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