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What Siblings Need to Know about Medicare and Medicaid

by S. Paul Prior, Esq.

Medicare and Medicaid can be very confusing. Medicare is provided to people 65 and over, to Social Security Disability Income (SSDI) recipients and permanently disabled Social Security recipients. Medicare is divided into two parts. Part A covers hospital and limited nursing care. Part B, which requires an extra premium, covers physician services, as well as a variety of therapies and other items. Medicare also has co-payments and deductibles.

Medicaid, in theory, covers all medical expenses and there are no deductibles and co-payments. However, in practice, a number of physicians will not accept it. Medicaid will also pay for institutional care in nursing facilities and in some cases in non-specialized placements to people with disabilities.

Eligibility for Medicaid is similar to that of SSI. The applicant must have monthly income in accordance with federal and state guidelines (which can change from year to year) and no more than $2,000 in countable assets. There are no income and resource tests for Medicare. Also, like Supplemental Security Income (SSI )income and resources of parents will be deemed to a child under age eighteen. However, Medicaid has the authority to waive deeming rules if a child has medical needs so extraordinary that if without Medicaid, institutionalization would be necessary. This is known as a Community Care Waiver, which is administered by the New Jersey Division of Developmental Disabilities.

Review Your Child's IEP Now

Believe it or not, the school year is nearly half over. Now is a good time to review your child’s IEP. Look at the description of the services and program: Are the services being provided as described? Are related services being provided as described? Look at goals and objectives: Is your child making measurable progress? Are the related services adequate in intensity and duration? Do you expect you child will need extended school year service? If there are issues or concerns, call your child’s teacher or Child Study Team to request a meeting. Do not wait for the regular IEP meeting next spring.

Overview of Health Care Issues

by
Valerie A. Powers Smith, Esq. and Herbert D. Hinkle, Esq.

There are many diverse and complex issues when dealing in the health care arena. This article provides a brief overview of the different forms of insurance and issues which, in our experience, have given rise to an appeal. More detailed discussions of the topics introduced in this article will be provided in subsequent articles.

There are a number of areas that may give rise to an appeal regarding your health care coverage. Disputes may involve denial of payment for a covered benefit, which is medically necessary; reduction, denial, or termination of a covered service (with or without notice); and denial or termination of eligibility for insurance or waivers. If you are covered by more than one form of insurance (e.g., private insurance and Medicaid or Medicare, or Medicaid and Medicare), coordination of benefits and billing dispute issues can also arise. If covered under Medicaid or Medicare, due process issues (notice and opportunity for a hearing), failure to continue services pending an appeal, and failure to restore services pending a timely appeal can also give rise to an appeal.

In order to appeal any determination, you must understand the type(s) of insurance plans under which you or your family are covered, as this will dictate eligibility, coverage, and appeal rights.

One may receive insurance coverage for health care services under: (1) private insurance; (2) public assistance (Medicaid or Medicare); (3) state-funded health benefits plans; and (4) self-funded/-insured plans.

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