Marie, age 29, has cerebral palsy, a developmental disability that affects her ability to walk and to speak clearly. She also has a seizure disorder that requires specific, non-generic medication and close monitoring by her longtime neurologist. She uses a motorized wheelchair for mobility. Marie requires regular wheelchair maintenance and repair, and customized seating to prevent back pain. She was covered by her partner’s healthcare policy until recently. Marie is employed, but her employer does not provide health insurance. Now she has to acquire healthcare insurance on her own.
What are key issues for Marie in selecting healthcare insurance coverage?
- Is Marie eligible for Medicaid?
Possibly. It depends on several key factors. Marie may be eligible for Medicaid depending upon her annual income and whether or not her state is participating in the Medicaid expansion program. If her state is participating in the Medicaid expansion and her income is below about $15,282 per year, she will be eligible for the Medicaid expansion program and potentially the benefit package available in traditional Medicaid, which may be desirable for her if it is different from the Alternative Benefit Plan and covers more services and benefits that she needs. In order to be eligible for traditional Medicaid, her state must verify that she meets the definition of “medically frail.”
- Can she continue to see her regular neurologist who is familiar with her primary condition, cerebral palsy, and her physiatrist (a physician who specializes in rehabilitation medicine)?
Possibly. Marie needs help to determine if her preferred providers participate in Medicaid or the physician networks of either Medicaid or private health plans she is considering. The role of Navigators is to advise Marie that one important factor for her to consider when choosing a health plan is whether or not her preferred providers participate and to provide information that will help Marie answer this important question. For example, some of this information might be available on the Marketplace website. The Navigator also could suggest that Marie check directly with her providers or with the plans she is considering. If it is likely that she will be eligible for Medicaid, then Navigators could suggest that she contact her state Medicaid office directly to determine if her providers participate in that state’s Medicaid program.
- What should Maria do if her preferred providers do not participate in any of the physician networks of the plans available to her?
Navigators should help Marie determine if the types of specialty care she requires, such as physiatry, are available in any of the networks of providers who participate in the plans she is considering. If it has been determined that she is eligible for the Medicaid Alternative Benefit Plan, and potentially for traditional Medicaid if she meets the definition of “medically frail,” then she should determine if these specialists are available through either or both of these Medicaid options by directly contacting either her state Medicaid office or her providers, themselves.
- Is Marie’s seizure medication available either through the plans she is considering or Medicaid?
Possibly. Because Marie takes a specific, non-generic drug for her seizure disorder, she requires prescription drug coverage that includes this particular medication in the prescription formulary. She does not have the option of substituting other medications because she has tried them in the past and either they are ineffective or she has had an adverse reaction to them.
Navigators should help Marie understand how to evaluate each of the prescription formularies for the plans she is considering to determine if her preferred medication is included. If this information is not readily available on the Marketplace website, then she should contact the plans she is considering. If some plans cover her required prescription drug while others do not, she may want to consider the plan that does cover the medication, even if it is more costly, because her cumulative annual healthcare costs may be lower after taking the unsubsidized cost of her prescription drug into consideration. Similarly, if she is eligible for Medicaid, she should inquire with her state Medicaid office to determine if the medication is covered and if it is available through both the Medicaid Alternative Benefit Plan and, if applicable, through traditional Medicaid.
- Is Marie’s trusted durable medical equipment supplier, who has maintained her motorized wheelchair and provided her specialized seating, in any of the plans she is considering or in Medicaid?
Possibly. Due to the complexity of Marie’s disability, she visits an equipment supplier who specializes in providing high mobility and complex rehabilitation equipment (e.g., motorized wheelchairs, customized seating systems, adapted electronic wheelchair controls, etc.). There is only one such supplier in her geographic area. Navigators should help Marie determine if the plans she is considering contracts with the supplier she currently uses to service and maintain her motorized wheelchair and supply her customized seating. If this information is not available for the plans on the Marketplace website, then Maria should check directly with both the equipment supplier and the carrier selling the plans she is considering. If she is likely to be eligible for the Medicaid expansion program, and if applicable, traditional Medicaid due to a “medically frail” status, Navigators should encourage her to contact both the supplier and her state’s Medicaid office for this information. If she is eligible for the Medicaid expansion, then she should be encouraged to determine if the supplier is available through either the Alternative Benefit Program or the benefits package for traditional Medicaid, or both.
- Will any of the plans Marie is considering continue to pay for physical therapy on the ongoing, twice-monthly schedule she requires?
Possibly. Navigators should help Marie determine the number of rehabilitative and habilitative services (e.g. therapy visits) that are covered by the plans she is considering, and their various premium, deductible, and out-of-pocket costs. Each plan is required to have a summary of benefits and coverage (SBC) that may provide more detailed and accurate information than is available on the Marketplace website. Therefore, Marie should check for any important differences by contacting the carrier selling the plans she is considering. The Navigator should also assist Marie to evaluate the overall cost of her therapy visits by comparing premiums, deductibles, and therapy co-payments for the various plans she is considering.
- Will Marie be eligible for financial help to pay for her insurance premiums, if she purchases a private insurance plan?
That depends on Marie’s income. While Marie is employed, if her income is below about $45,960 annually, she may qualify for lower costs on health coverage. Navigators should assist Marie to determine her eligibility for subsidies.