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Options When the Uninsured Have a Health Crisis
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PDF VERSION |
By: Barbara A. Isenhour and Sean R. Bleck
The following is a brief summary of possible options if you have no health
insurance (or
inadequate insurance) and have an illness or accident resulting in substantial
medical
expenses.
Medicare
Medicare is health insurance available to people who are either 65 or older,
or under the
age of 65 and meet the Social Security Administration definition of
"disabled". You
must have paid into the Social Security system for at least 40 quarters, with
twenty being
in the prior ten years. (There are some exceptions to the 40 quarter
requirement if you are
under age 31). There is no asset or income test to qualify for Medicare.
There are two problems with relying upon Medicare if you have a sudden illness
or
accident. First, the definition of "disabled" to qualify for Medicare can be
difficult to
meet. The Social Security Administration must agree that you are unable to
work in what
is called "substantial gainful activity" for the at least the next 12 months
(or determine
that you are terminally ill). Many people who are too ill or injured to return
to work
immediately cannot meet this 12 month requirement and therefore do not qualify
for
Medicare.
The second drawback to Medicare is that, even if you meet the disability test,
you will
not qualify for Medicare for 29 months from the onset of the disability. That
29 month
waiting period leaves a substantial gap in coverage with no health insurance.
Medicaid
To qualify for Medicaid you must be over age 65 or meet the same disability
test
described above (unable to work for the next 12 months). In addition, your
countable
assets must be below $2,000 ($3,000 if married). The home, household
furnishings and a
car with a value below $5,000 are exempt assets. Unlike Medicare there is no
29 month
waiting period if you qualify for Medicaid.
Depending upon which Medicaid program you are applying for it may be possible
to
transfer assets to come below the $2,000 asset limit. The transfer of asset
rules for the
Medicaid program are complicated, however, so you should get legal advice
specific to
your circumstances to determine if it is advisable to transfer assets.
If your income exceeds $599, the income above this amount must be applied
towards
medical expenses as a co-payment before Medicaid will kick in. So, for
example, if you
receive $1,000 of monthly income, you will have to pay the first $401 of
medical
expenses each month before Medicaid will pay the balance. This co-payment is
referred
to as "spenddown". Even with the required co-payment or spenddown, Medicaid
can be
very helpful to people with very high medical expenses and no other health
insurance.
Applications for Medicaid are submitted to the Department of Social and Health
Services.
General Assistance Unemployable (GAU)
GAU is a benefit program for disabled people who are under the age of 65,
unable to
work because of a disability and who are not receiving Supplemental Security
Income
(SSI) or Social Security Disability (SSDI) income.
The disability standard for GAU is less strict than Medicaid/Medicare so some
people
who cannot meet the 12 month disability standard may still be able to qualify
for GAU.
The disability standard for GAU is that you are unable to work for at least
the next 90
days. The medical coverage that comes with GAU is referred to as GAX.
The GAU/GAX program has asset limits that are similar to the Medicaid asset
rules.
Your countable assets must be below $1,000. The home and a car with a value of
less
than $5,000 are not included in the $1,000 asset limit. There is a two year
transfer of
asset penalty if you transfer assets to qualify for this program. To qualify
for GAU your
monthly income must be below $339 per month. Applications for GAU/GAX are
submitted to the Department of Social and Health Services.
Basic Health
Basic Health (BH) is a state sponsored health insurance plan for low income
families.
Enrollment will depend upon whether there enrollment spaces available. The
premium is
subsidized depending upon income. There is no asset requirement for BH.
To get more information on BH check their web site at
www.basichealth.hca.wa.gov.
There will be a nine month pre-existing condition waiting period for any
health condition
that occurred in the prior six months.
Private Health Insurance
To qualify for private health insurance you must pass a health screening
questionnaire.
This will be problematic in the case where you have just had a major illness
or accident.
Even if you passed the questionnaire there will still be the nine month
pre-existing
condition waiting period for any health condition that occurred in the prior
six months.
Washington State Health Insurance Pool (WSHIP)
The Washington State Health Insurance Pool (WSHIP) provides health insurance
to
individuals who do not pass the health screening questionnaire for private
health
insurance. The premium depends upon income, the plan selected, the deductible
selected
and geographic location.
You must first get a denial of coverage from the private health insurance plan
in order to
qualify for WSHIP. There will still be a nine month pre-existing condition
waiting
period but this can be waived if you were under-insured under another health
insurance
plan at the time the pre-existing condition occurred. To get more information
on WSHIP
check their web site at
www.wship.org .
Charity Care
Many hospitals have programs referred to as "charity care" to write off all or
a portion of
hospital bills for low income patients with no health insurance. The hospital
will provide
an application for you to fill out, requesting financial information about
your family and
then make a determination as to whether any portion of the hospital bills will
be written
off. This program does not apply to out-patient doctor expenses or pharmacy
expenses.
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