From Abled to Labeled

"While life may not be perfect, it’s still life and it's still to be enjoyed in anyway possible."

http://tinyurl.com/yllttym.

Into the Impossible...

“The limits of the possible can only be defined by going beyond them into the impossible.” Arthur C. Clarke

Civil Wrongs

There's always something....

The other day Keith was wondering what he would write about in his blog this week. Fortunately, when you see the world from a different perspective, there's always something.

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Second-Class Citizen Blues

by Keith Hogan

Yesterday, I went to a meeting with the insurance salesman to discuss managed Medicare products. My attorney, who is very well regarded for his disability law knowledge, recommended him to me. Unfortunately, the insurance salesman’s office was located in a historical building that was completely inaccessible to me. I could not even use a ramp or an elevator in the back of the building because there wasn’t one. I realize that this was a building of historic significance, but it was disheartening to find that it maintained the historical disregard for people with disabilities.

Please continue reading at http://civilwrongs.wordpress.com/2009/11/18/second-class-blues/

Humana: Our 800 Pound Gorrilla in the Oxygen War of 2009

A couple of weeks ago we were contacted by Humana to discuss Keith's oxygen situation. Specifically they were concerned that the home healthcare provider was requesting reimbursement from Humana/Medicare while still taking cash from Keith for his oxygen delivery. Additionally, as a Humana member, Keith has a cap of $6.25 per delivery as opposed to the ~$200 per delivery that the home healthcare provider was collecting. I informed Humana that we had been in contact with Rep Lloyd Doggett's office [D-TX] about this situation and that it was being investigated at the federal level. At the very least, the home healthcare provider is clearly violating federal law regarding oxygen delivery as detailed in the Patients & Providers Act of 2008.

The work to bring this to the attention of the right people has been exhausting. The amount of energy necessary to find people who care has been appalling. For me, insuring that Keith has the oxygen he needs to continue healing is of paramount importance and that has been the primary motivation to move forward. However, I am also driven by the unknown others who are being affected by this home healthcare provider's policies in this region. To top it all off, it sickens me to see the recent advertisements by this company expressing their commitment to their clients when I know our experience on the local level has been quite different. And, we are not alone. There are many oxygen dependent clients who are experiencing similar issues. I'm hopeful that with Humana on our side that we can not only sort out Keith's O2, but improve the options for others as well.

The Cost of Failure to Enact Health Reform

The Robert Wood Johnson Foundation and the Urban Institute have released a study that the groups say underscores the financial necessity of reform.

The report breaks out the coverage and cost estimates for each state. Below is a snapshot of Texas' data. You can see it in larger, clearer detail on page 57. If you live elsewhere, the state projections begin alphabetically on page 14.

Researchers from the Urban Institute used their Health Insurance Policy Simulation Model to estimate how coverage and cost trends would change between now and 2019 if the health system is not reformed. The report shows that under the worst-case scenario, within 10 years:

• The number of people without insurance would increase by more than 30 percent in 29 states.
  In every state, the number of uninsured would increase by at least 10 percent.
• Businesses would see their premiums increase—more than doubling in 27 states.
  Even in the best case scenario, employers in 46 states would see premiums increase by more than 60 percent.
• Every state would see a smaller share of its population getting health care through their job.
  Half of the states would see the number of people with ESI fall by more than 10 percent.
• Every state would see spending for Medicaid/Children's Health Insurance Program (CHIP) rise by more than 75 percent.
• The amount of uncompensated care in the health system would more than double in 45 states

Read the full report HERE.

Physical Disability v. Fiscal Disability

We received the following explanation of earning limits from our very smart, experienced lawyer who has a particular talent for simplifying & communicating the rules guiding participation in Medicaid programs. Keith & I are pretty astute and have had a reasonable amount of experience decoding legalese. We've had to read it a few times and I think the next step is drawing a diagram, LOL.

Start practicing your decoding now, it only gets more complicated!

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I'm glad you asked. Here are responses as to the short-term and long-term questions:

1. Short-term: To prepare an answer, I constructed the attached spreadsheet for calculating how much income you can have under Buy-In. That in turn led me to review the new HHSC Buy-In rules, and I found that the $2,167 limit applies only to earned income. There is no limit on unearned income (such as SSDI income). That is because under the old rules, all but $674 per month of unearned income had to be paid as a premium for Buy-In coverage. The new rules cap the premium at $500 per month, but they still don't include unearned income in the income cap (250% of poverty level) on countable earned income. And the first $65 of earned income plus one-half the rest doesn't count. Therefore, bottom line, you can have a maximum of $4,399 of actual earned income (only $2,167 of which is countable), and you can have unlimited unearned income (of which you will have to pay $500 as a premium).

That puts Buy-In back in the running as a possibility, but I'm still strongly recommending you look first at StarPlus to see what level of benefits it offers. You can get into Buy-In at any time later as your earned income develops. We do still have the problem under StarPlus that any income over $2,022 per month (after deduction of medical premiums) has to be paid as a copayment; and that program counts all earned income (no deduction of $65 plus one-half the rest).

2. Long-term: Your more general question motivated me to research a Buy-In issue that has puzzled me: what does it really mean that to qualify for Buy-In you have to have a disability as defined by SSA, "except the requirement that the person be unable to engage in any substantial gainful activity does not apply."? Here is the answer I've come up with, somewhat tentatively (excerpted from my summary of Buy-In, attached):

Under the Social Security Disability rules, a person with actual gross earned income exceeding $980 per month is (with some exceptions) presumed not disabled. The above-quoted rule removes that presumption. Where does that leave us? The answer would appear to require reference to the Social Security Administration's disability determination rules, which state that person who is not currently engaging in "substantial gainful activity" as defined in the rules may or may not meet the disability definition. If not, the next inquiry is whether the person's impairments are "severe." If so, they ask whether the person has an impairment that meets or equals the definition of a "listed impairment." If the answer to that question is also "Yes," then the person meets the definition of "disabled." This may resolve the apparent paradox that one can be engaging in substantial gainful activity (making over $980 per month) as defined by the Social Security Disability rules, yet still meet the "disability" requirement of Medicaid Buy-In. Notice that an individual in this category is likely to lose the Social Security Disability benefit and, after 24 months, the Medicare benefit. However, they can still have full medical coverage under Medicaid (for a very low premium if they have no unearned income) and $4,399 per month earned income. (Footnote: The basic rule on the 5-step process is at 20 C.F.R. §404.1505. It is broken down more specifically at POMS DI 22001.001 et seq. See especially the chart at DI 22001.035. The author does not practice in the area of disability determination, and these complex rules can be difficult to apply. Therefore, it is particularly important that the planning decision in such a case be based on advice from a specialist in this practice.)

The C.F.R. and POMS provisions cited in the footnote are attached.

Bottom line, it appears you can keep Medicaid Buy-In as long as your earned income is below $4,399 per month, because your condition is clearly severe and I'm sure you have listed impairments.

Whether you can also keep SSDI income at that level of earned income is another question. If you look just at the 5-step sequential evaluation chart, it would seem not, because you would be engaging in substantial gainful activity the chart says you should be denied at the first step. However, see the attached excerpt from a treatise on disability determinations for some important conditions and exceptions. Most importantly, "impairment-related work expenses" are deducted from earned income for the purpose of determining whether you have $980 per month earned income; and there are lots of other deductions, trial work period rules, etc. From a quick reading of it, because substantial gainful activity is an exception to the rule that you keep the disability benefit as long as your impairment continues at the same level, I think that (after a trial work period) you would lose the SSDI and (after 24 months) Medicare if you had earned income on a sustained basis over $980 per month (after deductions for IRWE, etc.). However, that still leaves you with up to $4,399 per month earned income AFTER those deductions. For example, if attendant care and other IRWE costs $5000 per month, you can have up to $9,399 per month earned income.

In summary, I've found that Buy-In eligibility won't be affected by your SSDI income, and you can have up to $4,399 per month earned income while still qualifying for it. StarPlus is much more restrictive on income, essentially requiring (at your income level) that any earned income be paid as a copayment (but not counting Ruth's income or assets at all). Long-term, you can have acute-care benefits plus limited home care under Buy-In if you have as much as $4,399 per month earned income, AFTER deduction of whatever attendant care, etc. you can deduct as income-related work expenses (probably several thousand dollars per month).

A Letter from Rep Lloyd Doggett [D-TX]

Dear Ruth:

You have probably heard about the organized group that disrupted my recent neighborhood office hours in South Austin. They came not so much to be heard as to deny others the right to be heard. And this appears to be part of a coordinated, nationwide effort.

While much has been reported about their protest, little has been explained about their broader agenda. During their protest, they made clear that they were not just determined to halt new health care reform, but also seek to end Social Security and Medicare. Now one of the organizers of this disruption has articulated her vision that we should rely exclusively on private education. Click here to read her own words as it appeared in the Statesman recently.

In visiting at local gatherings of teachers preparing for the new school year, I remain hopeful about public education-all that it can do to bind our community together and prepare our youth for tomorrow. I reject the extreme notion that public education or public health care deserve no place in our country.

As we return for a vote in September, I am more committed than ever to winning approval of legislation to offer more individual choice to access affordable health care. Too many of our neighbors go uninsured or underinsured; too many, after years of paying premiums, find themselves with inadequate coverage once they become ill, and too many are denied coverage because of pre-existing conditions. Attached is a recent article that I wrote explaining why I believe that the legislation on which I have been working in the House Ways and Means Health Subcommittee represents an important step forward in addressing these concerns. I will be speaking at a major public gathering in support of health reform at 3 p.m. on Saturday, August 29 at First United Methodist Church, 1201 Lavaca in Austin.

As always, I welcome your advice on these and other federal issues.

Affordable Health Care Indispensable to Healthy Economy
U.S. Rep. Lloyd Doggett (D), Senior Member of the House Ways and Means Health Subcommittee

I have been seeking a meaningful answer to the many shortcomings American families encounter with health care. Our House proposal has now won endorsement from the American Medical Association, AARP, and Consumers Union. But during recent Central Texas meetings, I have heard from some neighbors with legitimate concerns about the complexities of our approach, others who suffer from a steady diet of cable television misinformation, and a few who are just against anything that President Obama favors. Here is how this imperfect bill affects you.

Health care peace of mind --If you are among the 1 in 4 of our neighbors with no health insurance, the 24,000 additional Texans who lose coverage each month, or the many who have insurance with more exceptions than coverage, you will finally be able to get affordable health care through a new Health Insurance Exchange. An estimated 96% of the coverage available through this new marketplace will be from private insurance carriers subject to new national standards and no longer able to decline those with preexisting conditions. One alternative available through the Exchange is a public plan similar to Medicare but subject to the same standards as the private carriers. Like Medicare, the government would not own health care facilities or employ physicians. You can keep the same doctor, and health decisions will continue to be between you and your doctor.

Competition cuts costs -- Budget analysts project that in a decade only 4% of Americans under age 65 will choose this public plan option. What some shamelessly call a "government takeover," is in truth this very modest reform. The public option expands individual choice and spurs real competition among private insurers instead of just pouring billions more into the existing system that is failing too many while doing little to control costs. Opponents, who always insist that government cannot do anything well, now claim that a little public competition threatens these private insurance giants.

Ending coverage games --Even if you already have satisfactory coverage, perhaps through a large private or public employer, you gain much from this initiative. Insurers are prohibited from refusing to renew coverage, charging wildly different premiums to different people for the same coverage, using policy fine print to deny needed coverage, or shifting to you the cost of catastrophic illnesses. And insurers have less justification for substantially increasing premium and copays, while cutting benefits. As President Obama said, "Reform is about every American who has ever feared that they may lose their coverage." No longer will losing insurance prevent your seeking a better job or starting a new business.

If you rely on Medicare, you will get better access to preventive services and medications, including gradual closing of the "donut hole" gap in drug coverage. Increased payments to physicians means more will accept new Medicare patients.

To those fearing the "rationing" of health care, look more closely at existing rationing. In 2006, 22,000 Americans died because they lacked health insurance-that's real rationing. This bill ends rationing that already occurs every day.

Small businesses win -- With skyrocketing costs, limited bargaining power, and routine discrimination, many small businesses are struggling to maintain decent coverage, paying 18% more per employee than other employers. This bill ends coverage games for small businesses just as it does for individuals. For many small businesses, the new Health Insurance Exchange will offer lower cost, higher quality coverage. Eligible businesses will get rates and a wider choice of plans, currently available only to large employers. For most small business owners concerned that they will be penalized for not providing insurance that they cannot afford, there are tax credits to assist many with as much as 50% of the cost and a complete exemption for the smallest with an annual payroll below $250,000. And I want to do even more.

Keeping the price affordable -- If you are a taxpayer concerned about costs, covering the many uninsured does initially add about 4% to the cost of the current health care system. But rather than incurring more public debt, we pay for this -with about half coming from savings through improved health care delivery and most of the rest from a surcharge on those with incomes over $350,000. A family with $500,000 in income would pay an extra $1,500 a year. Other revenues are gained by closing some tax shelters and international tax avoidance schemes that I have fought for years. Additionally, this bill transitions us from a sickness system to a wellness system, which will save costs as people access the preventive care and other services they need on the front end rather than seeking more expensive care after becoming really sick.

If we can get a better handle on health care costs, which have consistently spiraled faster than inflation, families can devote less income to health care, employers can give raises rather than just pay higher premiums, and we can ensure Medicare's long-term sustainability.

I do agree that this bill is no panacea. It is not what I would have written by myself. During the legislative process, it will be changed, hopefully, to do even more to contain costs. But it can lead us to a victory for healthy families, a healthy economy, and a healthy America. Let's keep at improving it until we get this important job accomplished.

Sincerely,
Lloyd Doggett