Alexa, age 57, has heart disease, diabetes, obesity, and a limb amputation. She is developing diabetes-related vision problems that are progressing rapidly. She also walks using a below-knee prosthetic limb, which is fitting poorly due to its age. The ill-fitting prosthetic limb is causing her skin to break down where it makes contact with her residual limb. She has an expensive individual health plan, but recently reduced the number of hours she is working and can no longer afford the plan.
What are key issues for Alexa in selecting healthcare insurance coverage?
- Is Alexa eligible for Medicaid?
Possibly. It would depend on her income and whether or not she lives in a state that is participating in the Medicaid expansion program.
- If Alexa meets the eligibility requirements for Medicaid and her state is participating in the Medicaid expansion, would she meet the definition of “medically frail,” which would give her the option of selecting traditional Medicaid if it affords better benefits than those provided in the Alternative Benefit Program?
Possibly. HHS has provided guidelines on who will qualify as “medically frail” and therefore will be eligible to select the traditional state Medicaid benefits package. Each state expanding Medicaid will get to establish specific guidance on the issue that may place additional conditions on who can qualify as “medically frail.” Moreover, states are required by federal regulation to develop a screening tool or process to identify “medically frail” individuals within the expansion population who should get the option to enroll in traditional Medicaid. Because Alexa has multiple medical conditions including a leg amputation that causes limitations in activities including walking, she might meet the definition for being “medically frail.” Navigators should first assist Alexa in determining if she is eligible for the Medicaid expansion, and if she is, advise her that if she is eligible for traditional Medicaid by virtue of being determined to be “medically frail,” the benefits available to her may be different than those available under the Alternative Benefit Program. Navigators should assist Alexa to complete the required paperwork and inform her of the possible options available.
- Is Alexa eligible for subsidized health insurance from the Marketplace?
Probably. If her annual income is less than around $45,960, she may be eligible for insurance coverage at a lower cost.
- Will Alexa have access to prosthetics suppliers?
Almost certainly, yes. Prosthetic services are available from insurance plans being offered through the Marketplace. Prosthetics are included within the category of habilitative and rehabilitative services and devices, one of the ten Essential Health Benefit categories required by the ACA. However, the number of suppliers providing prosthetics may vary from plan to plan and Alexa’s preferred supplier may not be under contract with any of the plans she is considering. Also, almost every state includes coverage of prosthetics in the Medicaid program. Before the ACA was enacted, a number of states had existing laws covering Orthotics and Prosthetics, and in those states the mandate would already most likely already have been included within the plan that the state chose as its Exchange or Alternative Benefit Plan benchmark.
