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Health Care Self-Advocacy for People with Disabilities
Disability and Employment Rights Advocacy
Spring 2008
Health Care Rights
All people have a right to minimal health care in California
People with health insurance have additional rights
People with disabilities have some additional access to health insurance others do not have
Health care should be provided without discrimination, but the rules in the health care context are different
Access to minimal care in California The California Welfare and Institutions Code
requires every California county to provide minimal health care to people with disabilities
Generally, this means that counties must pay for medical treatment that is necessary to prevent death or disability
Counties must also pay for health care that treats communicable diseases like Tuberculosis
Care may be provided through hospitals, county clinics or private providers through county medically indigent programs
Why is access to minimal care important? People in need of emergency medical
attention cannot be refused treatment Inability to pay is not a barrier to accessing
emergency medical care Counties provide a health insurance program
that usually covers more than minimal care, including care for chronic conditions
County medically indigent programs may be the fastest way to get health insurance coverage, even if it’s not the best coverage
Health Insurance
Private Health Insurance Subject to underwriting rules – insurers can refuse
to issue a policy for a person who they deem to be high risk
Cost regulated by the market Provides 3 main benefits:
Negotiated rates for care Full or partial payment for care, services, prescriptions
Access to continued care
Types of Health Insurance
Public Programs Require that you meet eligibility requirements Usually there are income and resource/asset
limits Not subject to underwriting – cannot refuse
coverage or care because of health condition or disability
Provide extra “due process” protections
Major Public Programs
Medicare Medi-Cal Healthy Families County Medically Indigent Programs Managed Risk Medical Insurance Program
(MRMIP)
Medicare
Medical Insurance A – Hospital B – Out-patient & preventive “C” – Medicare Advantage D – Prescription Drugs
Eligibility People 65 years old and older People receiving Childhood Disability Benefits People receiving Title II (SSDI) benefits for 25 months or
more Covers medically necessary care within the scope of
covered benefits
Medi-Cal
California’s Medicaid Program Eligibility
Links through other public programs People with disabilities People older than 65 People with specific health conditions
Coverage Medically necessary care within the scope of services More broad than Medicare
Cost Can be free or with a share of cost (monthly deductible),
depending on income
Healthy Families
Health insurance for families Eligibility
Children that do not qualify for Medi-Cal, but are under 19 and cannot afford other health insurance
Cost Families pay monthly premiums Ordinary managed care costs like co-pays
Coverage – Broad Doctor’s visits, lab/xray, emergency care, DME, mental
health, skilled nursing, physical therapy, maternity care
Patient Tip
If you have a managed care plan through Medi-Cal or Healthy Families, you have 2 sets of protections Managed care rules Medi-Cal/Health Families rules
Appeal Rights Rights with the Department of Managed Health
Care Fair Hearing rights
County Medically Indigent Programs Eligibility
Coverage for otherwise uninsured adults Must meet income and asset limits
Coverage – services to protect “life and limb” Less than Medi-Cal More than imminent death Standard is whether or not a reasonable person
would believe it is an emergency
MRMIP
What it is Subsidized health insurance for people who do
not qualify for Medi-Cal or Healthy Families and who have been refused insurance policies from private insurers because of medical conditions or disability
Cost Premiums and other ordinary managed care
expenses
Patient Rights with Insurance Coverage Different laws apply depending on the type of
coverage Private insurance and employer insurance
are governed by California law Public programs each have their own
program rules
When you are denied a service or treatment you need Insurer appeals processes Independent Medical Reviews Complaints/Grievances Fair Hearing Requests (only with public
programs)
When your provider does not provide the treatment you need Second Opinions Medical or Dental Board complaints When you are treated differently because of
your disability Civil Rights Complaints (applies to hospitals,
clinics, etc. that receive government funding)
When your privacy rights are violated Doctors can share information about your medical
conditions for purposes of treatment and billing Exceptions – psychotherapy notes, HIV/AIDS diagnosis,
substance abuse Doctors and health plans cannot release health
information to your employer except in limited situations
If you believe your doctor or health plan violated your rights, you can make a complaint with: The insurance company’s privacy officer Department of Health and Human Services’ Office of Civil
Rights
When you disagree with a statement in your medical records You have a right to review your medical records
Send a written request your doctor’s office to review Provider must respond within 30 days of request
You can be charged a reasonable amount for any copies You have a right to amend to your medical records if
incomplete or incorrect Addendum can be up to 250 words per item Provider must add to records within 60 days of receipt
Medical Debt
Tips for avoiding medical debt Tell your doctor, hospital, or other provider about
all of the insurance coverage you have Show your insurance cards to the provider Make sure the treatment you receive is covered
by your health plan Never use a credit card to pay a medical bill
If you already have medical debt Set up a payment plan Apply debts to Medi-Cal share of cost
Resources for Help
Private Insurance HMO Help Center – (888) 466-2219 Department of Insurance (PPOs) – (800) 927-4357 Health Consumer Alliance (www.healthconsumer.org)
Public Programs Legal Aid (www.lsc.gov to find the program serving your
area) HMO Help Center - (888) 466-2219 Health Consumer Alliance (www.healthconsumer.org) Fair Hearings
Sacramento County Department of Human Services General Information and Referral Line
(916) 874-2072 Office Locations (not complete)
2700 Fulton Avenue, Sacramento, CA
(916) 874-3800 1725 28th Street, Sacramento, CA
(916) 874-2072