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Navigating the Benefits Maze & Exercising Your Rights


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Navigating the Benefits Maze & Exercising Your Rights

  1. 1. “Navigating the Benefits Maze & Exercising Your Rights” Presented by: Todd Rundle
  2. 2. Session Objectives 1. Learn what health care and other service options are available 2. Discuss your right to appeal and procedures 3. Provide future contact resources
  3. 3. Path’s of Transition  Community Living  School  Work  Health Care  Adult Independent Living
  4. 4. Health Care Transition What is available? Who can help? What are my rights?
  5. 5. Medicaid Medicaid is the typical health care transition from adolescent to adult care. Things to consider: • Transition Planning • Change of Health Care Provider • Guardianship • Medical Power of Attorney/Conservatorship
  6. 6. CHIP Program The West Virginia Children's Health Insurance Program (WV CHIP) provides quality health insurance to eligible children and strives to develop a health care system in which all West Virginia children can access health care coverage. WV CHIP is a free or low-cost health plan for children from birth up to age 19. Covered services include preventive care, such as well-child visits and immunizations, prescriptions, hospital visits, dental, vision, and mental health services.
  7. 7. SSI Social Security Income SSI is supplemental income to help aged and disabled individuals. SSI eligible participants are automatically eligible for Medicaid.
  8. 8. SSDI SSDI is supplemental disability insurance and financial income. Medicare coverage is provided after a waiting period of 24 months. Children are eligible if: 1. The disability occurred before the age of 22. 2. The parent worked long enough to be insured and is receiving the benefit.
  9. 9. Title XIX Waiver  24 hour services and supports  Medical coverage  Behavioral and psychological services Eligibility:  Diagnosis of MR/DD prior to the age 22  Substantial functional limitations in three or more major life activities  Require a level of care defined in an Intermediate Care Facility
  10. 10. Currently on Waiver Points to ponder during transition  Community access  Transportation  Vocational  Money management  DRS/ job coach  Medical transition visits
  11. 11. Private Insurance  Various Types  Various Plans  Review and research policies at annual enrollment  Determine needs of family and child and what type coverage is most beneficial
  12. 12. New Health Care Act Patient and Affordable Care Act  Coverage to age 27  No gap on pre-existing conditions  Child not required to be in school  Young adults can work and remain on parent’s health insurance  Child does not need to be a dependent  Eliminates life time payment caps
  13. 13. Ron Yost Personal Assistance Program  Enacted by the West Virginia Legislature  Enables people with severe disabilities to live at home  Provides financial resources for hiring personal care assistants  Must have a severe disability that affects one or more major life activities
  14. 14. West Virginia Children with Special Health Care Needs(CSHCN)  Provides Medical Treatment and Specialty Clinics to the age of 21  Care Coordination  Transition Services  Applicants must have a medical diagnosis listed in Appendix B of the Covered Medical Conditions by Category section of CSHCN Manual For more information visit
  15. 15. TRICARE TRICARE is health care coverage for both active and retired military members and families. Low annual enrollment fees exist for retired members $0 enrollment fees and co-pays at military treatment facilities Several plans available visit
  16. 16. Important • Transition begins at age 14 • Allow ample time to eliminate barriers • Exercise your rights • Educate your child’s adult health care provider (needs, history, medication, diagnosis,etc)
  17. 17. Exercising Your Rights Let’s Review the Process
  18. 18. Maintain your Cool Avoid showing frustration Be professional and stay calm Avoid the EGO issues (anger leads to problems) Tape your meetings
  19. 19. How can you make these things happen?  Attend your meetings/appointments and speak your mind  Take a friend or relative with you to assist you when needed  Stand up for your rights  Have your decisions written on your treatment plan  Put in writing any disagreements you have  Ask your doctor to explain health options
  20. 20. Be Knowledgeable 1. Know your facts before any meeting or writing any letters 2. Research your issue (any search tool on the Internet will assist you in this process) 3. Know your rights related to the issue in hand 4. Investigate what laws and policies exist that will help resolve your issue 5. EXAMPLES: Medicaid, private insurance, CSHCN, CHIP, Medicare, Waiver, HIPPA
  21. 21. Know who the Responsible Primary Payee or Agency is: 1. Department of Rehabilitation 2. School District 3. Medicaid 4. Medicare 5. Private Insurance
  22. 22. How to Appeal a Denial of Services 1. Be sure to file your appeal in a timely manner, (IN WRITING) shortly after receiving the denial 2. Request a copy of the appeals process from the denying agency 3. Request contact information and the responsible person and agency to whom to file your appeal 4. Send your appeal by certified mail
  23. 23. What information should be included in an appeal  Identify the agency responsible for providing the service/device/treatment  List the reason for denial  Document the problem and specific need for the service/device  Provide the law and regulation that entitles the individual to said device/service
  24. 24. What information should be included in an appeal  Name of the individual denied  Document the individuals disability and specify why the need is medically necessary. Include statements that will demonstrate how the service or device will enhance independence and care  Request assistance or options available to resolve the issue  Request a remedy and appeal response deadline EXAMPLE: please provide a written response by__
  26. 26. Family to Family Health Information Center  Located at the Center for Excellence in Disabilities (CED) at West Virginia University  Federally funded through Health Resources and Services Administration (HRSA). WVU CED has an active role under the PI of this grant WVPTI  Provides professional and family development, technical assistance, health care information and training
  27. 27. Primary Goal To ensure that children with disabilities have access to health care and health care service.
  28. 28. Project PartnersProject Partners West Virginia ParentWest Virginia Parent Training Information, Inc.Training Information, Inc. Center for Excellence inCenter for Excellence in Disabilities (CED)Disabilities (CED)
  29. 29. Goals and Objectives of F2F  Empower families to access health care through I & R, training and outreach  Provide F2F specialists to assist families with health care needs  Transition from pediatric to adult health care  Increase the medical home model  Increase communication and collaboration between families and professionals
  30. 30. Consumer and Family Input  Established Family Mentors (8)  Impact Data and Follow-Up  Family Support Groups  Youth Advisory Group
  31. 31. West Virginia Family to FamilyWest Virginia Family to Family HealthHealth Information CenterInformation Center Call: 800-281-1436Call: 800-281-1436 E-mail: WVf2fhi@gmail.comE-mail: Visit: