related to each of the steps in the CMS initiative. During the coming weeks we hope to examine the accessibility and formats of all of the resources associated with this CMS initiative.
- Rowland, et al, “Health Outcome Disparities Among Subgroups of People with Disabilities: A Scoping Review.” In: Disability and Health Journal. April 2014, pages 136-150
* Written for New York by Center for Independence of the Disabled, NY