CVC Case Manager L. Dani McGaha is a trained Social Security Administration disability advocate. She offers her tips for gathering medical records for disability applications.
Submitting medical records with your Social Security disability application can help expedite the process and ensure all of your records are received. So, consider gathering your medical records as a first step in the application process.
First, let’s examine why they’re important, then I’ll answer some common questions about how to gather and submit your medical records to Social Security.
Why are medical records important to disability applications?
The Social Security Administration (SSA) uses medical records as evidence to support your case. SSA evaluates your condition(s) using medical criteria known as the “Listing of Impairments.” The Listing of Impairments describes medical conditions, their severity, and the evidence required to determine if SSA an individual should be found disabled. Law requires SSA to request supporting medical evidence to properly analyze a disability application, which can slow the process and extend the life of an application.
SSA will only follow up with medical providers or facilities a certain number of times before deeming they have “sufficient evidence” to move forward with a decision in your case. So, a decision could be made on your case even if all of the requested medical records have not been received. If SSA does not receive your medical records within a set period of them, they will make a decision in your case, which could result in a denial.
Luckily, you can help move this process along. Read on to find out how.
Before I get started—what will this cost me?
Sometimes providers charge you for medical records. But, many states have special laws associated with the costs of medical records for Social Security disability claims that limit medical record fees or waive them completely.
To determine if your fees are correct, or whether you should be charged at all, follow this link to look up your state’s laws. Also speak with your doctor if you have concerns about medical record costs.
OK, I want to collect my medical records. Where do I start?
To begin the medical record collection process, first determine which providers or facilities you will request records from. A good place to start is the provider/facility that knows the most about your condition (ex: neurologist, pulmonologist, psychologist, primary care physician).
Next, determine how far back you would like to request records. At CVC, our general rule is to request records approximately six months prior to when your condition(s) started limiting you, or six months prior to when you started seeing a specific provider.
We recommend requesting records that far back to ensure you obtain all that are available. For example, if you believe you first began seeing your provider in June 2017, you would request from January 2017 to present.
I’ve made my list of providers and dates. Now how do I contact them?
Once you determine the providers or facilities you would like to request your records from and how far back to request, you can submit the request to obtain records. You have a few options:
If you have an online patient portal account, like MyChart®, most times you are able to download and save your medical records from there. Some portals also allow you to submit your request for medical records directly through the portal.
If you do not have an online portal, contact the provider or facility to verify the best way to submit a medical record request to them (ex: fax, email, mail, etc.). Some providers will send you records with a verbal request. All you have to do is call and ask.
Others may want a written request or authorization form. If you submit a written request, include important information such as your name, date of birth, address, phone number, the name of the provider or facility you are requesting the records from, the dates you are requesting, and your signature. If an authorization form is required, ask them where to locate the form.
Note: Your provider may submit the request to a centralized medical records department to complete, so confirm if they process their own requests. If they do not, ask them for the contact information for the office that does. This is important to have when you are trying to follow up on your request.
I’ve submitted a request. Nothing has happened. Now what?
After one week if you have not received the records, follow up with the provider or facility or medical records department to confirm the request was received and obtain the processing time. If the request was not received, reconfirm where to submit the request and re-send it. If you learn a third-party (Ciox, IOD, MRO, etc.) processes the request, obtain the contact information and reach out to them to follow up.
Once you have followed up, we recommend waiting another one to two weeks to repeat the process. Continue to follow up until you have received the requested records. This process can take anywhere from a few days to a few months.
I’ve collected my records. Now how do I submit them to SSA?
Each level of the Social Security disability application process has different submission methods available:
If you complete your initial or appeal application in person, provide your medical records to the representative that completed your interview.
If you complete your initial application online, you will have the option to download a cover sheet once your application is submitted. Print the cover sheet then mail the cover sheet along with your medical records to your local Social Security office, or drop them off in person. If you drop off the records in person, make sure to get a signed and date-stamped receipt for your records. This helps ensure the records are properly attached to your case and avoid the likelihood they will be misplaced.
If you complete your appeal online, for reconsideration or an administrative law judge (ALJ) hearing, you can attach you medical evidence directly to your appeal application.
We recommend that you keep copies of all of your the records for yourself, in case they are lost or misplaced and you need to submit them again. If you are unsure whether something was previously included in your file, submit it again.
What if I have more records to submit once my application is pending?
If your application is already pending with Social Security and you have additional medical evidence to submit, reach out to your local SSA field office. Let them know that you have additional medical evidence to submit and you need to know if your application is still in their office or if it has gone to Disability Determination Services (DDS). (DDS is the office that makes the medical decision.)
If your application is still with your local SSA field office: Confirm the best way to submit additional medical evidence. Remember to keep copies of the records for yourself.
If your case has been sent to DDS: You should receive notification in the mail with the contact information for the examiner working on your case. Reach out to the examiner to determine how to submit additional medical evidence to DDS.
If you have additional questions regarding this process or any other Social Security disability questions, please contact us.
CVC Case Manager Tomi Vega is a certified application counselor under the Affordable Care Act as determined by the Centers for Medicare and Medicaid Services.
Medicare Advantage—the private plan add-on option in the Medicare program also know as Part C—has new flexibility to cover expenses such as transportation or caregiver support. The extra benefits are fairly limited for 2019, but that’s expected to change in 2020.
Until March 31, anyone already enrolled in an Advantage plan for 2019 can make certain changes to their coverage. You can cancel your plan, switch to a different Advantage plan or sign up for a Part D drug plan. (Look for a blog with more about your options during this window soon.)
Whether or not you’re making changes this year, you may want to take a moment to learn more about what new benefits are coming, and what changes you could see this year and next.
What are the new benefits?
For years, Advantage plans offered a small, fixed list of supplemental benefits like vision, hearing and dental care. But the Centers for Medicare and Medicaid Services (CMS) relaxed that list in late 2018, allowing Advantage plans beginning in 2019 to offer coverage for any goods and services as long as they reduce avoidable emergency department visits, or are used to diagnose, prevent, or treat injuries or health conditions.
Advantage plans have used the expanded definition of items eligible for coverage to offer new benefits to their members. The new benefits (also known as wellness programs) seen so far are:
Nicotine replacement therapy.
Caregiver support services like respite care, counseling, and training.
In-home support and personal care services like assistance with housekeeping tasks, bathing, eating and dressing.
Expanded coverage of over-the-counter products like non-prescription medications, compression stockings, and pill bottle openers.
Social worker phone line.
In-home palliative care.
Transportation to places like the pharmacy or a fitness center.
About 270 of the 600 plans for 2019 included at least one of the new benefits, according to CMS.
CMS announced the rule change just a few months before insurers submitted their final plan designs. As a result, insurance companies had limited time to rearrange plans to include new benefits.
For those that did add benefits right away, the most common are:
Nicotine replacement therapy.
Caregiver support services.
Many think the addition of these supplemental benefits is a step toward offering more complete health services. Nevertheless, if you have Medicare, you should be aware that benefits might not be available to everyone. Insurance companies have the option to offer only certain wellness programs and also only make them available to individuals with certain health conditions.
Additionally, greater differences in available benefits between Advantage plans may turn the already daunting task of comparing Advantage plans and choosing the best coverage option into an even bigger job.
The plan finder tool on Medicare’s website does not yet provide information about supplemental benefits offered by Advantage plans under this new rule. Individuals looking for these specific supplemental benefits should check with each Advantage plan directly to find out what they offer and if there are any restrictions, such as having a certain health condition.
CMS expects many more insurers to add extra new benefits in 2020.
Even more changes in 2020
In addition to the extra plans expected, in 2020, under the Bipartisan Budget Act of 2018, Advantage plans will be allowed to offer supplemental benefits to chronically ill enrollees that are not primarily health related. These expanded benefit options must only “have a reasonable expectation of improving or maintaining the health or function of the beneficiary.” This means Advantage plans will be able to provide coverage for additional services such as:
Transportation for non-medical needs.
Home modifications like installation of grab bars in the bathroom, wheelchair ramps, and air conditioners.
With more flexibility and more time to update their plan designs to include new supplemental benefits, CMS expects that a larger number of insurers will offer more benefits beginning in 2020. Currently, it’s difficult to find information about the availability of these benefits, since Medicare’s plan finder tool doesn’t include them. However, it is still early in the year and the landscape could change for 2020 plan enrollment.
Shaun Bateman told his story in a blog based on a conversation from March 2018. One year later he answered a few questions about life after Social Security Disability Insurance approval.
How have you been since your SSDI approval?
It’s been a tremendous relief to have the Social Security Disability Insurance (SSDI) application process behind me. It’s such a long, huge process—especially the long years beforehand and all the mental decisions and planning, while also trying to stay focused and positive.
Of course, if I was stressed or confused, Allison (CVC’s disability attorney, Allison Bartlett) would take her time and explain things, which was really necessary for me. Because focus and energy are both impacted in people with HD. If it’s a long question, by the time you finish asking it, we can easily forget the initial directions and comments. Over those two years, she always made sure that I was prepared for the road ahead and understood the journey.
I had some annual tests done recently at my local HD Center of Excellence where they observe you to see if anything has changed. My results said I haven’t gotten worse except one little arm mobility issue. Everything else stayed the same. And actually, a few things got better. I think as you age, you figure out how to deal with things better—accommodate falls so they don’t happen the next time, things like that.
I have always been really sensitive to noise, and HD makes that a lot more pronounced, but now I just leave in my wireless earbuds and can remove as much of that distraction as I need to. It also allows me to play music a lot, which helps me focus and work out with higher energy.
Everything is less stressful not having to deal with Social Security. It’s a big thing it really, really is. I will also say I never really expected how much self-imposed guilt I was going to feel about the whole process, because I have known many people who didn’t qualify. But every single person has to sort of wrangle things down themselves—and also prepare for being more dependent on other people, people around you who love you and want to help.
Did it change your experience with health care?
My SSDI started in 2017. After you have been on SSDI for two years, you’re allowed to go on Medicare early. So that should start soon and is wonderful. I get breaks with the price of my insurance, based on how much I paid into the program over the years. It’s deducted from my SSDI check.
Has anything else noteworthy changed since SSDI was approved?
Shaun and his mother, who also had Huntington’s disease.
I haven’t heard much from them since, except I did get a little call from the office to see if I had received information about the back-to-work program. I know they check in on you periodically to see that you still need disability assistance. With some illnesses, you can get better and won’t need it anymore. But HD is progressive. While it comes on kind of fast, it does slow down for awhile. But the last 10 years of your life, you get worse more quickly. I had a doctor say one time that it’s like you live in a huge mansion and every day you turn off one light and at the end of a long time it will be darker. But the light is not extinguished until the end. While you’re alive, you always have light on.
I receive private disability insurance payments as well, which is approved until I turn 65. So that helps. If the world changes and a treatment comes between now and then, we might get to train for new careers in the future.
Probably 30 percent of all people are really against change. I am one of those people who love change. Whatever happens, happens. At some point if things have gotten bad enough and you have to ask for help, then you do. The programs are meant to keep people as functioning and intelligent as possible and I appreciate that.
The news around HD is changing a lot—has that impacted you?
I was pre-screened into a clinical trial in North Carolina, but it ended up closing down before it started. I talked to my HD Center of Excellence about it. They said that there were some safety concerns. We’re so close—of course nobody wants to do it wrong, when we are on the very cusp of change.
Our options are improving all the time and there are probably five really, really hopeful things on the horizon related to HD. Technology has increased tremendously. I finally feel comfortable saying that to some of my friends. I balance what I tell my friends, because they go through all of the emotions, too.
Hope is extremely important. And it’s also how I’m wired. That’s not everybody. If there was a cure tomorrow and everybody got better, I would be elated. At this juncture I think everybody is ready for a cure, but we’re nervous that it’s not going to work for everybody.
All of that however is a lot more than our parents ever got to hope for. There was no Internet—there were just support groups. It was a death sentence. Sometimes people just opted to commit suicide. I think there were people who gave up a lot earlier than they had to. It seemed like while they were still strong enough to make that decision. If more of those people had a little bit of hope, we would have more people around longer.
What are your current challenges or needs? Have you had any bad experiences navigating the health care system with HD?
I have found that while doctors are very informed about their specialties, and all of mine have been wonderful at my Center of Excellence, the health care system isn’t typically set up for one point of contact that knows everything about your care. Instead, that sort of becomes the patient’s role. You have to personally take control over your own health to have a good experience.
And what’s amazing is how possible this is now. We have easy access to information to help make decisions about our care. It seems like, for five years, I haven’t heard anything from an HD doctor I hadn’t already read online. You can find the answer to anything. Although, you have to be able to parse the information.
I don’t think we’re ever going to be in a situation where things are so organized and tight where everyone can just have one doctor. But it would help me to have one person who I could bring all my questions to and who could troubleshoot across the aisles.
Also, I am an “under-medicate” kind of guy. I’d rather be more grouchy and clearer than take more pills. I think providers feel obligated to offer solutions to any issue I raise, but when they offer a new medication, I’ll go read about it before I agree. If it has side effects that might affect my clarity or whatever, I don’t want it.
Some people I have known throughout the years like lots of medicine, but I have always been the kind of person who takes a less is more approach to medicating, I think I want to be able to minimize interactions as much as humanly possible.
If you had one thing that would make your day-to-day life with HD easier, what would it be?
Newer cars have so many safety functions built into them now. It makes driving a lot less stressful. So that’s something sort of simple that could make life easier for people with HD.
HD is a family disease. Almost our whole family has passed away. Most people have died early. Everybody in our family totally understands. I joke a lot that my sister is my oldest living relative, but she is my sister through marriage—her father married my mother. So actually, my brother—who is only a year and a half older than me—is my oldest living blood relative. Every other older blood relative is gone. I have uncles and aunts by marriage, but no parents and no grandparents.
That’s a huge loss—but our whole lives we have been preparing for the early goodbyes. Still, I really miss asking them questions and listening to their stories.
Shaun Bateman on what it’s like to win Social Security Disability Insurance—and what it means to him to play the long game against Huntington’s disease.
Growing up, on some level I knew that my mother was sick. When I was in second or third grade, her older sister who had Huntington’s disease (HD) came to visit us. She told me my mom had HD.
There was no Internet back then. So for a couple years, whenever I would go to the library at Duke University, which was down the street from us in Durham, N.C., or the high school or public library, I would always look HD up and just sort of learn about it.
I had decided I wasn’t going to get tested until my mom passed away because I didn’t want to have to force that conversation. She died when I was 39. At my big, age-40 physical, my general practitioner said: It’s time for you to make some serious decisions about growing old.
I’d always been super active and totally healthy. I was ready to just turn 40 and get fat, watch TV, go see movies and be a normal person. He didn’t want to say yes to all of that, but suggested the first step might be to get tested for HD.
I didn’t want to go to the neurology center by myself and get my diagnosis. He asked if I’d be more comfortable if he ordered the test and talked to my neurologist. I said: That’s so much better.
A few weeks later he told me the results—I had 43 CAG repeats (repetitions of the genetic error that predicts the severity of HD). He said: Shaun, this is really, super, super serious, and I know you know that, but sometimes when something is in somebody’s family, they don’t hyper-personalize it or they ignore it because it’s always been their reality. You can’t do either of those. You have to figure out what to do medically and survive the best you can. You also have to respect it and you can’t just stop going to the gym and watch TV. The very next day I went back to the gym and I never gave up and that has helped me in the long run.
For about a year, I told maybe four people. But then, knowing—it just became something that I couldn’t bear. I’m better at friends than anything. I’m still really good friends with people I went to high school with. I think part of me has always been working on that—because I knew on some level that I would need them. After I started getting stressed out about not telling these lifelong friends, with the help of one of them, I told them all one by one.
Telling them my diagnosis made it easier for them to understand if I was having a bad day, or if I just wanted to be by myself. They asked me to post a few times a day on Facebook—a picture or a check in to where I am, or anything. Before I started doing that, I would kind of disappear. They said: If we just hear from you a couple times every day, we feel better. So that’s what I do. With Facebook you can see what you’ve done on the same day in previous years. So, it’s become a little narration of my memories. I like it a lot. I am sort of documenting the whole thing.
Sometimes I take a picture and realize I look as angry as humanly possible. And, instead of deleting that, I post it, because I feel like it’s important to know. I also want to be able to see when things get better. If it’s been a couple days of frown-y pictures, other friends will give me a call and ask: What’s up? Can you smile tomorrow? They don’t need the whole story. We’ve been friends forever. They understand and sympathize. But if I wanted to not talk to anyone for 1,000 years, they’d prod me out of that.
You have different financial priorities if you’re trying to figure out how to exist long term while you’re sick. I had a conversation with Social Security Administration (SSA) early on about Huntington’s. The woman I talked to said an HD diagnosis was enough to be considered disabled. She said: You’re probably going to be able to work until you are 50 or 55. So from the second you leave this SSA office, work as much as you can while you’re strong, so you can pay a lot of money into Social Security.
I worked selling fragrances and skin care. After talking to SSA, I decided I would do anything my job asked. If they needed me to go to Seattle for a few months, I agreed. It was all an adventure. As travel became less easy, I changed to a local job.
When I started having the final spurt of hard times at work, I went to the Huntington’s Disease Society of America’s website and found the national number to ask some very general questions about retirement, the disability process and timing. I called and they gave me contact info for Caring Voice Coalition (CVC). I called the next day and talked to CVC Patient Advocate Allison Bartlett. She said that I qualified for assistance applying for Social Security Disability Insurance (SSDI).
She said she was going to send me stuff to fill out and warned me it would take a little while for the email to send because it was a ton of stuff. She suggested I fill it out as quickly as possible while I was clear in thought and focused on this. I got the email, and part of me didn’t even want to open it. I forced myself to fill it all out over the weekend and had it back to her by the very next workday. As disgusting as all that paper work was, I knew it would be much worse to have to figure it out without anybody pulling the right forms and telling me what to do.
I don’t know if this is true for everybody with HD, but when I first see a task like that it just looks insurmountable. I thought: I can never print all of that, read all of that, etc. This just gets more severe as the time goes by. It was exhausting. But I just sort of forced myself. And then CVC was able to corral so much more information to build my case and help me work toward an eventual approval. I would have never, never, never been able to do it by myself.
The whole disability process took a couple years. Everybody said: You just have to make peace with that. My brother had Huntington’s as well and he had long-term disability coverage with his employer. So for about two years, while he was being approved for SSDI, he was getting long-term disability from his employer. So that’s exactly what I did. It’s not a lot of money, but it’s something to live on during the longer disability application process. Every time Allison would call and say, “Well, it’s been delayed,” or, “They said no this time,” I just reminded her I was getting long-term disability.
If your employer gives you an option, especially if you are approaching retirement years, my advice is to opt-in to long-term disability. It was probably only $5 a pay check. Knowing what my future held, I purchased the maximum coverage I could. And it came through quickly when I needed it. I filled out two little teeny tiny forms.
The SSDI process can be really discouraging at first because it takes so long and there’s so much to do. But having a legal advocate is crucial. The alternative is filling a shoebox with every receipt for your entire life, keeping that organized, filling out all the forms and representing yourself. It is not possible. I don’t say that lightly. All of that is zero percent possible for a person with HD. I am probably the most type A person in the history of HD, so I was probably better than most. But I would never have been able to do it all by myself. It’s just too long, too thorough, too many things to think about, to balance and remember. There’s no way that anybody with any sort of mental disorder would be able to do it themselves.
But it’s essential because it allows me to get paid for the rest of my life. The amount will change when I hit retirement age at 65. And two years after you’re approved you get Medicare. Normally you don’t get that so early. That’s really nice. There are people trying to pass the Huntington’s Disease Parity Act, which would waive the two-year waiting period for people with HD. But even waiting two years—it’s a really good deal. I mean I don’t think anything is ever free or perfect. But it’s nice to get medical benefits before age 65.
A hopeful time
With so much new research-related stuff, I think it’s a hopeful time to have HD. Doctors have always told me that if they can cure any of the weird diseases that aren’t curable, Huntington’s should be it. Because they can test someone at any age and know if they’ll get HD, maybe they can stop it right out of the gate. It’s something that makes HD a little special and keeps a level of hope in there as well.
Sometimes I think if somebody could just fight hard enough or play a long enough game, they could survive HD. And I know that’s not something that happens, but I also know that I’m different than most people. I’m hard headed and I work out all the time. The HD buzz out there is exciting and I think that energy could keep me going, because I’m kind of stubborn about stuff like that. If there’s any hope at all, I think I’m just the kind of person that’s going to make it through. All the time I’m awake and speaking and fighting, they’re working on cures and learning things and that could mean a lot more time. I think as long as I remember that I’m good for the fight.
This post was based on a conversation with Shaun that took place in March of 2018. Look for an update from Shaun in the next blog.
CVC Case Manager Rhaisa Lopez is a trained Social Security Administration disability advocate. She offers her tips for completing the adult function report form.
When you submit an application for disability benefits, the Social Security Administration (SSA) gathers information about your daily activities and how your condition impacts them. SSA uses this information, in addition to your medical records, to determine if you have the ability to work. In most cases, SSA gathers this information by sending out a form called the “Adult Function Report.”
People often find this form overwhelming, but if you receive it, don’t panic. We have several tips to make things easier.
Five tips for completing the report
1. Describing your activities: Answer the questions from the perspective of a bad day, be honest, and provide detail.
Photo by rawpixel on Unsplash.
Many people struggle when completing this form because they have forgotten what life was like without their daily limitations. So, take time to think about all of the changes you have made to adjust to your life because of your condition. For many, describing these limitations is embarrassing and painful, but the more detail you can provide for your case, the stronger it is.
Remember: SSA does not get the opportunity to physically see you. They have to rely on your medical records and the forms you complete to understand why you cannot work.
Follow these guidelines when describing your activities:
Report all limitations you have while doing your daily tasks. Include any accommodations you make or assistance tools you use during the day. For example:
Do you only shower once a week instead of once a day because of mental or physical fatigue?
Do you require a shower chair or handrails to bathe?
Have you chosen certain clothing because it’s easier to dress?
Do you only cook using the microwave?
Explain your answers when possible. For example, if you do cook only using the microwave because of your health, explain why. Otherwise, SSA might assume that you can cook meals from scratch, which takes time and energy and could indicate that you have the ability to work.
Explain all of your limitations, including the time it takes to complete a daily task. Think about any activities you can only do for a short amount of time or require a break to complete.
Finally, always include whether you receive help with any of your daily activities or if someone has to do something for you.
2. Tricky questions: Take time to understand and review questions carefully.
Questions on the report are designed to determine if you are capable of working. Answering incorrectly could adversely impact your disability claim. Yet, many people find certain questions confusing.
Review some of the most commonly misunderstood and inadequately answered questions to make sure you accurately represent your situation:
How do your illnesses, injuries, or conditions limit your ability to work?
SSA wants to see medical reasons why you are unable to work. Always include your symptoms when answering this question. Examples might be issues with your memory, concentration, difficulty being around others, or even walking or sitting for extended periods of time.
PERSONAL CARE (Check here ___ if NO PROBLEM with personal care.)
This question tricks a lot of people because SSA is asking if you have difficulty with or have made changes to your personal care, not if you can care for yourself. For example: Do you have to sit down when getting dressed or showering? Do you shave less often? Do you require help dressing, bathing, or brushing your hair? Unless you have no issues with personal care, do not check this box.
Are you able to pay bills, count change, handle a savings account, or use a checkbook/money orders?
To many, this question sounds like an inquiry into your finances. But SSA asks this question to determine if you would receive your own disability check, or if someone else would need to receive the check on your behalf. So SSA only intends you to check “no” to this question if you have physical and mental difficulties as a result of your symptoms and medical condition, not if you have limited finances.
What are your hobbies and interests?
Include both hobbies and activities that you can no longer perform and those you have now. This highlights how your life has changed because of your medical conditions.
3. The “remarks” section: Make use of this space for overflow.
The adult function report includes a lot of information, so many of the questions do not provide enough room for answers. If you run out of space when answering a question, use the remarks section for additional space. Include the number of the question you are answering. The remarks section can also be used to share additional information that you would like SSA to know. If you run out of space in the remarks section you can attach additional pages to the form. So, take as much space as you need.
4. Don’t rush: Ask for an extension as necessary.
The letter attached to the function report states it is due within 10 days of the letter’s date. If you need more time, you can call the number of the examiner listed on the form and ask for an extension. Submitting a thoroughly completed form a little late is better than submitting a hurried, partially completed form. A determination on your claim sometimes comes down to what information is provided on this form, so it is very important to complete the form entirely.
5. Get help: Don’t feel like you need to do this on your own.
If you have trouble understanding the questions or have difficulty writing, you can have someone else complete the form on your behalf. Also, you may not be aware how much your impairments affect you and impact your activities of daily living, so an outside perspective can be helpful.
After you finish
Once you complete the form, read through it to make sure you did not miss any important details, and make a copy to keep for your own records. You may need this information again. If you have to file an appeal, SSA may send you another adult function report and it will be beneficial to have your original report so you can highlight any changes in your condition and provide consistent information to SSA.
The adult function report gives you the opportunity to provide a first-hand perspective of how your condition(s) impact you physically and mentally on a daily basis, from the time you wake up until the time you go to bed. Make sure to use this form to describe what you go through every day, how your daily routine has changed, and how your condition prevents you from working on a sustained basis.
If you have any questions about this form or any other Social Security disability questions, please contact Caring Voice Coalition’s disability team.
CVC Case Manager Tomi Vega is a certified application counselor under the Affordable Care Act as determined by the Center for Medicare and Medicaid Services.
Nearly one third of Americans have received medical bills they didn’t expect, according to the Consumer Financial Protection Bureau. Forty-three million Americans received surprise medical bills in 2014 related to unexpected surgery, outpatient procedures, or emergency room visits that led to medical debt reported to the credit bureaus.
You can prevent some surprise bills by verifying insurance coverage and asking for an estimate of your expected costs for services in advance. But more and more often, bills are surprising people, despite efforts to verify coverage in advance.
We collected five tips for avoiding and navigating surprise medical bills.
1. Review the bill carefully and check for perceived billing mistakes, or charges that don’t seem quite right.
Doctor offices and hospital billing departments manage a lot of data. As a result, roughly eight out of 10 medical bills contain mistakes. Two common errors are billing someone for a service or procedure they didn’t receive and using inaccurate insurance information.
To help with this process:
Confirm that your provider has accurate insurance information each time you visit, particularly if you have more than one insurance policy.
Hold onto bills and any other information you receive from the provider, including through email.
Keep track of who you speak with and when—as well as any other communication. A paper trail can help your case if there is a disagreement later on.
If you received an advance estimate of a procedure’s cost and the bill goes over the estimate, it’s best to ask why. You or your insurance can inquire whether your health care provider will accept the lower rate originally agreed upon.
2. Consult and negotiate with your health care providers.
Get in contact with your insurer, doctor, or hospital as soon as you can. Obtain detailed information including an itemized statement showing each charge. You can negotiate with the provider for a lower rate, especially for charges that were not covered or for charges that seem unreasonably high.
Research the typical cost of the procedure or service you received. Know the in-network price or the average cost of a service. Sites like Fair Health Consumer and Healthcare Bluebook can help you find this information.
3. Appeal or file a complaint about charges that don’t meet your expectations.
You have the right to file a formal appeal with your insurance company if coverage was denied or you feel you were incorrectly charged out-of-network. Medical bills generally come with instructions on how to appeal the charges. While you file the appeal with your insurance, inform your doctor you are disputing the bill with your insurance company. Request them not to send the bill to collections, if possible.
Important note: Though you have the right to ask, doctors are not obligated to refrain from sending delinquent or overdue bills to collections.
In order to dispute a denied service or unreasonable bill, you need to submit a written request. Collect any paperwork related to the disputed charges from the provider and medical records that can help you create a strong argument. Make copies to send and keep the originals.
Try your disease-specific advocacy organization for more specific help.
For very large bills, you might consider hiring a medical billing advocate. But be sure to understand their hourly charges and commission of reclaimed funds. Learn more about billing advocates here.
4. Request a payment plan or financial aid.
If you dispute billed charges and the provider determines they are valid, you will owe the amount stated on the bill.
Contact the billing department to discuss your payment options. You can request a payment plan with little to no interest. This is a much better option than putting a huge charge on a credit card which likely has a higher interest rate and will be much harder for you to pay off.
Also ask about financial aid programs the medical provider offers. These programs are especially helpful if you’re on a fixed income. You’ll need to provide financial records like proof of income and bank account statements in order to be considered for financial aid.
If you have the resources to pay a significant portion of the owed amount all at once, you can usually negotiate a reduced amount in exchange for an immediate one-time payment. A provider may accept half of the owed amount as payment in full if you can pay all at once, right away.
Remember, appealing or negotiating a medical bill can take time. Stay calm and make sure to communicate with your health care providers at each step in the process. If you understand your coverage and rights and take the proper steps to dispute charges you feel are inaccurate or unreasonable, you can avoid surprise bills or pay a lot less than the original bill.
5. Understand the common practice of balance billing.
Many billing mistakes happen through a practice called balance billing, which generally means you’ve been billed for charges beyond what your insurance company agreed to pay. But the concept and why it’s worth knowing is complicated enough that we described it in its own blog.
CVC Director of Patient Services Lauren Ruiz explains the basics about balance billing.
Balance billing is already a hot topic this year in health care. Of course, like many health care practices, most people don’t understand or hear about balance billing until they experience it—in the form of an unexpected bill for hundreds or thousands of dollars.
Understanding more about how it works can help you avoid that. So, take a moment to learn:
What is balance billing and why is it noteworthy?
When is it legal?
When is it not legal?
What laws exist to prevent surprise bills?
What is balance billing?
“Balance billing” is simply the industry term for when medical providers charge a higher price than the amount your insurance agreed to pay and you are billed for the difference.
These otherwise normal bills are noteworthy because they can be surprisingly high or are unexpected for the health care user for a number of reasons.
Some reasons these bills surprise people:
Medical pricing in the U.S. health care system isn’t very transparent. For example:
People may assume the cost of a service is affordable because they’ve never paid it in full. In reality, prices can vary a lot and even basic blood work can be over $1,000 out of network.
People might confirm a price with a provider beforehand and then something changes before the procedure.
Out-of-network providers unexpectedly work in in-network facilities. Providers that insurance companies have negotiated cheaper rates with are referred to as “in network” and typically cost you, the health care user, less. However, many health care facilities use outsourcing services for providers like anesthesiologists, emergency room physicians, pathologists, radiologists, and ambulatory services. So, even if you go to an in-network facility and an in-network doctor performs the procedure, other services you receive could still be out-of-network.
Changes to care happen last minute while a person is in an emergency health situation and too frightened or out of it to approve or ask the price.
An important thing to note is that balance billing can happen as a mistake—so if you understand when it is or isn’t legal, you can better spot these mistakes.
When it’s legal
Providers can legally balance bill you when:
You use a health care provider that does not have a negotiated, in-network contract with your insurer, including:
Concierge medical providers.
You receive services not covered by your health insurance plan.
When it’s not legal
Balance billing is illegal if the provider has a contract with your insurance that requires them to accept the negotiated rate for covered services as payment in full. So, if you receive a balance bill for any costs above your plan’s in-network rate, contact your doctor and insurer and ask about the contract to see if it’s an error.
If you have Medicare or Medicaid, the contract between your insurance and the provider is known as “accepting Medicare/Medicaid assignment.” If your provider “accepts assignment,” then it can not legally bill you for costs higher than what your insurance agreed to pay for covered services.
Before choosing a provider or before utilizing medical services, you can ask whether they accept assignment. If they say yes, you will know that any balance bill you receive is a mistake. Contact them immediately to appeal the charge.
Remember, if you are inappropriately charged more than your insurer will pay through balance billing, you are still responsible for your regular cost-sharing portion (copay/co-insurance). Providers just can’t bill you for costs beyond that.
Avoiding balance bills
The best ways to avoid balance bills are to:
Ask a lot of questions about costs and record the answers.
Insist that all of your care, services and providers are in-network. One thing you can do is write this on every form you sign.
And ask whether your provider has a contract with your insurer to accept negotiated rates. Record the answers and keep your own copy of every document in case you have to file an appeal.
In reality, most people aren’t aware that they are responsible for preventing surprise bills. Even if they are, few have time or—especially while sick—energy to do everything on that list. Particularly in cases involving emergency decisions, most people don’t have the wherewithal or time to research their network coverage before receiving care.
California, Connecticut, Florida, Illinois, Maryland, and New York have enacted a comprehensive set of laws, but in other states, balance billing protections vary. Check out these resources to see what exists in your state:
Until the laws change, health care users are likely to start seeing more of these bills, according to analysis by The Commonwealth Fund. They found insurance-provider networks are shrinking. That could mean pricier out-of-network charges will surprise more people accustomed to services being in-network.
CVC Patient Billing Specialist Lara Dodd, a certified financial health counselor and debt settlement specialist, outlines how you can use life stages as a guide to plan for your financial future.
It’s hard to make a financial plan. The unknown can be quite scary. Those facing chronic illness often must start planning much sooner than others. Planning for each part of the typical financial life cycle can ease some of the burden when you face difficult decisions or unexpected costs.
Navigating an unexpected financial burden
George Bernard Shaw said, “Life isn’t about finding yourself. Life is about creating yourself.”
This year my parents have me thinking about the life they created, its different stages—and the importance of advance care planning. My father, who is 75, suffers debilitating complications to seven back surgeries. Recovery has been slow, with weekly physical and occupational therapy, doctors appointments, and readjustments to a new normal.
A major complication for the latest surgery was both physical and emotional—his loss of mobility means no more driving and few stairs. He gets around the house with a wheelchair or slowly on his walker. My mother turned their living room into his temporary bedroom and, without notice, became his primary caregiver.
Illness placed a huge burden on my parents financially—from adapting their three-story house to accommodate my father’s needs, to ultimately deciding to leave their house of 34 years and move into a retirement community.
An accelerated timeframe
My mother told me they always had a two-year plan, but they were forced to expedite that by selling their house and moving to an independent living facility within six months.
My sister and I weren’t prepared for the accelerated timeframe in which my parents decided to sell their house. Though my parents also hadn’t imagined such a short timeline, they knew this day would come eventually, and the plans they had made readied them for these unexpected changes. I spent countless weekends packing up my childhood home—filling boxes with Kentucky Derby glasses from my grandparents, cherished photographs, and my father’s beloved gardening and cookbooks.
My family and I just spent our last Christmas in the house where we grew up. I’m not sure anyone was entirely ready for it, but deep down I know it’s the best thing for my parents. I’m so glad that, because of the planning they did throughout their life stages, they were able to mitigate the unexpected costs they faced without sinking into debt. Because of the work I do each day to support individuals facing a chronic illness, I know that many aren’t as prepared as my parents were.
So how can you prepare for the future?
Part of preparing for the future financially is envisioning what you want your future to look like. It’s going to be different for everyone. We all have different goals, realities and things we want to accomplish in life. Think about making a five- or 10-year plan. When you start envisioning it, jot down your goals for your career, your family, and even for retirement.
Remember: You can always come back to them and make changes along the way, but the most important thing is that you take the first steps.
Here are some tips for planning for your future:
1. Career planning
When you’re thinking about your career, ideally you’ll seek something fulfilling that also meets your financial needs. Think about compensation as much as possible, especially what benefits you’ll need to lead a healthy life. Compensation can come in many forms beyond your hourly wage such as bonuses, low-cost insurance benefits, flexible scheduling, robust retirement options, or continuing education reimbursement. In the long-term, you’ll want to consider your financial well-being and the right path to get you there.
2. Debt and savings planning
Debt planning is just that: planning on lessening debt without getting more of it and saving for the future. Goals around debt and savings planning involve putting an adequate portion of your income towards paying off your debts and saving for life’s expenses. You might plan for expenses such as housing repairs or annual tax increases, having children, and “unexpected” emergencies like the cost of a flat tire or travel for a funeral.
Though unexpected in the moment, we all know we are bound to experience some of these things at some point. Your first goals might be to develop a savings plan and create a budget to help you with unexpected expenses and build your nest egg over time.
3. Retirement and investment planning
When you’re thinking about your finances, you should also identify and prioritize your financial goals. If possible, work with a financial advisor to help manage your money, begin investing, and review your plans for retirement. Financial advisors can provide insight into what kind of insurance you should have and any tax implications for your estate (more on that later). Knowing where you want to go and how you’ll get there will help your advisor understand your life and financial goals.
Many free or low-cost financial planning tools exist. Try one of these resources:
As mentioned, financial advisors can help you determine what types of insurance you should have (including long-term care, life, health, and others) now and in the future. Adequate insurance will help you during unexpected job changes, a health crisis—whatever curve balls life throws your way. Because certain types of insurance have specific eligibility requirements or can become more expensive over time, this financial planning step is important to consider as early as possible.
5. Estate planning
Planning for your estate should never be overlooked. It may be difficult to talk with your family about what happens after you pass away. But it’s a conversation you’ll need to have as you’re preparing for your future. Speaking with an estate planner will ensure that your wishes are carried out and your possessions will go to who you see fit. Don’t overlook planning for this part of your life. Think about your loved ones now and protecting your family, as well as removing some of the burden from them in the future.
The hardest step
Don’t forget that beginning life cycle planning is the hardest step. Life planning is as important for you now as it is for your future—the sooner you make plans the better. Once you go through the process you’ll see what’s it truly about: giving peace of mind to you and your loved ones.
For me, these past few months have been about an overwhelming sense of happiness, nostalgia, and love when I’m at my parents’ house. As the pictures were taken down, fragile things packed with care, and boxes strewn everywhere, I could see that we created this place we called home—and this life. My childhood home was always there for my family and me and it will be there for another family.
When I take one last look around I’ll remember the memories and know that we’ll be creating more in a new place my parents will call home. And a new home was made possible because they thought about this stage of life in advance.
CVC Director of Patient Services Lauren Ruiz explains the basics about short-term health insurance plans.
As a result of recent changes to federal health care law, short-term health insurance plans are more widely available in 2019. These plans may seem like a good option because the premiums tend to be much cheaper than those for marketplace plans.
Premiums are lower because laws allow short-term plans to significantly limit what they cover: They don’t have to cover everyone, they don’t have to cover specific services, and they can cap the total amount they cover for a person.
In general, only under specific circumstances where health costs are very minimal will these plans save policyholders money. So before you consider a short-term health insurance plan, be sure to understand their limitations.
Below, we explain more about:
What short-term health insurance is, including recent changes.
What to know before signing up.
Reasons you might consider it.
What prescription drug coverage might look like with these plans.
What is short-term health insurance?
Short-term health insurance—also called “term” “temporary” “gap” or “limited duration” insurance—is designed to cover a healthy person during temporary gaps in their more comprehensive health coverage. Common gaps occur between jobs or while transitioning to a new type of insurance plan. (For example, you might change from private to publicly funded health insurance).
Short-term plans are exempt from most Affordable Care Act (ACA) requirements. Among other things, this means they don’t have to cover the full array of essential health benefits required of plans sold through ACA marketplaces.
Recent changes to short-term health insurance
On Aug. 1, the Centers for Medicare & Medicaid Services finalized a new rule to amend the definition of short-term health insurance plans. It took effect Oct. 1.
A 2017 regulation limited short-term insurance plan coverage to three months or less. The new rule states:
Short-term health insurance plans can have a coverage period of up to 12 months.
Individuals can renew short-term health plans for up to three years.
To address concerns of opponents of these plans, the rule also includes consumer protections through education about the potential limitations of the plans. Consumers purchasing short-term health insurance must be informed that these policies do not comply with ACA requirements.
What to know before signing up
No one likes to be hit with unexpected or expensive health care costs. Before considering short-term health insurance plans, be sure to understand all of their rules and limitations. Short-term health insurance plans:
Are not required to cover people with pre-existing health conditions or services for pre-existing health conditions. This also means insurance companies can charge an individual with a pre-existing health condition a lot more for their monthly premium, or can exclude health services that address pre-existing conditions.
Are allowed to impose annual coverage limits and/or lifetime coverage limits. Once the plan pays a certain amount during a coverage period, or over the lifetime of the plan, they will stop paying for any costs, leaving the consumer responsible for 100 percent.
Are not required to cover the ACA’s 10 essential health benefits. Therefore, short-term health plans can exclude coverage for things like: prescription drugs, maternity care, mental health and substance use treatment, and more.
Coverage for certain essential health benefits may exist under the short-term plan but likely have limitations.
When would I consider a short-term health insurance plan?
You might want to consider a short-term health insurance plan if:
You cannot afford the monthly premiums of an ACA-compliant plan on the health insurance marketplace. Make sure to check first if you qualify for advanced premium tax credits or premium subsidies through the federal or state exchange marketplaces—which can make the comprehensive marketplace plans cheaper than the short-term plans. (Follow link to section “What are subsidies?”)
You missed the annual enrollment opportunity for an ACA-compliant plan but still want to enroll in a plan. Unlike with marketplace plans, you can apply for short-term health insurance at any time.
You only need coverage for a short period of time during a coverage transition.
You don’t want to pay for the extra comprehensive services required by ACA-compliant plans because you are healthy, don’t have a pre-existing condition, and/or don’t intend to use them.
Prescription drug coverage and short-term plans
Coverage for prescription drugs is important to many people. Let’s look at some examples of short-term health insurance plan’s limitations on prescription drug coverage:
No coverage for prescription drugs. Consumers can use a prescription drug discount card at their pharmacy to reduce out-of-pocket costs.
A four-tier drug option where the consumer pays $20 with no deductible for Tier 1 drugs, $40 for Tier 2 drugs after a $500 deductible, $75 for Tier 3 drugs after the deductible, and 40 percent the cost of Tier 4 drugs after the deductible. This option also imposes a $3,000 maximum benefit, per term. (This means once the health plan has spent $3,000, the consumer will become responsible for 100 percent the cost of prescription drugs).
The consumer pays a $500 prescription drug deductible and then 30 percent of the cost of all drugs. This option also has a $3,000 maximum benefit limit.
Other prescription limitations that may apply:
Drugs are only covered during an in-patient hospital stay.
Limits on the number of refills allowed during the term period.
The option the consumer chooses will partly determine the final monthly premium cost of the plan.
As you can see, typical short-term insurance limitations could easily result in someone with more extensive or costly prescription drug needs paying much more out-of-pocket. And, insurers can apply these sorts of limitations not just to prescription drugs but to any part of coverage offered under short-term health insurance plans.
If you are considering a short-term health insurance plan, make sure you understand all of your likely medical costs and then contact the plan to check specifically if they will be covered or whether any limitations will apply. Ask for a copy of the Plan Benefits, Exclusions, and Limitations before you enroll.
A final note
On a final note, some states have passed state laws that prohibit certain practices of short-term health insurance plans. For example, California, Hawaii, Massachusetts, New Jersey, New York, and Oregon prohibit the sale of short-term health insurance plans that do not cover individuals with pre-existing conditions. State laws may impact the cost of the monthly premium you pay and covered services. You can find more information about laws specific to your state by calling your state health insurance department or visiting their website.
CVC’s health insurance counseling program can help you understand your health benefits, including short-term plans. Don’t hesitate to contact us with any questions or for more information.
CVC Director of Patient Services Lauren Ruiz offers tips for getting the most out of your health insurance plan in 2019—and minimizing costs to you.
Open enrollment periods for both Medicare and Marketplace insurance receive a lot of attention toward each year’s end. Millions of dollars are spent on advertising and outreach and a variety of insurance assisters are available to help with the enrollment process.
Once the hubbub of enrollment activities settles down, people tend to assume consumers are all set to go for the year. As a certified application counselor for Caring Voice Coalition, I have enrolled and answered insurance questions for thousands of individuals over the years. In my experience, I receive just as many questions after enrollment as I do during the plan selection process.
To address some of those, we’ve collected three things you can do now before you go into a new year to save you money and heartache.
1. Take advantage of what you can get for free.
Your insurance plan has an invested interest in keeping you healthy and avoiding major costs down the line, so many preventive care services are available at no cost to you even before you have met your deductible (if your plan has one). Many services aimed at slowing down an illness you already have fall in this category too.
Medicare covers shots for: Flu, hepatitis B and pneumonia.
Medicaid covers all recommended vaccines for children.
Private health insurance typically covers recommended vaccinations.
Alcohol misuse counseling
Diabetes self-management training
Tobacco use cessation counseling
A few things to know before you seek out preventive care:
Find a care provider in your insurance plan’s provider network to ensure the preventative care is covered.
Preventative service coverage can vary depending on your age or health history. Talk to your doctor each year about the preventive care you should receive.
A complete list of preventive services covered by Medicare Part B can be found here and one for services covered by private insurance plans that comply with the Affordable Care Act (ACA) can be found here. (Note: ACA-compliant plans offer additional preventive services for women and children.)
Supplemental health benefits are benefits that are considered extra because, unlike preventive health benefits and essential health benefits, they are not required by law. They may include things like:
Discounted gym memberships
In-home personal assistance
Respite services for caregivers
Check the booklet you receive from your plan to see if they offer any additional benefits or contact them directly to ask. These benefits are not always made obvious but taking advantage of them is a great way to truly get the most out of your health insurance.
2. Know what to do if your provider networks change.
Figuring out who is in network for your health insurance plan can seriously impact how much you end up paying. Confirm that any doctors you want to keep seeing are in network before signing up.
Of course, midyear changes to provider networks can happen.
Below are three types of laws that can protect you if you are experiencing this kind of network change. Contact your insurance plan or health care provider to find out if any of these apply to your situation.
You may have out-of-network rights if your health plan does not have in-network providers sufficient to meet your medical needs in a reasonable and timely manner, you may have the option to receive care from an out-of-network doctor.
Continuity of care protections exist in some states. They allow you to temporarily continue seeing your health care providers and to pay in-network costs if they leave your plan’s network midyear. View this map to see the continuity of care protections for each state, so that you are prepared to talk to your doctor or insurance provider if you encounter issues with your network.
If you are enrolled in a Medicare Advantage plan and your plan terminates its contract with a provider group or medical facility midyear, the Centers for Medicare and Medicaid Services (CMS) may determine you have the right to change your plan outside of the normal open enrollment period. If CMS makes this determination your plan must notify you at least 30 days in advance of the network changes. You then have a 90-day “special enrollment” opportunity after the network changes take effect to either switch back to Original Medicare or select a different Medicare Advantage plan.
3. Learn all about your local urgent care centers—especially which are covered by your insurance plan.
Urgent care clinics are expanding everywhere and are a more convenient and much cheaper option than the emergency room. Your insurance will only cover care received at urgent clinics in their networks, so check that yours is in network before visiting.
Typically if you are seeking urgent care you may not be in a position to contact your insurance plan to confirm which urgent care centers are considered in-network. At the beginning of the year you should check your plan’s “Summary of Benefits and Coverage” document or call them directly and find out which urgent care centers are in-network. This may help you avoid large bills later on.
If you experience a life- or limb-threatening emergency, you should seek care from an emergency room at the nearest in-network hospital.
For more help navigating your health insurance in 2019, don’t hesitate to call Caring Voice Coalition at (888) 267-1440.