Juan, age 56, has recently become blind due to his Type I diabetes. He also has long standing depression. He takes medication for depression and also uses an insulin pump to maintain appropriate glucose levels. He is employed part-time, but his employer does not provide health insurance. He relies on County operated mental health clinics for limited mental and behavioral health counseling. He pays out-of-pocket for his prescription drugs. When he became blind, he received some “vision rehabilitation” services from a local nonprofit, but those services have ended even though he would continue to benefit from them.
What are key issues for Juan in selecting healthcare insurance coverage?
- Is Juan eligible for Medicaid?
Possibly. If Juan’s state is participating in the Medicaid expansion and his income is below about $15,282 per year, but too high for traditional Medicaid, he will be eligible for the Medicaid Alternative Benefit Plan. If he is eligible for the Alternative Benefit Plan, he will also have the option to enroll in traditional Medicaid because, as a person who is blind, he is a member of an exempt population with high medical needs. This is an option Juan should consider if traditional Medicaid offers a greater level of benefits he requires than those available through the Alternative Benefit Plan. Navigators should help Juan explore and understand these various options so he can make an informed choice.
- Is Juan eligible for lower costs on private health coverage?
Possibly. If Juan’s income is less than about $45,960 annually, he likely will be eligible for lower costs on his health insurance coverage. Navigators should assist Juan to evaluate his income eligibility for lower costs on private health coverage.
- Will healthcare insurance pay for vision rehabilitation services?
Possibly. The term “vision rehabilitation” includes a wide range of professional services that can restore functioning after vision loss, just as physical therapy restores function after a stroke or other injury. Historically, health insurance plans have not included vision rehabilitation as a covered benefit and for this reason it likely will not be included in the state’s benchmark plan, which guides benefits available through plans offered in the Marketplace. However, the ACA prohibits disability-based discrimination in healthcare coverage, so Juan could try requesting vision rehabilitation services under the Essential Health Benefit category of habilitation, rehabilitation and devices, even if all of the individual services he requires are not explicitly mentioned as a covered benefit by the plans he is considering. Navigators should also suggest that he contact his state’s Department of Rehabilitation and other community-based organizations serving people who are blind, which may be able to provide the services. (See Resources.)
- Will mental health services be available to Juan?
Yes. The Affordable Care Act includes mental health services as an Essential Health Benefit category that health plans must offer. These services include behavioral health treatment, such as psychotherapy and counseling. They also include mental health inpatient services and substance use disorder treatment. The specific mental health benefits available to Juan will depend on the state he lives in and the particular health plan he chooses. Navigators should help Juan understand and evaluate the overall cost of his healthcare if he chooses a plan with higher premiums because it offers access to more visits and/or the cost of co-payments for each visit is lower as compared with other plans. (See Scenario Two for more information on mental health coverage.)
