Todd Rundle presented on navigating health care and benefits options for transitioning youth. He discussed Medicaid, CHIP, SSI, SSDI, private insurance, and waiver programs. The presentation covered exercising appeal rights, including filing in a timely manner and providing necessary documentation. Contact information was provided for the Family to Family Health Information Center for additional assistance.

1. “Navigating the Benefits
Maze & Exercising Your
Rights”
Presented by: Todd Rundle

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. Path’s of Transition
 Community Living
 School
 Work
 Health Care
 Adult Independent Living

4. Health Care Transition
What is available?
Who can help?
What are my rights?

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. 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. SSI
Social Security Income
SSI is supplemental income to help
aged and disabled individuals. SSI
eligible participants are automatically
eligible for Medicaid.

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. 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. Currently on Waiver
Points to ponder during transition
 Community access
 Transportation
 Vocational
 Money management
 DRS/ job coach
 Medical transition visits

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. 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. 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. 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
www.wvdhhr.org/CSHCN/

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
TRICARE.mil

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. Exercising Your Rights
Let’s Review the
Process

18. Maintain your Cool
Avoid showing frustration
Be professional and stay calm
Avoid the EGO issues (anger leads to
problems)
Tape your meetings

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. 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. Know who the Responsible Primary Payee
or Agency is:
1. Department of Rehabilitation
2. School District
3. Medicaid
4. Medicare
5. Private Insurance

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. 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. 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__

25. IF YOUR APPEAL RESPONSE IS
NOT SATISFACTORY, YOU HAVE
THE RIGHT TO REQUEST DUE
PROCESS UNDER THE
ADMINISTRATIVE HEARING
PROCESS HEARD BY AN
IMPARTIAL HEARING OFFICER

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. Primary Goal
To ensure that children with
disabilities have access to
health care and health care
service.

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. 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. Consumer and Family Input
 Established Family Mentors (8)
 Impact Data and Follow-Up
 Family Support Groups
 Youth Advisory Group

32. 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: WVf2fhi@gmail.com
Visit: www.cedwvu.org/programs/familyVisit: www.cedwvu.org/programs/family