Navigating Health Coverage During a Pandemic: Three Options
By Kate Gilliard, JD
While policy makers at all levels are working to respond to the COVID-19 public health emergency and get the country back to normal, the unfortunate truth is millions of people have lost their jobs and consequently lost their health coverage. This is true for PTs, PTAs, and the patients they treat.
So, what happens when you find you find yourself without coverage? And if your patients need to find alternative coverage, how could that affect the services you provide? Here are the three most common options available.
Keep in mind that this post does not constitute legal advice, and you should speak with an attorney or licensed insurance producer for more information. Also note that APTA cannot respond to individual questions about a specific situation; so any comments asking for this type of feedback will go unanswered.
U.S. Department of Labor COBRA webpage
Employee Benefits Security Administration's Employee's Guide to Health Benefits under COBRA
If you or your patient recently lost access to employer-sponsored health insurance, the first option in maintaining coverage is COBRA. The Consolidated Omnibus Budget Reconciliation Act, from which COBRA gets its name, gives workers and their dependents the right to maintain their health insurance benefits for limited periods of time under certain circumstances including involuntary job loss. This means you keep the exact same plan you had while you were employed, with identical benefits.
COBRA is a federal requirement, so it's available in all 50 states, and covers all group health plans offered by private sector employees with 20 or more employees, as well as state and local government plans. Your health plan and/or employer is required by law to provide you information on COBRA if you qualify. Information about what COBRA plans are available to you and how much they will cost should come from your human resources department or directly from your health insurance carrier.
COBRA and Your Patients
If your patient was able to see you for a reasonable copay under their employer-sponsored coverage, that should not change if she or he elects to enroll in COBRA. However, the employer probably will discontinue paying any of the premium, which means this option may be too expensive, especially for those without an income. Some employers offer to pay COBRA premiums for a limited amount of time after separating with an employee, but they are not required to do so.
Keep in Mind …
If you think you're entitled to COBRA, but haven't received any info, contact your HR department as soon as possible, as you only have 60 days to sign up. COBRA coverage due to job loss can last for up to 18 months; sometimes longer if other qualifying events occur.
Another consideration outside of COBRA: Let's say you are employed but are enrolled in your spouse's or other family member's plan instead of your employer's plan — and then the family member loses their job. There's a strong chance you can enroll you and your family with your employer's plan, if they offer coverage, even if it's outside open enrollment. Contact your HR team as soon as possible to find out how to enroll and what your options are. This also works the other way around: If you lost coverage but your spouse is still employed and her or his employer offers coverage, you might be able to enroll on their plan.
Zipcode-based search for marketplace coverage options
If COBRA isn't an option or your coverage has expired, you may choose to look to your state's health care marketplace. Most states use the federally facilitated marketplace, although many states have their own marketplace. The link to the zipcode-based search above can help you find out what's available in your area.
You are eligible for a subsidy to reduce your monthly premium payment if you make less than 400% of the federal poverty level ($49,960 for an individual or $103,000 for a family of four) as well as additional subsidies that reduce your cost-sharing, copays, and deductibles. You also can purchase additional coverage such as dental and vision insurance through the marketplace.
The Marketplace and Your Patients
Plans sold on the marketplace are subject to the Affordable Care Act's essential health benefits provision, which requires 10 major benefit categories to be covered by all plans (to some extent). This includes habilitation and rehabilitation services, meaning every plan on the marketplace covers physical therapy. However, prior authorization and visit limits vary from state to state and plan to plan, so patients on a marketplace plan could face certain restrictions. Patients shopping for plans should be encouraged to carefully review the way in which plans cover essential health benefits.
Keep in Mind …
Usually, you can only join a plan during the open enrollment period, but losing coverage due to a job loss qualifies you for a special enrollment period, during which you may enroll in marketplace coverage anywhere in the country. You should determine your options as soon as possible, as most special enrollment periods require you to enroll within 60 days of the qualifying event.
Listing of state Medicaid agencies
KFF List of Medicaid programs that cover physical therapy
If your income is low enough, you may qualify for Medicaid. The requirements vary greatly from state to state, so to determine if you qualify, you need to visit your state's Medicaid website (check out the link above).
Medicaid and Your Patients
Physical therapy is not a mandatory benefit in Medicaid. Some states cover it with visit limits, or only for certain populations (such as pediatrics), while others don't cover it at all. The online resource from The Kaiser Family Foundation, listed above, identifies which states' Medicaid programs cover physical therapy.
Keep in Mind …
If you make too much to qualify for Medicaid, but have children who need care, be sure to see if they qualify for the Children's Health Insurance Program, which provides care specifically for children in this situation.
Kate Gilliard, JD, is a senior regulatory affairs specialist at APTA.