Chapter 11 of 127.3% of exam

Health Care and Disability Management

This domain covers health insurance programs, workers' compensation, leave and return to work, and privacy of health information.

Public health coverage

Medicare and Medicaid follow different rules, and work incentives protect coverage for people who return to work. Loss of health coverage is one of the main fears that keeps beneficiaries from working. Accurate information about how coverage continues is part of benefits counseling. Premium amounts change yearly and should be checked with SSA.

Medicaid structure

Administered by states under federal requirements and funded jointly.

Medicaid.gov

Extended Medicare

Coverage continues for at least 93 months after the trial work period for most working SSDI beneficiaries.

SSA Red Book

Medicare Buy-In

Part A can be bought alone; Part B cannot be bought without Part A.

SSA Red Book

Workers' compensation and return to work

Workers' compensation varies by jurisdiction, with separate federal programs for federal employees. The ADA continues to apply when an injured or ill employee returns. Return-to-work planning should consider both workers' compensation rules and ADA obligations. Leave that runs out under one law may still be owed under another.

Who administers

DOL's OWCP runs federal programs; private and state and local government workers go to their state board.

U.S. DOL, Workers' Compensation

Benefit types

Wage replacement, medical treatment, and vocational rehabilitation.

U.S. DOL, Workers' Compensation

Leave beyond FMLA

After 12 weeks of FMLA leave, additional leave may be required as an ADA accommodation absent undue hardship.

EEOC Enforcement Guidance (2002); 29 CFR 825.200

Chronic conditions and privacy

Episodic conditions are covered under the ADA, and health information flowing to payers is limited by HIPAA. Conditions such as Crohn's disease, MS, or cancer in remission can be covered even between flares. Information shared with insurers should be limited to what the purpose requires. Diagnosis coding follows the HIPAA code set standards.

Episodic conditions

An impairment that is episodic or in remission is a disability if it would substantially limit a major life activity when active.

29 CFR 1630.2(j)(1)(vii)

Minimum necessary

Uses and disclosures of protected health information are limited to the minimum necessary, with exceptions such as treatment.

45 CFR 164.502(b)

Diagnosis codes

ICD-10-CM is the HIPAA code set for diagnoses.

45 CFR 162.1002

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