Benefits and Cost-Sharing for Working People with Disabilities in Medicaid and the Marketplace

Appendix 3

Hypothetical 1: Susan, age 21, Diagnosed with mild cerebral palsy (CP)

Education and Work History: After graduating from high school, Susan enrolled in a local community college.   She received her Associate’s degree and then transferred to a four-year college to complete her Bachelor’s degree. At that point, she moved out of her parents’ house to attend school and live on her own.

While attending community college, Susan worked as a cashier at a retail clothing store in a local mall. She worked 25 hours per week, earning $8.25 per hour, with annual earnings of $10,725, or about 92% of the federal poverty level for a single adult in 2014. She continued this job during her junior year of college to cover her living expenses and tuition costs that were not covered by grants and student loans.

In her senior year of college, Susan was offered a job as a bookkeeper. She continued working 25 hours per week, but earned $13 per hour in her new job, with annual earnings of $16,900, or approximately 145% FPL in 2014.

Health Insurance Coverage: While living with her parents, Susan was covered under a family health insurance policy that her parents purchased in the individual market, and her parents paid out-of-pocket for all of her disability-related expenses that were not covered by the policy. Susan’s parents now receive employer-sponsored health insurance through their respective jobs. Neither of their policies offers coverage for dependent family members, so Susan was unable to maintain coverage through her parents’ insurance.

Susan’s state expanded Medicaid as of January 2014. While working as a cashier, Susan qualified for Medicaid as a newly eligible adult with earnings below 138% FPL. When she changed jobs and started working as a bookkeeper, Susan became eligible for Marketplace coverage with premium tax credits and cost-sharing reductions.

Health History: Susan’s needs for acute physical health and preventive services are the same as those of other, healthy young adults. She also has some additional medical needs associated with her CP diagnosis. A common symptom of CP is paralysis, which varies significantly across individuals. Susan is able to walk but uses crutches or a power scooter when she travels significant distances, including getting around campus. She takes prescription medication to control muscle spasticity, which is a common condition secondary to CP. The muscle spasticity results in lack of fine motor control, which makes brushing her teeth difficult, and she also has dental issues related to tooth grinding, another complication of muscle spasticity. Because her vision is affected by her CP, she wears prescription eyeglasses.

Susan receives physical therapy twice a month to manage contractures stemming from muscle spasticity. Her physician believes she would benefit from weekly physical therapy and monthly occupational therapy to improve her fine motor skills. However, her coverage for these services was limited to 20 visits per year under her family’s health insurance policy, so she has not received more frequent visits. Since she is relatively young, she has not yet experienced additional complications from her abnormal gait, but she is at risk for developing chronic joint pain and degeneration from the additional strain on her legs due to her gait and on her shoulders due to long-term use of crutches, which could require additional physical therapy.

Because Susan’s fine motor skills are mildly impaired, her family sometimes helped her button or tie clothing, prepare meals and do laundry. Susan had no plan for seeking assistance with these needs when she went away to college, so they will likely be unmet, or performed to the best of her ability, without formal personal care services in place.

While she is not currently in treatment for mental health issues, Susan was bullied in school because of her gait and use of crutches. She may have undiagnosed mild depression and/or anxiety as a result and might benefit from mental health diagnostic services, and if warranted, treatment.

Hypothetical 2: John, age 35, Diagnosed with clinical depression

Education and Work History: John is a high school graduate with a limited work history as a day laborer for a local construction company. The company has employed John seasonally, and in three of the last five years, he earned approximately $15,000 per year, or about 129% FPL for a single adult in 2014. In two of the last five years, due to the economic downturn and bad weather, John’s earnings have been as low as $9,000 per year, or about 77% FPL in 2014.

John was recently offered a year-round job as an assistant to an auto mechanic. The position pays $8.15/hour for a 40-hour work week.. If he takes this job, John would make $16,952 a year, or about 145% FPL in 2014. John prefers working outdoors and feels better when he is not inside all day, but the consistent schedule and regular pay offered by the auto mechanic job is appealing to him.

Health Insurance Coverage: None of John’s past jobs have offered health insurance, and as a single adult without dependent children, he did not qualify for Medicaid before his state implemented the ACA’s Medicaid expansion in January 2014. Based on his current earnings of 129% FPL, he is eligible for Medicaid in 2014. If he accepts the auto mechanic job, John will become eligible for Marketplace coverage with premium tax credits and cost-sharing reductions.

Health History: John was first diagnosed with depression after a failed suicide attempt at age 32 when he was taken to the emergency department and involuntarily committed to inpatient treatment. The hospital released him after 72 hours of observation when the psychiatric staff determined that he was no longer a danger to himself.

John needs regular doctor appointments and takes a prescription anti-depressant medication.   When he was uninsured (prior to becoming eligible for Medicaid through the expansion), John was unable to take his medication consistently, because it is expensive for him to afford out-of-pocket. John’s doctor has encouraged him to seek individual and group therapy, but he has been unable to follow up on this recommendation because he was uninsured and unable to pay out-of-pocket. .

While uninsured, John visited the doctor when he is physically ill and paid out-of-pocket when he had the resources. Otherwise, his health care-related expenses went unmet. He also could benefit from regular preventive health care services.

Hypothetical 3: Mary, age 40, Diagnosed with multiple sclerosis (MS)

Education and Work History: Mary finished high school but never went to college. She recently divorced and has no children. She currently rents a two-bedroom apartment with a friend. Most of her jobs have been in food preparation, and she currently works at a fast-food restaurant. Mary works 30 hours a week at $8.25 per hour, with annual earnings of approximately $12,870, or about 110% FPL for a single adult in 2014. She has not been able to find full-time work.

Mary recently began looking for a second job since her current employer is unable to give her any additional hours. She decided to take a job selling tickets at a movie theater on the weekends, where she will earn $8.50 per hour. She will work 9 hours per week, earning$3,978 per year and bringing her total annual income to $16,848, or nearly 145% FPL in 2014.

Health Insurance Coverage: Mary has been uninsured all of her adult life. When she recently was admitted to the hospital, a social worker helped her apply for health insurance. Because her state implemented the ACA’s expansion, she is eligible for Medicaid while she is working at the fast-food restaurant. However, once Mary takes her second job, she will become eligible for Marketplace coverage with tax credits and cost-sharing reductions.

Health History: Mary’s lack of health insurance and limited income have made it difficult for her to afford basic preventive health care, such as annual physical examinations. She only seeks medical care when the need is critical, and she does not have a regular primary care provider.

In January 2014, she visited the emergency department after experiencing an extended bout of blurred vision and muscle weakness. She previously noticed these symptoms, but they typically lasted less than a day. With recurring symptoms and a marked reduction in her ability to lift her left arm, Mary decided to seek medical care. She was admitted to the hospital for additional evaluation, including a visit from a neurologist. During the hospital stay, the neurologist conducted a battery of tests, including an MRI. Although her symptoms resolved by the time she was released from the hospital, the tests revealed that she had multiple sclerosis, and the neurologist gave her the formal diagnosis.

After her discharge, she followed up with the neurologist as an outpatient. The neurologist recommended that she begin receiving regular doses of an injectable drug to slow the progression of the disease. He also referred her to a physical therapist for regular treatment of her muscular weakness and ordered some additional tests to assess the extent of impairment in her vision and fine motor functioning.

Mary does not currently need assistance with activities of daily living as her symptoms of muscle weakness and blurred vision typically do not interfere with her ability to work and take care of herself at home. However, if her symptoms worsen, they are likely to interfere with her ability to continue to work.


Appendix 2

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