3. Primary Insurance Limitations
Incontinence * Home modifications
supplies, specialized car seats * Vehicle modifications
Formula thickeners * Portable suction
Certain medications * C-pap
Respite * Transportation
Ongoing nursing services * Therapies
Bath chairs * Communication devices
Ramps * Adapted equipment
Walker/stander combos * Strollers
Jseats
Diapers
4. Resource Options
Title V
Hospital Financial Assistance
All Ohio Medicaid Programs
Waivers
Board of DD Services
Family Support Services
Social Security
State Plan Services
Nonprofits
Community Resources
Guardianship and Special Needs Trusts
5. Medicaid BCMH Waiver
Aide/Home Health/PDN Formula Respite/PDN services
Incontinence supplies
Did you know?....
Car seats Car seats
Certain Medications/Specialty Formula Thickeners Behavior management and assistance
pharm. with daily living skills (KY)
Braces/shoes 5-30 inpatient days/ER Summer camps
visits/Anesthesia
Deductibles/copays/ Certain Medications Bath chairs
coinsurance
Bath chairs Bath chairs Ramps
Wheelchair (manual/power) Wheelchair (manual/power) Wheelchair (manual/power)
Transportation Ramps J-seats
Formula Leg Braces Lifts/elevators
Communication Devices Glasses/contacts Specialized/adaptive
Equipment(bikes)
Portable suction Home Care Supplies Home/vehicle modifications
Special Needs Daycare Deductibles/copays/coinsurance Emergency Funds
Bi-pap/C-pap Therapies Specialized Stroller
Therapies Dental Services Specialized therapy
6. BCMH
Bureau for Children with Medical Handicaps
Ohio resident
Age (21 and under)
Needing to see a specialist to determine if they
have a handicapping condition
Family needs assistance w/ medical bills for
children w/ chronic conditions
Family has insurance, but out-of-pocket expense
is causing them to not seek treatment
Forms/Applications: http://www.odh.ohio.gov
7. Medicaid
Traditional Medicaid Programs Alternative Medicaid Programs
Covers children up to age 19 Medicaid Spend-down
Covers both insured and (Medicaid Disability)
uninsured depending on
where families income fall Institutionalized Medicaid
within the Federal Poverty Medicaid Waiver
Level Guidelines
9. OHIO HOME CARE WAIVER
* Must have skilled nursing need
* Patient must be financially eligible for Medicaid
* Must have an unstable condition
* Includes:
1. Medicaid
2. Private Duty Nursing
3. Home Modifications and Equipment
Allowance
10. TRANSITIONS WAIVER
The Transitions Waiver is a limited-enrollment, cost-capped
program of home and community services for people who
are eligible for Medicaid coverage in an intermediate care
facility for people with mental retardation or
developmental disabilities (ICF-MR). Only people who were
originally enrolled on the Ohio Home Care Waiver and have
an ICF-MR level of care are eligible for the Transitions
Waiver, and the Transitions Waiver has the same
services, providers, and method of operation as the Ohio
Home Care Waiver.
11. DD Services
Eligible individuals may qualify for a variety of specialized services
including educational programs, behavior supports, crisis
intervention, transition services, vocational skills, functional
skills, residential facilities, supported living in the
community, vocational training, employment and therapy
services.
Help Me Grow/Early Intervention
Service Facilitator
Family Support Services
Level I/IO Medicaid Waiver
Transitions Waiver
12. QUALIFYING FOR DD SERVICES
Ages 3 to 5 Years (Early Childhood)
Early childhood services are provided to children ages 3 to 5 if they have two developmental
delays or a risk of developmental delay due to medical or environmental risk. Some areas
offer preschool programs that are individualized to meet each child's needs and offer
assistance and support to families. Families should also contact their local school district to
see if their child is eligible for admission into the district's preschool program.
Ages 6 to 15 Years (Children)
Many children who received support before the age of 6 may not continue to qualify for
services. Additional criteria for eligibility must be met. A child must have a diagnosis of a life
long developmental disability. The diagnosis must be made by a qualified professional and a
report submitted verifying the diagnosis. A representative from the Board of Developmental
Disabilities will evaluate the child asking a series of questions from the Children's Ohio
Eligibility Determination Instrument (COEDI). In order to be eligible for services, the child
must show deficits in at least three of the six life skill areas considered:
Self-Care
Communication
Mobility
Learning
Self-Direction
Capacity for Independent Living
13. QUALIFYING FOR DD SERVICES
Ages 16 Years and Older (Adult)
The individual must have a diagnosis of a life long developmental disability
that began before the age of 22. The diagnosis must be made by a qualified
professional and a report submitted verifying the diagnosis. A
representative from will evaluate the individual asking a series of
questions from the Ohio Eligibility Determination Instrument (OEDI). In
order to be eligible for services, the individual must show deficits in at least
three of the seven life skill areas considered:
Self-Care
Communication
Mobility
Learning
Self-Direction
Capacity for Independent Living
Economic Self-Sufficiency
14. DD Waivers
Individual Option Level 1 Waiver
Waiver * The Level 1 Waiver offers
* Spending limit is different services with a
determined base on spending limit up to
individual assessed needs $5000
Approval = Medicaid Card
15. Supplemental Security Income
(SSI) Program
* It is designed to help aged, blind, and
disabled people, who have little or no
income; and
* Must qualify financially.
* Must be a U.S. citizen or national, or a certain category
of alien; and
* Must be a resident of one of the 50 States, District of
Columbia, or the northern Mariana Islands; and
* Is not absent from the country for a full calendar month
or more than 30 consecutive days; and
* It provides cash to meet basic needs for
food, clothing, and shelter.
16. CCHMC’s
Financial Assistance Program
* Discounts on medical bills for families
living in our primary service area
* Must be medically necessary
* Meet financial guidelines
* 100%-400% FPL
* Includes the underinsured population
17. Non-profits
Purpose: To assist with items that other programs or agencies do not
cover.
Types: Every nonprofit designates the funds for specific
groups, individuals, dx, or items.
Income Guidelines: Vary depending upon the non-profit
Applications: Some are on-line and some are by mail
Process: Non-profits take time. A FFA can provide you with access to
the applications based on family need. Family will need to provide the
documentation and submit.
18. Family Financial Advocates
* Help the underinsured/insured chronic care navigate the
Healthcare system.
* Help families apply for local, state, community and
federal programs to limit out-of-pocket and bad debt for
patients/hospital.
* Track applications & arrange interviews for programs
* Resolve billing/insurance issues
* Direct point of contact for all resource/billing needs for
the families we represent
* Advocate and partner.
19. Our process
Assessment of need
Past, present, future (short term/long term)
Initial phone call (2), intro letter, follow-up call, final letter-
contact referral source
One point of contact
Apply for identified resources
Clean-up any old issues
Track/Follow-up on resources
After acquisition-
Train/teach and apply it.
21. Take Away-Insurance Terms
* Balance Billing - A billing practice in which you are billed for the difference between what your
insurer pays and the fee that the provider normally charges.
* Coordination of Benefits (COB) - Provisions made to avoid duplication of payments if more than
one policy holder in the family has medical insurance. For purposes of filing claim
forms, generally, one individual is determined to be the primary insured, or the insured adult with
the earliest birthday in the year is the primary insured over all others in the family
* Coinsurance - A form of medical cost sharing in a health insurance plan that requires an insured
person to pay a stated percentage of medical expenses after the deductible amount, if any, was
paid.
* Copayment - A form of medical cost sharing in a health insurance plan that requires an insured
person to pay a fixed dollar amount when a medical service is received.
* Deductible - A fixed dollar amount during the benefit period - usually a year - that an insured
person pays before the insurer starts to make payments for covered medical services. Plans may
have both per individual and family deductibles.
22. Insurance Terms continued
* Exclusion - An exclusion is any condition, procedure or item that the insurance policy does not cover.
Group policies and individual policies typically have a list of conditions, types of equipment and situations
that are not covered for anyone insured.
* Explanation of Benefits (EOB) - The statement sent to a participant in a health plan listing
services, amounts paid by the plan and total amount billed to the patient.
* Pre-authorization - An insurance plan requirement in which you or your primary care physician must notify
your insurance company in advance about certain medical procedures (like outpatient surgery) in order for
those procedures to be considered a covered expense.
* Maximum plan dollar limit - The maximum amount payable by the insurer for covered expenses for the
insured and each covered dependent while covered under the health plan. Plans can have a yearly and/or a
lifetime maximum dollar limit.
* Maximum out-of-pocket expense - The maximum dollar amount a group member is required to pay out of
pocket during a year. Until this maximum is met, the plan and group member shares in the cost of covered
expenses. After the maximum is reached, the insurance carrier pays all covered expenses, often up to a
lifetime maximum.
Editor's Notes
Layering the resources /short and long term planning
