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Northrop Grumman Information Technology

Moderator: Laura Coffey

June 8, 2010

12:00 p.m. CT

Operator: Good afternoon. My name is (Steve) and I will be your conference operator today. At this time I would like to welcome everyone to the Health Coverage Options conference call. All lines have been placed on mute to prevent any background noise. After the speakers remarks, there will be a question and answer session.

If you would like to ask a question during this time, simply press star then the number one on your telephone keypad. If you would like to withdraw your question, press the pound key. Thank you. Ms. Laura, Coffey you may begin your conference.

Laura Coffey: Thank you, (Steve). Good afternoon or good morning everybody. Again, I'm Laura Coffey with the VCU with the National Training Center. And I'd like to welcome you to our Teleconference Training Session today on Counseling Beneficiaries on Public and Private Group Health Coverage Options. Now we've have a great response to this training in the past so we are offering it a second time. We're very excited about today's call.

We have a total of 125 participants registered and we don't have quite that many on the phone or in the Wimba format with us, but the total number of folks on the lines really are – including WIPA project staff and community partners from all across this country. So, we're very excited to have you all joining with us and there will be plenty of opportunity to share experiences and questions as we go through the webinar this afternoon.

But before I introduce our speakers, I'd like to take just a couple of minutes to touch on a couple of housekeeping items. First of all, today's presentation is scheduled to last for two hours, from one to three Eastern, and as I just alluded to, there will be opportunities for you to ask questions and share information at multiple points during the two hour presentation.

We do want to make sure that all of your questions are answered. So if you have remaining questions that are not able to be addressed during our time on the call today, please feel free to send those on to us either in your evaluation form or in a separate email or and we'll make sure that we respond and get back to you.

Secondly, you should have a total of eight handouts for today's training. This include one PowerPoint presentation and seven resource documents that our trainers will be referring to. If you don't have any of those documents, please send me an email or call me and I can resend those to you as we're on the phone. And I can be reached on my cell phone 407-401-4092 or via email at lcoffey6@. Or if you're in the Wimba format, you can certainly send me a message through the text chat box. OK?

And finally, we'll be sending an email with a link to the evaluation form after the call. So, please take the time to provide us some feedback so that we're able to improve any future training events.

OK. Now, I'm going to go ahead and introduce our trainers and then I'm going to give you a couple other instructions regarding asking questions during the webinar and then I will turn it over to Bryon and Mason. So our trainers this afternoon are Bryon MacDonald and Mason O'Neal, both from the World Institute on Disability.

Bryon MacDonald is the founder and program director of the California Work Incentives Initiative at the World Institute on Disability. He manages a team of benefits and technology experts that develop Disability Benefits 101 Information Services, you may also know of this as DB101. This program provides public policy, education activities and multimedia information services on healthcare benefits, paid work and disability. A member of the National Council on Independent Living, NCIL since 1996, Bryon has chaired NCIL Social Security Subcommittee since 1997. From 2000 to 2004, he participated as a member of the Social Security Ticket to Work and Work Incentive Advisory Panel which is an appointment made by President Clinton.

And Mason O'Neal is a trainer and program analyst at the World Institute on Disability where he works on the California Disability Benefit 101 website. Before coming to WID, he was a CWIC at the Independent Living Resource Center in San Francisco. Mason has a Masters in Social Work from Boston College and a degree in business from the University of Pennsylvania.

Now before I turn it over to Bryon and Mason, I just want to review a couple of things regarding asking questions for those of you who are in the Wimba format – OK. All right just a second here. OK. You all should see a screen now.

Those of you in Wimba that says, "Asking questions during the webinar," and one of the formats would be to use the text chat box, which is in the lower left-hand corner of your screen, and you can see where your question will appear in the box. And what you want to do and down at the very bottom where it says, "Main Room" and right next to that is another little box where you would type your question and then hit the enter bar and that will send your question to everybody who is within Wimba. And at the appointed time, I would be reading those texted questions to Bryon and Mason for them to answer.

OK. Now, the other method of asking questions would be to queue the operate – when the operator (Steve) comes on and says, "We are taking questions now," and he'll give the instructions on how to go about asking a question. You can hit the appropriate buttons on your phone and then that will allow you to be heard through the phone and go ahead and ask your question directly.

If you have any difficulty with the – accessing the text chat, you can contact the Wimba help desk at 866-350-4978 or you can email them at technicalsupport@. And I would ask – I see that there's lots of stuff going on in the text chat box now, and some people are having some issues, but if we can reserve the text chat box, other than technical issues, at the moment to just be for asking questions directly and not necessarily just chatting with the other participants that would be great.

Mason O'Neal: And Laura, can I make a comment?

Laura Coffey: Of course.

Mason O'Neal: There's a couple of people that seem they're not hearing us and that's most likely because they're trying to use Wimba but they needed to call in the separate call-in number.

Laura Coffey: Right.

Mason O'Neal: Maybe we could rid off that call in number or we can email it to them and...

Laura Coffey: I'll type it in into text chat box so everybody has it. I had already address that with one person directly but actually (inaudible) giving the dial in number.

Mason O'Neal: And is there a code they'll also need?

Laura Coffey: Yes. I will add that. And while I'm doing that, I'm going to go ahead and turn this over to Bryon and Mason.

Bryon MacDonald: Thank you. Hopefully those who are not hearing will be hearing very very shortly. This is Bryon MacDonald at the World Institute on Disability and...

Mason O'Neal: Mason O'Neal, here as well.

Bryon MacDonald: And welcome everybody. This is our second year doing this training series. And I want to make a couple of opening remarks to get us in a comfort zone of where we're headed for the next two hours.

This is a part one of a two-part training webinar series. And the topics of both webinars is the integration of public and private healthcare systems that can improve quality of life and employment outcome. I will argue that the architecture, so to speak, of what we're talking about is the integration of using public benefits and public healthcare systems with the private sector and healthcare coverage that's available there.

Architecture is a good term except for the fact that there's far more than one architect to how you access health coverage in this country. And the art, so to speak, of program interaction or program integration where you can use public and private benefits at the same time and inclusive of an employment outcome. We would argue from our experience in both Mason and I lived with lifelong disabilities and as many staff do at WID. Many if not most of the successful people I have come across in my 30 years of doing this kind of benefit funding work have a in fact access private health coverage as part of the employment support that have increased the quality of their life. So the importance of this training, we cannot underestimate it enough.

It's just a very important piece of the puzzle in terms of increasing economic self-sufficiency and quality of life. Having said that, part one of the training is going overview that architecture. Part two is going to take that architecture, the second training next week, and apply that architecture to four different case studies. Four different case stories that you will have in front of you as we talk about the lives of four different people and how that architecture works to increase quality of life.

Today we're going to review the architecture in a more intellectual or didactic or learning kind of way. And as you will note in the training sections, which is should be the slide that you're looking at, it is slide number five, and the training sections are what we hope to cover with some dispatch today. And I say with some dispatch, we want to keep this on a lively pace so that there's room for the Q&A session that we have built in and hopefully that we get to the end of all five sections of this training.

Briefly put, we're going to start by debunking current myths about public and private health coverage that you will hear from family members and consumers repeatedly. And secondly we're going to talk about assessment. What health coverage does the beneficiary have now that you maybe working with? And how does that understanding help you plan – help the person plan into the future?

When and how do beneficiaries access private health coverage options, we will cover that in some detail. And then a didactic or an overview of the main types of private health coverage plan and the terminologies they use. And finally, we hope to have time today for some healthcare counseling tips and tools that would be very helpful for you in the work that you do. So we're going to pry right into this and get started on an overview of the healthcare picture in this country.

Many of the overview comments we go into in some depths as we proceed but the overview sort of the girders of the building kind of thing in American – enacted to American healthcare is that there are primary pay rules in terms of who pay the bills first. And the type of health coverage that a person is accessing is going to determine; number one, how they'll interact with each other with other forms of healthcare, and in fact who pays the medical bills first.

So, that's a very important feature to understand that because someone is accessing two or more program, there still need to be an understanding of who's going to pay the bills first even though it is perfectly fantastic that the person access two different types of benefit. We want that CWIC and that consumer to understand how those programs interact in terms of coverage and who pays the bill first.

There isn't a single type of health coverage out there in this country. Most people who I, as I said earlier, who have a quality of life usually have two or more healthcare systems or benefit programs at their disposal to increase their quality of life. And it – that program interaction when things get sticky. And that's essentially a fundamental of why this training is so important.

The three main types of program that your customer, your consumers are going to be accessing are listed next in your PowerPoint. Briefly, they are means tested programs, social insurance programs and private sector benefits. Means tested program, and I'm going to go as quickly as I can through these slides because you have them afterwards to review again. Some of this is new material, some of this is looking at material you understand but maybe in a new way.

Means tested programs are strictly limited to folks who have limited income and assets for both, essentially people who are poor. And the kinds of program that you're working with most commonly are poverty based programs and means tested program that also have a disability component. For example, supplemental security income below the age of 65, you not only have to be poor but you have to have a significant disability.

So, means tested programs are going to be payers of last resort. They're going to ask about personal or family assets. The benefits are most often paid through general tax revenues. They are subject to annual budgets and changes at state and federal legislative levels on, at the state level on a chronic and annual basis. And in fact, they are the payer of last resort so that if there are other types of benefit programs on the table, this program is going to pay the bills last.

Supplemental Security Income is one of those great programs that tell you what it is by the name that it has. If there's other forms of income, SSI cash benefit supplement are the forms of available income. Medicaid is the same way. It is going to pay the bills after other health coverage on the table is paying the bills.

So understanding that these programs are payers of last resort and means tested program gives you an understanding of why they have so many questions about what's in your bank account and how much you're earning, or how much income you have, from your Aunt (Martha) for all they know.

Secondly, social insurance is the bedrock, is the foundation, is the guiding principle of most of the other, if not all of the other Social Security Administration Benefit program. Insurance is not a means tested program, it is the polar opposite. There's at least one family member in a family who is paying FICA taxes or payroll taxes; F-I-C-A, is the technical term for payroll taxes.

Once a month, the family member is paying FICA taxes or having money deducted from their paycheck even if they're self-employed and that person, that wager and it does not get a benefit month in and month out. They get a benefit or a family member gets the benefits when that family member or that wager in there meets the terms in the policies that Social Security has around their benefit program. Social Security programs are based on an insurance model and, in fact, a social insurance tries to build a bigger trust fund, a bigger pool of money as possible to pay the most benefits to the most amount of people when they meet the terms in the policy.

This is not a poverty program by and large. They weren't started that way and so their rules are different. And you do not have to be a wage earner in the family to access a benefit from Social Security's family package of benefit. You could be a child growing up with a disability and access a benefit from Social Security even though you don't have a wage record of your own.

Ninety-six percent of American jobs, you may want to write in the margin, that 96 percent of American job, at least, are covered and pays FICA taxes into the Social Security Trust Fund. That's where the money comes from to pay benefits when people retire or become disabled or become a widow or become a disabled out of child so on and so forth. So without reading all the glory details in that slide, the differences between social insurance and Medicaid or SSI, for example, are night and day. They are very, very important.

Finally, private sector health coverage. Private insurance and non-insurance types of health coverage can be accessed by connections to various big buckets of access so to speak. The most predominant is paid work. The, a vast majority of Americans access health coverage through their job. This is the normal way that most Americans access health coverage who deny them a disability.

You could also be a member of a professional group. For example, graphic artists or a union, any association or a union may carry a group health coverage that a person with the disability could access. I emphasize group health coverage and we'll talk about the difference between group health coverage and individual coverage in a few minutes.

These various, or family health coverage plans. So from the employer, from an association, one might belong to, AARP for example, Association for Retired Persons, they file insurance. Or self-employment or family health coverage plan are the main buckets or main arenas where folks can access private health coverage plans. The initial and the ongoing eligibility rules for each of these plans is going to differ because they're in the private marketplace. They're going to differ now, they are going to differ quite frankly after the healthcare reform is fully implemented. And we will touch on those points of contact as these training proceeds.

Other factors about private health coverage that are very important to understand. Again, I'm laying out the architecture of how we and where we go to, to find health coverage in this country. In the private sector arena, the state has the regulatory authority to govern health coverage plans, not the federal government. This can add and does add a significant level of complexity. Mason and I today are the messengers. We didn't make this stuff up. We are just the messengers of how it operates.

And so, your individual state is the number one regulatory body if you're talking about a private health coverage plan even if it's group health coverage. I'm going to add something here you might want to write in the margin. You'll note that one of your handouts is the healthcare summary from the World Institute on Disability dated May 28, that's our latest version of it.

The healthcare reform, otherwise known commonly now as ACA or the Affordability Care Act, ACA that's very easy to remember, that sort of the brand name that's coming into vogue for the two different laws that were passed in March to reform healthcare in this country. States will continue to have a very significant role in regulating private health coverage after healthcare reform is ruled out, or as healthcare reform is ruled out. The states will have an even larger role than they have today in terms of administering a lot of the healthcare reforms. That's something to keep in mind.

Private health coverage plans are available in two main flavors; group coverage, individual private health coverage plan. For the most part, 99 percent of what we're talking about today is about the access to group health coverage plan. Individual health coverage plans are completely different sets of regulation. They have much more freedom to kick people out. And there isn't, there aren't too many people you will work with, if any, that will be able to access healthcare coverage in the private individual market. They will access freely and easily the group health coverage market because they're better protected.

Moving forward, a group health coverage plan then which is where we focus, it runs slide 11. A lot of our attention in the training is offered in the range of health plans such as in employee benefit, a union of fresh known association for groups of eligible people. This lowers the cost and enable that plan to revive medical services to a wide range of people, some of whom may have very low healthcare cost and some of whom may – have may, may have higher healthcare cost.

But when you have a group plan, you're spreading out the cost of those plans amongst a wider group of people. It isn't social insurance because it isn't everybody but it's a large numbers of people. For example, Safeway has its own healthcare coverage for all of its Safeway employees. That's group health coverage as an example.

The individual healthcare market which we touched on, on slide 12, is individual insurance purchased by an individual in the private market. And in this situation, monthly premium which can be very expensive are ascertain to be born by the individual and they can also include co-payments and co-insurance and deductibles; terms of art that we're going to unravel for you as we proceed here.

A very few people that you are working with can access the individual health market because they all have pre-existing conditions that would be on plus security benefit embedded so we are focused today mostly on a group health coverage plan offered by employers or associations for union. There's a 19-day difference between group health coverage plan and individual market plan. It's the concept of medical underwriting.

Medical underwriting is a term of art, it's a legal term, and it means a serious review of someone's past medical services received or prescribed; to ask, to assess whether eligibility for health coverage is even possible. The individual market is allowed to do medical underwriting night and day all day long, 24/7. And the group health coverage market is not allowed to do medical writings, underwriting, or is severely limited in doing it especially for the folks we work with who have pre-existing health coverage when they come to you for help. And we will get unravel those details as the training progresses.

One of the things that we like to stress at the beginning here then, and that is a helicopter ride overview of where we're headed today, is we are hopeful that you and your assistance can impart a beneficiary understanding of how to navigate this world. And the concrete steps that, or the elements of understanding that rule, start with the sort of little bullet list on slide 14 which is looking at the beneficiary's current benefit profile. That's job one, you're very familiar with that.

Then you're looking at the current opportunities or employment plan. Then, you're looking at the healthcare adoptions that may or may not be available in that context in terms of accessing the private market and seamless attachment to health coverage. As that understanding gets more robust and more interesting, the consumer and you are going to want to know who pays the bill first, the primary payer rule, and what are the costs out-of-pocket for that beneficiary that you maybe working with.

So, what are the plan – what does the plan cover? What does it cost that may not be a cost today? And how do those new plans interact with current benefits or the current benefit assessment?

The primary takeaway from all of these is that the type of the health coverage that may be available with that employer or with that situation which is about to change due the paid work, the type pf health coverage can determine which plans or program pays the medical bills first and how to proceed moving forward with the affordability of being able to access that new health coverage.

Now, I'm going to turn it over to Mason and he's going to burrow down into some details.

Mason O'Neil: OK, thank you, Bryon. And I'm going to go more into depth into the primary payer rules and guidelines.

Bryon MacDonald: Slide 16.

Mason O'Neil: Yes. When someone else multiple type of health coverage that a general federal rule that relates to the primary payer rule and that is that private health coverage pays the medical bill first, Medicare pays the medical bill second and Medicaid is last or third. So, Medicaid is often termed as the payer of last resort.

Coordination of Benefits is the term that is used by Medicare and also with group and private insurance when deciding who pays first. So, you'll see that term in some of the Medicare manuals or in the Medicare new 2010 guide. Medicare has specific guidelines that determine whether they'll pay first or a private health insurance from an employee will pay first.

And if company is – has 100 or more employees then Medicare pays the bills after the employer-sponsored health coverage pays the bills first. So, if a employer is larger or over 100 employees, then the private health insurance for that company will pay it first and Medicare will pay in your remaining amounts on the – for the medical services. If it's a small company, if the company has less than 100 employees then Medicare will be the primary payer and the employer-sponsored group health plan will pay second.

So that's Medicare's general guidelines on who pays it first. And we'll talk a little bit later about why it's important to understand who pays first; essentially, to make sure that the beneficiary doesn't have any billing problems when they see a medical provider. And when I'm finished with this session and we'll deal a little bit more and then we'll come to the question and answer session, so there'll be an operator to ask questions as well.

On this next slide, slide 17, you see three examples of primary pay rules which are all a little bit different. So in the first example, the three types of health coverage; employer-sponsored health coverage, Medicare and Medicaid, they all provide and pay for the same service. So the general federal rule will apply, that the private health insurance will pay first and then Medicare and then Medicaid will be the last or payer of last resort.

In the second example, Medicare provides and pays for services X, Y and Z but the employer-sponsored health coverage does not cover these services. So in this case, Medicare will provide and pay for the service because if you can't access the service due to private health coverage the Medicare will pay for that.

And then the last example, if Medicaid is the only provider of the service or equipment, the only health coverage that covers that services then Medicaid will pay for the service and equipment. Even if the individual has other health coverage, private health insurance and Medicare, Medicaid is the only one that covers that service.

And lastly, the – an important tip to give to beneficiaries when you're working with them is that they need to inform their provider when they have multiple types of health coverage of what type of health coverage they have. So if an individual is – thinks of using their health coverage from their employer, they also need to say whether they have Medicaid then you tell the provider if they have Medicaid and Medicare as well, to avoid any billing problems.

OK. On this next slide, we're going to give an example and we put a statement but this could actually be the same rule of applying to any state. We're going to use the example in California; and Medicaid is called Medi-Cal for California in California. So here's an example where a beneficiary is a provider that accepts both private insurance and also Medi-Cal for the same service.

The beneficiary must access the service fee of the private insurance. So, Medicaid knows that it's the payer of the last resort and it's going to want that service fee to be paid for by the private insurance that the individual has. So for example, if the individual sees a provider that does not accept the private insurance then there's going to be a problem because Medicaid wants the private insurance to cover that service because Medicaid will always ask and know if that individual has other types of benefits that may pay it first.

Another important guideline is that if a healthcare provider does accept both Medicaid and private insurance, the patient cannot be charged co-payers or other cost sharing higher than the standard allowable Medicaid co-payers in cost sharing. And this means that if a provider or a doctor or a hospital accept both types of insurance, the individual must be paid the lower co-pays or amounts of the, that Medicaid accepts.

There may be cases where a beneficiary wants to use their private health insurance from the employer because let's say that the service is not offered by Medicaid and if they see a provider that only accepts a private health insurance that's not, then they may have to pay the higher co-pays or whatever, anyone else would have to pay in that employer group health insurance.

So the takeaway from the fourth section of primary pay rule is that beneficiaries need to be careful about what type of coverage is accepted by the medical providers that they use. As I mentioned in the last slide, this can determine how high their co-pays and other co-insurance payments will be, and also they can avoid any problems if the insurer or the provider doesn't accept one of their types of health insurance.

As an example, if a beneficiary has a Medicaid and private health insurance and they see a provider that doesn't accept their private health insurance they can have problems because Medicaid will want their private health insurance to pay for the benefit, but the provider does not accept the private health insurance. So this is a general guideline; beneficiaries need to be careful about which providers they're using when they have multiple types of health insurance.

And I'll turn it over now to Bryon who's going to talk about some of the out-of-pocket costs and other.

Bryon MacDonald: And as a transition here, Mason, I would just also add for folks that when you get into these greedy and sticky areas, the training today and next week will emphasize that if you're unsure, get some third-party help. You can talk to other state resources, resources in your state that can help with the primary and secondary pay rules and navigates the system. If you want to take a deep breath, not pretend that you know at all because quite frankly no one knows it all.

But getting outside help, third-party help with the health insurance programs and/or other services, the Medicare beneficiaries for example, and/or other expertise in you area, maybe the strategy that you have to put into place in order to, that person to have the quality employment outcome that you've been planning on anyway but you run into this healthcare difficulties. There is always a solution. I would just sort of wrap that up in a bow with that.

Now, I'm transitioning here because we're going to talk a few minutes about out-of-pocket cost and health coverage. And I wanted to again pause for a second and take 10 seconds for an understanding that between the PowerPoint and all the handout, I would put all these – I would three whole punches in all these things and put them on a binder so you can have them handy on your desk.

There are kinds of art in the integration of public and private health coverage they are indispensable to understand and learn and use. One of them is out-of-pocket cost, a second is cost sharing, both of those terms are in this particular slide. As you use multiple programs, you want to, as much humanly possible, use the terms of art or the definitions or the language that the program is using to explain in the future.

This is, increases communication when you're interacting with other agencies and health plan. If you are all using the same jargon, it's highly likely you're going to have better communication than if you're making up the term on your own. Out-of-pocket cost refers to what's coming out of the beneficiary's pocket to pay for that health coverage and that part is not getting reimbursed by any third party. It's actually a technical term in healthcare circles.

Cost sharing is also a term of art and it refers to how much a healthcare beneficiary is paying out-of-pocket on an annual basis. And there are other terms of art that we're going to be talking about that health coverage plans use; we want you familiar with them. Trust me, they will put you to sleep.

So you want to keep this PowerPoint handy so that you can refer back to this definition and this terms of art about cost sharing because healthcare or no healthcare reform, you are invariably going to run into cost sharing at some level no matter what the program is, inclusive now on Medicaid which really has the least amount of cost sharing of any health coverage. But even with Medicaid and state budget being so tight, cost sharing is coming into play as well in Medicaid.

A few main types of cost sharing are on slide 21. The monthly premium is an amount often paid in monthly installment to purchase an insurance policy or access medical services. For example, in the Medicaid Buy-In, they have premiums as well private health coverage, whether it's a monthly premium paid, you do not necessarily get a benefit when you pay a monthly premium. You may get a benefit if you meet the terms in the policy but a premium is a monthly set amount that you pay every month when you get a benefit or not and this is the price of enrolment in that plan.

A deductible is a different form of cost sharing than the monthly premium and it's an initial out-of-pocket specified amount that is paid before to health coverage plan or the program begins to contribute towards the medical cost. So, a deductible. I go to – and my healthcare at Kaiser, quite frankly, is going through the roof. I go to the doctor at the Kaiser and I have to (flock) down a deductible just to see my doctor, for example. Before they will allow me in and Kaiser will pay the rest of the bill, I have to pay a deductible when I see the doctor.

Co-insurance is a slightly different form of cost sharing. It is a percentage of medical cost that the enrollee pays towards the cost of medical care in an ongoing way. So, if there is a regimen going on that is protracted, there could be co-insurance, a different form of cost sharing that your plan, public or private, would explain to you and to your beneficiary. These are terms of art. These are terms to understand how they work and whether or not the program has them or doesn't have them, determine the level of cost sharing.

A couple of other cost sharing terms that you want to be familiar with, co-payment; for example, I go to the drug store at Walgreens and I slot down my prescription and Walgreens says, "There's a $5 co-pay for that drug before I'll put it over the counter." You have to pay that co-pay, it's a fixed fee, to purchase a specific medical service or a drug. Co-payment is a point in time, usually pretty small, fixed fee before that medical service is triggered.

Out-of-pocket maximum is a term of art that is going – you're going to see more of as healthcare reform is implemented over the next five years. Out-of-pocket maximum refers to the total amount out of my pocket that a health insurance plan is allowed to charge me per year. And those rules will get stricter as the healthcare reform is implemented.

But an out-of-pocket maximum is an annual cap on the money that is out of my pocket, via premiums, deductibles, co-insurance, co-payments, whatever, and that's the maximum of which that plan will be allowed to pay for those – the maximum dollars out of my pocket that the carrier, the plan will be allowed.

And with that, we're going to basically describe that with what we've heard so far, the regimen that we would like you all to consider is probably not unfamiliar, not too much different than what you're already doing. You don't want to take all these to consumers in a didactic A-B-C-D kind of way. You want them and you want to work with them so that they are planning in place.

Planning in place means plan to the job situation at hand, it's benefit package options that you and the consumer may know about and then find out what that is, and then look up these rules and look up the terms, and strategize if this is – what the best plan is in terms of finances and in terms of coverage.

And we're going to pause there and ask our moderator to come on and take questions for us or give us questions. This is our first Q&A period is what I'm trying to say.

Laura Coffey: Thank you, Bryon. (Steve), if you'd like to go ahead and give the instructions on how our callers can indicate if they have a question. Go ahead and queue up the lines and I have no questions in the text chat box at this time.

Operator: OK. So at this time, I would like to remind all participants in order to ask a question on the phone, please press start then the number one on your telephone keypad. We'll pause for just a moment to see if there are any questions.

Laura Coffey: I have a question in the text chat box from (Allison Toon). Just as I do have a question, (Allison), if you'd like to type your question into the box, I'll be happy to share it.

Operator: And there are currently no questions on the phone.

Laura Coffey: OK. (Allison)'s question is, "You'd mentioned that the co-pay is the lower of the two insurance co-pays."

Bryon MacDonald: Am I on?

Laura Coffey: Yes.

Bryon MacDonald: If I did, I didn't want to – I didn't mean to say that. A co-payment can be of varying degrees of difference. And I wouldn't compare the amount of co-payment with just about anything. It's not really an apples and oranges comparison.

A co-pay is a point in time out-of-pocket cost. For example, at a drugstore when you're paying for a prescription, you maybe asked for a $5 co-pay. I wouldn't compare it to other cost sharing items. There's no reason to, quite frankly.

Laura Coffey: And she goes on to continue to ask is that if you're asking both of the insurances to cover a service.

Mason O'Neil: Right. I can comment briefly on that. So, if you see a provider that accepts Medicaid and also private health insurance, you can only be charged the Medicaid, the lower Medicaid rates because at the letter it accepts Medicaid.

If you see a provider that only accepts the private health insurance then you may be charged the higher amount. But that may be beneficial to you if you want to access that medical service that Medicaid doesn't cover or you want to see a provider that doesn't accept Medicaid. So when you have those two choices, there may be times where you want to access different types of benefits through your employer-sponsored health coverage.

But in general, if you see a doctor, what – you would probably want to find a doctor that accepts both Medicaid and the private health insurance. And then it is correct if you pay the lower amount which should be the Medicaid in this case. In general, Medicaid has lower co-pays and out-of-pocket cost than other private health insurance.

Bryon MacDonald: I, Mason, I think did a great job there. And the reason I want to re-enforce what Mason just said, the question is dynamic and terrific. But it re-enforces that this is a one-on-one analysis. Cost sharing is an assessment that goes along with quality of medical services. I may want to pay more to get the medical services that meet my medical needs for my independent living needs.

So it is not always cheap is the best. There is a dynamic ratio between the quality of services I want or I can access and the, my ability to pay for it. And they are interconnected as what I think Mason is saying and solved on a case-by-case basis.

Mason O'Neil: Yes, great.

Laura Coffey: And (Allison) goes on with her question like, "If the coordination of benefits is such that the private health insurance will cover it and so Medicaid will not be triggered for coverage?

Bryon MacDonald: That is a rule of thumb. That would be normal, yes. The Medicaid would in fact be saving money which is something not insignificant to keep in mind here. When our folks access employer-sponsored health coverage that are their primary payer and they provide an incomparable service to Medicaid, you want to grab that service from the employer-sponsored health coverage and save Medicaid's money so that Medicaid will be around in the future.

Laura Coffey: OK.

Bryon MacDonald: So, basic answer there is both health coverage is on the table, I'm enrolled in them. But whenever your needs are met by employer-sponsored health coverage, you should grab it.

Laura Coffey: So we can continue to her question to ask, "Will you still pay the Medicaid co-insurance amount if both insurances are accepted but Medicaid will not be billed?"

Mason O'Neil: Yes, you will. You cannot be charged the other, the higher amount because that provider accepts Medicaid. The – what's happening in the billing is often invisible to the actual beneficiary. But if they're seeing a provider that accepts your Medicaid, they cannot be charged the higher amount.

Whether or not Medicaid actually needs to pay anything for it or the private healthcare is going to cover all the expense, it's kind of invisible and it doesn't really affect the beneficiary.

Laura Coffey: Thank you. (Steve), do you have any questions that have come up in the meantime?

Operator: There's still no questions on the phone. And just a remind to participants, it's star, then the number one, in order to ask a question.

Laura Coffey: OK, thanks. Now, I do just have another text chat question from Mark. "If private health insurance and Medicare pay for a service, can this amount be applied to a Medicaid spend down?"

Bryon MacDonald: Great question, very topical. If there isn't out-of-the-pocket cost to the covered services by a Medicare employer-sponsored, then providing the service in of itself can not be applied to a share of cost. But if there is an out-of-pocket cost sharing from the beneficiary in those services, that debt can lower a share of cost without a dime out of the beneficiary's pocket. There's a distinction there, I hope you get it.

Mason O'Neil: In general, share of cost or spend-downs are usually met by what the individual pays themselves.

Bryon MacDonald: Or incurs the debt.

Mason O'Neil: Yes.

Bryon MacDonald: Yes. So if the covered service by the employer or Medicare does not ask for any cost sharing from the beneficiary there's no share of cost connection. But if there is some cost sharing by the beneficiary in that service by Medicare or the employer-sponsored, that cost sharing can be used to lower share of cost. That's a great question. I hope the answer was clear.

Mason O'Neil: And I'd like to just mention that you can enter a text question any time during our presentation. So if we say something and you want us clarify it, Laura will actually assist us in capturing those questions that when we start our question session, we can answer some of those questions as well.

Bryon MacDonald: And if I can just add one more thought, we are unfortunately willfully behind. We've got an hour and 10 minutes left. But share of cost is an issue in many states right now because the rules are tightening around Medicaid eligibility and share of cost Medicaid issues are popping-up all over the place.

Do not underestimate the value of a Medicaid buy-in in your state if you have one. If there's a capacity for that person to earn even modest amounts of earned income, they could get full scope Medicaid services in your state via a Medicaid buy-in, if possible, and eliminate the share of cost issue completely even if the earnings are very, very low. So, that's something to think about when you are having share of cost issues come to your table.

Mason O'Neil: OK. I think we're going to move on to the next training section, and I'll – I will be doing this section.

Laura Coffey: Thank you.

Mason O'Neil: And going so briefly talk about assessment and look at the question of what health coverage does the beneficiary have occur in the access right now. I sent everyone a health coverage planning checklist, that was one of the attachments, and this is a tool that you can use when you're doing an assessment. You can sit down with the beneficiary and fill out together or that you can give it to them and they can fill it out.

You can adopt this tool. You know, put it on your own stationary or use it to modify several to make it the most useful it is to you. It asks – it does a thorough overview of someone's current health coverage, looks at questions about if they're working or are the other family member that needs to be enrolled and touches base on some of the main loss we're going to talk about today as well, which is COBRA and HIPAA; which we'll get into in the next section.

It's important when a beneficiary, when you're meeting with the beneficiary to do a through assessment and determine what types of health coverage they have. And on this side, I'm going to talk about some of the different possibilities.

One obvious one is employer-sponsored group health coverage. Some of the outside family coverage and this might be based on a spouse or family member or parent. If that person is working, you may have covered to them. One of the important changes that has been implemented in the short term of the healthcare reform legislation is that starting on September 23, children will be able to stay in their parents insurance policy until they are 26.

The current law says that children are dropped off from their parents plan when they turn 19 or finish college but the new legislation will allow individuals to stay on longer. So it's actually more likely that a beneficiary will have family coverage. If an individual has a Medicaid, on this side, I list out some of the different Medicaid categories. And they may not have an idea, but you can work to determine what Medicaid category are they on.

If they're on SSI, it's most likely Medicaid based on SSI eligibility; sometimes it's called SSI link to Medicaid. If an individual doesn't have SSI, they may be on Medicaid through a different program; one is the categorically eligible and low cost Medicaid. There is also the Medically Needy Medicaid program, that's the program that often has a share of cost or spend-down.

The Medicaid Buy-in program, which is currently in 32 states, is the program that Bryon mentioned where an individual is disabled and working and pays a premium and is able to access free or low cost Medicaid. And lastly, it's becoming increasingly common that if an individual is on Medicaid, they also have to choose an HMO which will manage or distribute the healthcare services through an HMO program. HMO is a Health Maintenance Organization.

You also need to determine an individual to Medicare and what Medicare options they've chosen. If someone has Medicare and no Medicaid, you want to look at whether it's a possibly that they would be eligible for Medicaid, because there's many individuals on SSDI who have Medicare but don't realize that they may also qualify for Medicaid. Particularly, if their savings and assets are low enough, and that may give them a lower cost option to access medical services.

At the bottom of this slide, I list some additional types of health coverage. I'm not going to go over them but there is, the veterans or VA health coverage, State Children Health Insurance Program, SCHIP, Federal Employee Health Benefits program, and I'll talk about that a little bit more on the future slide.

Lastly, I just want to very briefly mention during assessment of someone's health coverage when they have Medicare. And, on this slide, you can see the basic four parts of Medicare. Part A is hospital insurance. Part B is medical insurance or out-patient treatments. Part C is the part that Medicare beneficiaries only have if they're involved in a Medicare Advantage Plan. Medicare beneficiaries can choose to be in the original Medicare, free for service Medicare, or they can choose general in a Medicare Advantage Plan. And part D is our prescription drug coverage.

And a beneficiary and also as a CWIC, you may not know the best offer for the individual, but there is excellent counseling and health they can get in the State Health Insurance Program, or SCHIP, which exists in every state. And we have in our handout on state resources and federal resources a link to the local SCHIP in your state.

Last thing I want to mention is that there are some significant changes to Medicare program that are rolling out slowly through the healthcare reform legislation. And most of these are many years in advance, you can read about these changes in the attachment we've sent you, the Healthcare Reform Summary. I'll just mention one example which is going to come this year, which is if a beneficiary falls into what is called the donut hole, this is a period where they have high enough prescription drugs cost that their Medicare Part D plan is not going to cover much to their drug cost for a while, that's called the donut hole.

If someone does found the donut hole, they can actually get a $250 rebate this year, and there's more information on that in that healthcare summary.

Bryon MacDonald: Excellent. Turning over to me?

Mason O'Neil: Yes.

Bryon MacDonald: What I'd like to add to that, Mason, is we have a plan or a construct between what is the current law, what is happening now, and that's this training, and then what is likely to happen soon or going to happen soon or later with healthcare reform? And that is the handout called Healthcare Reform Summary. I would keep those two next to each other.

We want to be clear that the PowerPoint is describing current law. As current law gets in – as new reform gets implemented, we will import it into PowerPoint and say, "This is now current law." But until it is, we're keeping the two documents separate so that you'll know that it's either its eminent or coming or it's going to be here in a year, but its part of this very large reform.

And we don't want to confuse you as to what the current law is versus what's coming down the pike soon. We've – we're veterans, frankly, of the Medicare Part D rollout, that they could do workout rollout, when the major bill becomes law the first causality is disinformation and misinformation. And we're trying to be very clear here to keep things separate between, "What should I know now that in current law and what should I know this coming soon that will change current law." And we're keeping those two separate for reasons of clarity.

The Medicare Part D donut hole is a financial mess for people who cannot get the low income subsidy in Medicare Part D. So starting June 10th, there will be a rebate of $250 dollars for anyone who gets into the donut hole. Those are not folks who have a low income subsidy now. They'll never get into the donut hole because they have already financial support with Medicare Part D.

So moving right along here, training three, and I'm going to go as lightly and as quickly as I can because we are running behind a bit. But the first thing we want to do is look at exactly when does anybody access private health coverage options. So we are in training section three and we're going to the first slide on slide 28, and for everybody whose accessed the employee-sponsored healthcare coverage, these are the terms of art and these are when folks access private health coverage through their employer.

There's normally a service wait and if it is a Health Maintenance Organization, the service wait is called conciliation period. But again, these are terms of art you want to be familiar with. A service wait basically means any employer that's staying in the business and is in the black is not going to offer healthcare coverage on day one of a job if they don't know that you're going to make it for the first week.

So most all employers have a legal authorized service wait where they wait 30 days to six months and see if you're going to stay at the job. And then they'll give health coverage after the 30 days on the job, three months on the job up to six months. The average service wait is three months. So, anybody taking a job at Target or Safeway is going to wait 30 days up to six months for that healthcare coverage to kick in.

And the same as true in an HMO, for example, Kaiser, it's just a different term of art for the same service wait. People with disabilities however, urban myth or otherwise, think that they can't get into group health coverage. And we are here to tell you that HIPAA changed that picture in 1996, that's slide 20...

Mason O'Neil: Seven.

Bryon MacDonald: Nine.

Mason O'Neil: Twenty-nine, yes.

Bryon MacDonald: Twenty-nine. HIPPAA is the Health Insurance Portability and Accountability Act. It has some honor in its positions but it is also has incredibly important protection for any beneficiary you're working with who has been on Medicaid or Medicare for any period of time.

Essentially, at the bottom of slide 29, HIPAA can't exempt your beneficiaries from the medical underwriting practices and the pre-existing exclusionary periods when employer-sponsored health coverage becomes available to everybody else after the service wait. In other words, you folks who have been on Medicaid or Medicare for any period of time can use that prior period of time and access to Medicaid or Medicare to get into employer-sponsored health coverage on the same day as anybody else taking that job at Safeway or the bank or wherever; HIPAA does that for you.

And it does it by offering a credit month-to-month. For every month of prior credit; in other words, I've been on Medicaid, for example, for 12 months. So I have 12 months of credit then that I can apply towards reducing or eliminating a preexisting exclusionary period because I have a disability with the new job.

And that is the beauty and the elegance of HIPAA. It allows our folks to get into employer-sponsored health coverage the same day that anybody else taking that job would get into without a disability. HIPAA is incredibly important and it's not as well-known or used as it should be. And it breaks down that urban myth that, "Oh, my god. I'm on public benefits, I can't get private benefits." Well, that is not the case.

One of the main deals here, and I'm not going to read these slides, is that there has to be at least 63 days. There has to be no more than 63 days between the prior healthcare coverage and the offer of the new employer-sponsored health coverage. Well, mostly our folks going to work are still probably on some form of Medicaid or Medicare. So any flavor of Medicaid or Medicare is going to get you or your customer eligible for HIPAA protection. And access that employer-sponsored on the same date as anybody else taking that job; which would be again, back looking at the service rate and asking, "All right, when is the service rate?"

So, that is HIPAA in a quick nutshell. And I want to emphasize, I'm just going to skip to slide 30 real quickly. At the bottom, you see a definition of creditable coverage. That's that prior period health coverage which is used to reduce the length of a preexisting condition. But if I have three months of prior health coverage, I have three months credit towards reducing a preexisting exclusionary period. Again, most of the folks you come to are probably have been on Medicaid through six months, or Medicare at six months or longer, and they're going to be automatically eligible for HIPAA protection. It's a very big deal.

With that, I'm going to skip down to slide 34 and talk about other features of private health coverage in terms of when people normally access private employer-sponsored group health coverage. The initial enrollment period, again, these are all terms of art, is when that health coverage is first offered by an employer at the start of employment. You want your beneficiary to look very carefully at the initial enrollment period and say, yes or no, to choosing to take on the employer-sponsored health coverage.

By way of guidance, I would advice, it's free, take it, period. And if it has some cost sharing, you still want to look at it carefully to access it rather than deny it.

But again, that's a case-by-case situation. The reason I'm so important about the initial enrollment period is that HIPAA protection are the strongest during the initial enrollment period and not later when someone decides not to take the health coverage in the initial enrollment period. So please understand initial enrollment period when it's first offered by the employer and it's a very important time to make important decisions about whether that person want pick up the employer-sponsored or not.

The annual enrollment period is usually once a year, December in our case here at WID, where a person can drop out or change or switch plans, you know once you get into a private healthcare plan the likely to stay there for at least a year, and then there's an open annual enrollment period with both plans where you can change the terms and the policy or drop it or get a better one, annual. Then there is a special enrollment period which is a 30-day period in which a beneficiary can enroll in or change group health coverage depending on specific prior situations.

When the initial was offered for example, the customer may not have needed it because they had all the health coverage they needed, and they didn't – and there was the cost involved. And maybe down the road, the cost is eliminated or if they have different health care needs, well, they can get into a special enrollment period under certain circumstances. But again, I want you folks to bear in mind to takeaway here is that the initial enrollment period is really, really important.

OK, moving on. Special enrollment period, let's just touch briefly on that, occurs when an individual has other health coverage loses that health coverage if a person becomes a new dependent through marriage, birth, or adoption. So, you know, life changes. And those qualifying events for special enrollment include marriage, birth, or adoption, and they can now allow access to benefits under special circumstances that normally wouldn't happen otherwise.

So we'll just end it at that. And for this transition, I'm going to turn this over now to Mason and we're going to get into COBRA which is a companion health coverage protection for the HIPAA protection. HIPAA is on the way in to a job; HIPAA is on the way in to new employer-sponsored or group health coverage. COBRA is what happens after I might lose a job and I still need attachment to my health coverage. Go ahead take a minute.

Mason O'Neal: Thank you, Bryon. And I'd like to make two quick comments. The first is that, in the handout on state and federal resources, there's a link that gives a specific guide for a state. And you can see if there's any changes to HIPAA laws or the COBRA laws on your state. So states may give additional protections or may extend the periods for HIPAA or COBRA and its health insurance spot info, and you'll see the link on that guide as well. So I would encourage everyone to download the specific guide to find out more information about any state laws. We're going to cover the general, federal laws in this training.

The second thing I'd like to mention is that, HIPAA will be changing due to the health care reform in the Affordable Care Act. And most of the changes are several years down the road. I just want to mention briefly two important changes. One is by the year 2014, insurance companies will no longer be able to deny any one coverage because of their pre-existing condition. So this means that pre-existing conditions exclusionary periods and the needs for HIPAA will go away in some form in 2014.

The changes in the Affordable Care Act that are coming further down the road are often undefined and that's why I just want to get a heads up that HIPAA rules will be changing but we can't say specifically what will happen. Yes. The second thing is that there is a healthcare legislation, part of it that is being implemented sooner, and that is starting on September 23rd 2010, insurance companies are not allowed to deny coverage to children under 19 because of pre-existing conditions. So, this is our – this is one of the HIPAA regulations that will come into effect this year and affect pre-existing condition for children.

In this next section I'm going to talk about COBRA continuation coverage. And COBRA stands for Consolidated Omnivous Budget Reconciliation Act. This is the Act in 1986 that created the COBRA legislation. These are protections that Byron that said when someone is leaving a job. And essentially, COBRA is a law that gives employees the right to choose to continue their employer-sponsored health coverage for themselves and also for any family members or dependents if that coverage has ended for certain reasons.

COBRA let's you, when your job is ending, continue your health insurance. And in return, you have to pay a premium and you, even when your job ends, you can continue the health insurance from that job. Coverage can continue for up to 18 months, and if someone is disabled according to (inaudible) rules, they can extend that for an additional 11 months for a total of 29 months of possible COBRA continuation coverage.

In order to qualify for COBRA coverage, an employee must have lost their group health insurance because either voluntary or involuntary termination of employment for reasons other than gross misconduct, or they've had a reduction in the hours that they work which have made them no longer eligible for the group health care plan, but they can choose to continue their coverage with COBRA.

Employers that have 20 or more employees are subject to the federal COBRA rules. And in the upcoming slide I'll show you where you can find out if there's differences in your state which may say even smaller companies are also required to follow the state COBRA rules. And the employer must give the employee at least 60 days notice after losing their group health coverage to choose whether they want to continue their health insurance under COBRA.

So traditionally, COBRA has been very expensive. There is recent legislation that have reduced the premiums but traditionally COBRA has been almost prohibitively expensive as an option for health insurance. And Medicare and Medicaid has been a better choice for the benefit rates that we see. As an example, an individual may have to pay at small amount on their job but when they leave their job they have to pay a higher monthly premium at maybe $300-400 or even more after continuing family coverage. And the guidelines are that the employee must pay a premium up to 102 percent of the plans' total cost of the coverage.

When they're working they may only be paying a small portion of that and the employer may pick up the rest. But afterwards, they'll be paying the full amount of the plans' total cost. If an individual is accessing extended COBRA, the period after 18 months up to 29 months, then they can be asked to pay a higher premium up to 150 percent of the plans' cost.

As a CWIC, you may encounter individuals who have stopped working because of sudden disability or onset of disability, and they are either in the process where they've used up their savings trying to maintain their health coverage by paying for COBRA, and we can help them by seeing if there's other ways they can access health coverage such as Medicaid. Maybe there's a Medicaid program or a Medicaid buy in that can help them to access more affordable health coverage than COBRA.

In 2009, there was a legislation passed which was COBRA premium assistance which made COBRA much more affordable for the initial months for individuals who are eligible for this program. And that was the American Recovery and Re-investment Act of 2009, often called ARRA. An ARRA provides for premium reductions for COBRA health benefits for up to 15 months if they meet all the qualifications.

If they do meet the qualifications for the premium assistance, the beneficiary will actually only pay 35 percent of the monthly cover premium, and the employer will pay the remaining amount and be reimbursed directly through a payroll tax credit. So this can make COBRA a much more affordable option for individuals who are working and have to stop working because of a disability or some reason and lose their health coverage.

And the two important qualifications is that, the job must have been lost involuntarily. So if an individual quits their job, they can access the regular COBRA protection but they will not get the premium reduction assistance. And also, the job must have been lost between September 1, 2008, and May 31, 2010.

Congress has been extended the, has been extending the COBRA premium assistance. As it runs out for, actually two times they've already extended it, and it's possible they will further extend it so individuals that lose their job after May 31, 2010 can be eligible. But currently, the program actually ends on May 31st, 2010. It doesn't mean someone can access it but if someone loses their job after that date they cannot get the premium assistance. They can only access the regular COBRA and have to pay the full premium amount.

Lastly, this slide shows some of the variations in the states to the COBRA continuation coverage. So, 40 States currently have COBRA extensions. These are specific state COBRA legislations, and these laws can extend the maximum duration of possible continuation coverage. They can define a minimum level of benefits that COBRA policies have to cover. And they can also put a cap on the maximum rates that can be charged to the beneficiaries when they access COBRA. And the link here, and also on the handouts, will bring you to a webpage where you can see your states and their specific variations in the COBRA legislation.

Bryon MacDonald: And I'd like, before we open up for Q&A, I'd like to add one other comments to Mason's good work here. You may want to write in your margins here the following; COBRA is very, very helpful in circumstances for people with emerging disability and they need attachment to that private health coverage as well as whatever else they might have.

Many in those people in that situation may also access Medicaid in your state. And in the margin, you should write here HIPP; Health Insurance Premium Payment program, H-I-P-P. If your charge is in a COBRA situation which is out-of-pocket premium payment, the Medicaid program in most state has a health insurance premium payment program called H-I-P-P, HIPP, to separate application.

But that COBRA premium could be picked up and paid for by state Medicaid, if Medicaid decides that paying that premium will save the state of Nebraska, or whatever, money. So that's another option to alleviate and access COBRA financially because COBRA can be terribly expensive.

With that, we're opening up again to our Q&A session number two.

Laura Coffey: OK, thank you. (Steve), if you'd like to queue up any lines and give instructions again, I do have a few questions in the text chat box that you can go ahead and give instructions on how to ask a question on the phone.

Operator: Just a reminder in order to ask a question over the phone, please press star then the number one on your telephone keypad.

Laura Coffey: Thank you. Now, I have a question from (Lori Tee). "I recently had a situation where the consumer had private health from – health coverage from an employer, Medicare and Medicaid. Even though the doctor accepted the private and Medicare, they would not see the consumer because she had Medicaid."

Bryon MacDonald: And the provider accepts Medicaid?

Laura Coffey: It says the provider accepted private and Medicare.

Bryon MacDonald: And Medic – and didn't – would not accept the consumer because the consumer was Medicaid eligible?

Laura Coffey: Yes, as well as having private and Medicare.

Bryon MacDonald: (Inaudible).

Mason O'Neal: I don't – yes. I don't believe that that is legal.

Bryon MacDonald: Yes.

Mason O'Neal: If you have Medicare and the provider accepts Medicare, they have to accept your Medicare.

Bryon MacDonald: OK. She said they've got private health coverage through the job.

Mason O'Neal: Yes.

Laura Coffey: Yes.

Bryon MacDonald: Medicare and Medicaid but the doctor refused to see the person period because they were Medicaid eligible.

Mason O'Neal: Right. But you don't need to use your Medicaid. I have actually all three of those cases and I've seen Medicare providers. And the disadvantage is that I don't, you know, I have higher co-payment when I pay but those providers, I have Medicare and they accept Medicare. So they can't discriminate against me just because I also have Medicaid.

Bryon MacDonald: I would agree with that. And I would argue that the protection and advocacy, now called disability rights across the country, I would give them a call and troubleshoot with them on the legal legality of the employer of the doctors positioning there.

Mason O'Neal: Yes.

Bryon MacDonald: I don't think what I'm hearing is either ethical or possibly illegal. But I would want again, to keep it at a higher level here, we don't have all the facts in front of us but I would investigate that and I would consider at the prevue of the Protection and Advocacy for Beneficiaries of Social Security, the PABSS program, which is troubleshooting about benefits and work incentives and employment. I think they would love to hear about this case and brainstorm further in that state where that's happening.

Laura Coffey: Thank you. We have our next question from (Dawn) who says, "That exclusion – this is back to the HIPAA, that exclusion only applies if they have access medical services for that condition, right?"

Bryon MacDonald: No. HIPAA protections are for access to the employer, employer-sponsored health coverage that is offered to everybody on the job. No, that's incorrect. It's not disability specific or medical services specific. It is accessing employer-sponsored to a group health coverage at the same time as anyone else able-bodied and non-disabled who doesn't have a pre-existing condition the way most of our folks do.

Laura Coffey: OK. And our final text chat question comes from (Chris Cokery), "Is that 63-day rule based on the date healthcare coverage ended to date employer healthcare is available or date employment was started?

Bryon MacDonald: That's a great question. It is my best understanding that it is from the termination of the prior health coverage to the date of the new eligibility for the new health coverage. It is not about the start of employment date. That's a very sound question. And again, most of your beneficiaries we would hope at this point, you know, don't give up healthcare under any circumstances. If you got it then keep it.

So if you're in non-Medi – share of cost Medi-Cal, you're regular Medicaid, keep it. And most people don't have a 63-day wait because they're coming to you already on healthcare. And you're helping, you're instructing them how to answer that. But it's from date of loss of prior health coverage to date of onset of new health coverage, 63-day break, no bigger.

Laura Coffey: OK. Thank you. And (Steve), do you have anybody lined up to ask a voice questions?

Operator: There's currently one question from the line of (Aine Casey). Your line is now open.

(Aine Casey): Hi, there. I had a question about the state COBRA laws, so. And you are saying that if you got a 20, I think it is, or less employees that you're subject to state COBRA laws rather the federal. Am I getting it right?

Mason O'Neal: Actually, the federal COBRA laws apply to larger employers who have 20 or more employees.

(Aine Casey): OK. And does that mean if you have less than 20, you're subject to...

Mason O'Neal: No, it does – it does not.

(Aine Casey): It means you can't get COBRAs if you have less than 20?

Mason O'Neil: Well, it means that if – let's say that an employer has 18 employees.

(Aine Casey): Yes.

Mason O'Neil: I mean, under the federal law, they're not required to follow the COBRA provisions. But you need to look and see what your – if your state has any changes. And let's say that the state that your in that all employers greater than, you know, what 10 or more employees are covered under the state COBRA laws. So, it's not that the smaller the company has the less likely that it has to follow this exact COBRA provisions but a state COBRA law can say instead of, you know, company that are 20 or larger, it could be 15 or larger or 10 employees are larger, have to follow the state COBRA laws. But you need to specifically find out the rule in your state.

(Aine Casey): Yes.

Mason O'Neil: It's not true.

(Aine Casey): I have to follow the federal COBRA laws you mean?

Mason O'Neil: You need – well, we've trained on the federal COBRA laws which says 20 employees or over have to follow these laws and you need to look up on that website what's your state coverage. And they may say that it's, you know, companies with 15 or larger have.

(Aine Casey): Yes. Yes, I got you. I got you, thanks. Thanks very much.

Bryon MacDonald: Very good. Anyone else?

Laura Coffey: If there's no one else on the line, I do have one more text chat question from (Wendy).

Bryon MacDonald: Yes.

Laura Coffey: "I have problems with some people who will accept adult Medicare as primary but not adult Medicaid as primary. Even though one has Medicare but Medicaid is primary because Part B has not been paid by the state (buy end)."

Bryon MacDonald: Well, I'm trying to un-bundle this. Medicare as we all know and we just learned has four parts; four moving parts, A, B, C, and D. Medicare under most circumstances, and again the size of the employer can make a difference, is still primary payer over Medicaid. Medicaid is never primary if both are providing that service. Medicaid would be primary if Medicare is not providing that service such as personal assistance or maybe durable medical. But I'm not sure of the question quite frankly when you mix in the Part B. Can you clarify a little bit more?

Laura Coffey: (Wendy), if you would type in a little bit of clarification, please. I'm going to go and read the next question while you type in and then we can come back and revisit your question.

The next question comes from (Dawn), who says that, "The portability handout states only if medical advice diagnosis care et cetera was recommended or received during six months prior to enrollment date. I'm confused."

Bryon MacDonald: OK. I'm glad you said, I'm glad you told us about the confusion. This is the HIPAA law restricting pre-existing exclusionary periods to no longer than six months. That's what that is mostly meant to explain. So, medical services provided prior to six months ago are not even part of pre-existing exclusionary period issues because HIPAA limited pre-existing exclusionary periods to six months to less. Does that help?

Laura Coffey: Thank you. I'm still not seeing a clarification from (Wendy) if she can restate her question.

Bryon MacDonald: And we'd be happy to follow up one-on-one via email with (Wendy). The general rule of thumb there with the dual eligible is that Medicare is going to pay the bill first if they provide that service. And what I'm hearing is that some Part B nuance to whether that person's getting that Part B picked up by the state or not. That's not really, that's apples and oranges issue to who's paying the bill first.

Laura Coffey: OK.

Bryon MacDonald: About whether Part B is being paid for by the state or not. It's not exactly the same issue as two different issues roll up into one.

Mason O'Neil: That's it.

Laura Coffey: We have a clarification from (Wendy).

Mason O'Neil: Yes. And it looks like this individual, it says it's waiting for Part B to be paid by the state. So it seems like there's a delay or a problem with accessing the Part B coverage and that's maybe why the provider is saying, it gets (why) as the doctor in the out-patient coverage and may see that something is happening with the Part B coverage. She needs to get that result and...

Bryon MacDonald: (Inaudible) is the employer would be the primary payer. If there's no art B because their premium isn't being paid yet and it's not on the table, it's not an issue.

Mason O'Neil: Yes. Yes, and there's going to be many, many cases when as a CWIC you find out about an issue and refer or get assistance from an outside agency. If, you know, with Medicare and Part B issues, the SCHIP program, the state health insurance program, health insurance costing program should be able to assist her with that. Medicare as well has an extra 800 number and often the representatives there can be of assistance as well, so.

There's going to be many cases where you don't have any answer but the best solution is to hook up the beneficiary with an expert who might be protection efficacy or a local relater and they can essentially help with Medicaid that they can give further help and time to solving the problem.

Laura Coffey: (Steve), do we have any other lines queued up with questions?

Operator: There are no currently questions over the phone.

Laura Coffey: OK. Thank you.

Bryon MacDonald: Again, regarding both of those technical assistance questions, we would welcome follow-up emails from both (Wendy) and...

Mason O'Neil: (Dawn).

Bryon MacDonald: (Dawn), to further clarify the issues on the table there. We really would appreciate that.

Mason O'Neil: Yes. And we are always available to provide either phone or email technical assistance on healthcare questions. My email is mason, mason@wid, , and you can reach either of us that way.

Bryon MacDonald: Good. I am going to pick up on training section four. And I'm going to breeze through lightly if I could the terminology in the private healthcare market so that again you get your feet wet with the terms of art that programs use.

You want to keep this binder and this PowerPoint handy for the case situations as they arise. You will not memorize or remember all the terms, it's pointless, nobody does. But we want you to know they're out there. For when you get the comment from the beneficiary, "I'm at an HMO," or "I'm in an indemnity plan," you will say, "Well, yes, I know what the indemnity terms of those plans are."

And that's our next training segment, followed by some healthcare counseling tips. A sort of a main view of healthcare counseling tips which is a great segue into our training next week which is all about the case studies. But I'm going to turn you through this next two sections with enough time for a final Q&A from all of you because number one, we really love the Q&A and we think the Q&A is helpful to everybody on the call.

So, when you are accessing private health coverage, you are accessing it through various types. And as a brief overview, the most economical, cost efficient, may not be exactly the medical services that your consumer needs. But in terms of cost, HMO is usually the cheapest, Health Maintenance Organization. You are paying a monthly premium or someone is, the employer, there could be a co-premium. I'm paying now a monthly premium from (Mike Tizer) at WID and WID is paying part of a monthly premium or most of it. And HMOs are good for some people and not good for some others.

The main feature is that you can get sort of a whole rainbow of services usually under one roof. They are medical services provided from and via a referral by a primary care physician in the network of service providers. So there is a gatekeeper in HMOs most commonly and that's the primary care physician who will authorize and approve if you're going to see a specialist. And that is one of the main features of an HMO.

On the plus side, there is less paperwork for the beneficiary to handle. HMOs handle 90 to 95 percent of the paperwork. And for certain people, HMOs can work out really well. They are the most economical. They are a one-stop shop with services under one roof. You can see your doctor and you can get x-rays and blood test and all that good stuff usually in the same building. And people find that convenient.

But for the convenience and the low cost, they are trade-off in levels of sophisticated service for specialty needs. So HMO is usually the most inexpensive. There's a primary care gatekeeper and there is convenience in getting off the services under one roof but they may not meet the need of the person you're working with.

And indemnity plan is not an HMO. It's a completely different type of private group health coverage. It is fee for service insurance from any, for any doctor who will accept payment from this plan. There's no select network. It's either the doctor accepts this type of coverage or they don't. They are not as preventative as HMOs are.

I should have mentioned with HMOs they're really big on preventative services. Indemnity plans cover illness and injury after their onset. They're not big on keeping you healthy as much as HMOs are. An indemnity plan is going to have a monthly premium. It's going to have a deductible and co-insurance by and large. Again, all plans were differ – different, will be different.

There is more paperwork for a beneficiary with an indemnity plan than with an HMO. Point of Service plan, again, these are terms of art, we're just a messenger here but these are the terms that you'll hear when someone comes to you and says, "I've got a job offer at Target and here are the plans, which one should I pick?" You'll at least have an understanding of the types of plans that are available in group employer sponsored health coverage.

Point of Service can offer a combination of coverage types. In other words they can blend the best features of an HMO and Preferred Provider Organization and they have many plans. They usually have one annual deductible in addition to coinsurance and co-pay cost.

They have a network of providers. The cost of service is lowest if the beneficiary stays within the group and insured by the primary care provider in the group during the network and if they have an in-network referral for a specialist. Once these referrals start to go out of the network in a Point of Service plans then the cost can go up accordingly.

On slide 46? Yes. Other features of a Point of Service plan; if the beneficiary goes out of the network to see healthcare providers then cost can get higher. So again, if you stay within the group, your cost can be less. You go out because you need to, the cost can go up. The TLS plans do offer the most flexibility in the choice of medical providers and this can be very important to some beneficiaries. But with increase choice in the private market I'm going to have to say as a rule of thumb the cost are going to up, OK?

Preferred Provider Organizations or PPOs are health insurance plans that have a network of providers that the insurance company has contacts with. So, an insurance company is going to have a group of providers all available through a PPO. The monthly – the features of a PPO monthly premium and generally the low cost of medical services once the annual deductible has been met. But that annual deductible is what we've started talking about when we first started the training that's out-of-pocket expenses per year that you have to meet out-of-pocket before the medical services cover the rest of the bill.

Beneficiaries will pay a higher portion of the medical cost to see a doctor outside of the PPO network, the same is true for POS, and the beneficiary don't need a referral from a primary care physician to see a specialist. So that's a big difference between an HMO and a PPO, is that you can choose on your own to see a specialist but you may wind up being in a more expensive healthcare plan than the HMO was. It's trade-off between cost and services. It's what it's all about with private healthcare. PPOs offer more choice and they require a minimal type of work if you stay inside the network of providers.

Finally, self-insured trust is a plan to know about. Many of you folks may not like this one the best, to be honest with you. But self-insured trusts are for employers with what I would call deep pockets. An employer, for example, Safeway, and this is a real life example. Safeway offers health coverage to all of its full-time employees out of its self-insured trust. Safeway says, "I've had enough for you, guys. Your insurance company needs – you're taking me to the cleaners. I'm going to take my deep pockets and set up my own health coverage plan."

And in fact, Safeway profit dollars pay for the healthcare services provided to Safeway employees through what they call a self-insured trust. This is the employer ensuring his own health coverage for his employers or her employers based out of the profits from a company. These self-insured trust are the least regulated at the federal level. So they may have more whistles and bells and maybe more costly, and they have limited value to some of your folks because of the nature of the beast. And again, we're just the messenger here.

So the company is providing the deep pockets to pay for the plans and these plans have the least amount of regulation so they can vary very, very likely. I go very quickly over this so that you know those are the main types of group health coverage plans that you will find in just about 95 or better of employers. HMO is the cheapest, self-insured trusts are the least regulated and all the different flavors in between.

With that, I'm going to ask Mason to comment on some other features of mixing and matching in health coverage programs.

Mason O'Neal: OK. Thank you, Bryon.

Bryon MacDonald: Yes.

Mason O'Neal: I'm going to talk about a few different other types of health coverage options. And the first one that you'll see is high risk pools, and you may have heard about this in the news related to the healthcare legislation. High risk pools are set up by states to provide coverage to individuals who have no other health coverage and who have been denied private individual coverage because of their health status or medical history.

So these are state programs set up as a last resort for individuals who have high medical needs and because of that have been denied in the private individual health coverage and have no other type of coverage. These are another option that many of the beneficiaries that we see would be able to access Medicare or Medicaid so they wouldn't need to be in a high risk pool. But if someone could not access either of those, this is an additional option.

Part of the healthcare reform legislation kind of a first step that the American Health – Affordable Care Act is implementing to try to expand health coverage is expanding the high risk pool coverage to everybody throughout every state in the country. Currently, there maybe, I think there's about 30 states who have their own high risk pools. But starting on July 1, 2010, every state has to either create their own high risk pool or allow individual to access this federally-run and federally-managed high risk pool.

So that's going to give all individuals who can access Healthcare or Medicaid or any other healthcare options and opportunity to enroll in the high risk pools and we have a whole page on this in the healthcare form summary talking about some of those details. So for people in states that don't have high risk pools or maybe the high risk pools are kind of limited or too expensive, there's going to be a new option and more affordable access to high risk pools for everybody throughout the country.

Bryon did an excellent job of talking about the state-run HIPP programs or Health Insurance Premium Payment programs. As he mentioned these are programs where if Medicaid finds it cost effective to pay the premiums for additional health coverage that may be employer-sponsored health coverage or some other health coverage that has out-of-pocket premium, if they find a cost effective meaning if it costs less for the state to pay that monthly premium than to pay the actual healthcare for the individual, the family then the individual can enroll in the HIPP program or Health Insurance Premium Payment program.

Lastly, I just want to make some county Healthcare programs. And for individuals who cannot access Healthcare or not eligible for Medicaid without a high share of cost or spend down this is another option. And many counties has developed their own low cost of programs for low income individuals, which are separate from Medicaid and can allow access to healthcare coverage.

Bryon MacDonald: And on that point, Mason, if I could, we hear anecdotally from CWIC and others there is a lot of brouhaha around Medicaid share of cost because of state budgets, and more and more people are winding up in Medicaid, Medically Needy or Medicaid share of cost. You want to look at all the options and I would also look at the county healthcare programs as one of them as an alternative to share of cost that people can't afford.

Mason O'Neal: OK, thank you. On this next slide we get into some more details. I'm going to cover this briefly, you have this as a reference. We talk about VA coverage, there's important interactions between VA coverage and Medicare.

TRICARE is the name of the military health coverage program that covers all current active service members in the military. It also covers family members, dependents and military retirees. So the Indian Health Service program and the individual may also have four national coverage, health coverage by a national health program in another country which also covers a (inaudible) in the United States.

And on the next slide we have a few other different options, the Federal Employees Health Benefits Program, and an individual may have student health insurance such as through their college or university.

Just to sum up there is many different types of private health coverage programs, and the plan benefits vary by their cost structures, what benefits are covered. In general, these programs are regulated at the state level. There may be a state health insurance agency where you could get assistance with these programs and there's more details on all of the different types in the different health coverage options in module four of your CWIC manual.

Bryon MacDonald: And one other unbundling I'd like to add to that, Mason, is the VA health coverage will be an extended part of the new module four, which Mason and I are working on with VCU to revise over the summer. There's an excellent piece that we've crafted for a VCU just on VA benefits and that interactions with employee-sponsored and Medicare.

I believe it's up on the training site, the vcu-, and that VA brief on health coverage for veterans will also be part of module four by the end of this year. But you can access it now, I believe, on the VCU website.

So we are gratefully more or less on time. I'm going to try and wrap the next couple of slides in about five minutes, and we are on training section five, and a taste of where we'll be going next week. The rest of this training today is I hope maybe five or seven minutes, so we can open up for a last round of question, which we really enjoy by talking or ending this training with counseling tips themselves. And the first thing we recommend are in, as you can already guess and from your workloads and your direct experience doing this work as a CWIC, life gets messy for beneficiaries who are returning to work.

One of the strongest thing we've come up with at WID and we recommend beneficiaries to pull together individually is a benefit in work three-ring binder. And this is a portable three-ring binder, it should be at least an inch thick or an inch and a half thick, and you can go down to Office Depot and invest about 18 bucks in this organizational tool and save your client a world of grief down the road because this benefit in work binder can help organize their employment planning and their maintenance of benefits that they need to be employable in the first place.

This benefits binder is a one-stop place. You want to buy some clear plastic sleeves or the consumer does, this is not for you to develop this is for the beneficiary as a suggestion that they develop. And they buy the binder at Office Depot, they buy some clear plastic sleeves, some page dividers, all that good stuff you remember for when you were in high school and college, that you put inside the three-ring binder; divider sections, plastic sleeves, places to put envelopes, places to put wage stubs, places to put letters of notice of action for Social Security or the Medi-Cal office, anything to do with work and benefits would go into this three-ring binder in an organized kind of way and an ongoing kind of way.

At the back of the three-ring binder would be a spiral notebook. That's a line portable organizational tool. And the binder has a spiral notebook at the back of it with a three health plans so that you can keep it in there.

And from day one of reporting wages to Social Security, let's say, your friend (George), that you're working with, is going to work in July and – no, he's going to work in June because he's you've been advising him in May and June in fact to work on benefit and he's starting work on June 15th and he's going to get two paychecks in June. And you advise him to go into Social Security by the 10th of the following and report those wage stubs.

When he got in there with that binder and the wage stubs in that binder and he opens up his spiral notebook and he sits down with the Social Security field office staff and he writes down the date and he writes down the person he's meeting with.

And he says, "Here are my wage stubs and I'm reporting my income that I just started the new job, and Mr. (Simpson), how do you want me to report my wages from now on?" And your beneficiary crackles what he hears from the Social Security field office into that binder and every time that charge of yours interacts with a benefit program from now on they record the events, the date and who they spoke to and what they said and what happened.

After a period of years that spiral notebook can become a legal defense against an overpayment or a change in benefit that is adversarial. Trust me; I have used such evidence in front of an administrative audience. So I can't stress enough how this technique of encouraging folks to get their own benefits at work binder can have your beneficiary take a level of control of this process in a way that will empower them to be not only successful with their job but successful with the employment – with the benefits filing and the benefits interaction. So that's one tool.

On slide 52, we basically recommend, what we'll be going into gory detail next week, a four-part strategy that we basically sort of outlined at the beginning of this call. The first are performing an initial assessment using a health coverage planning checklist that we have offered as a handout here. I'm not going to review that today because we don't have a time. But you can look at it between now and next week if you're going to join us again next week.

And you perform a current assessment of where that person's health coverage issues are. You identify (current) sets of these issues and concerns. You identify whether you need to get some extra help. Don't take it on yourself that you need to know it all because you never will. We don't know at all here at WID. But if you need some extra help because of the complexity of the situation or try and build that up and in at before that person takes a new job.

And then you and the beneficiary work out an action plan based on these four steps in terms of understanding the rules that that person needs, plan in place for taking that job with that particular job health coverage regimen in ways that protect the existing health coverage, or replace it with health coverage that's just as good as or better than the health coverage they came to you with.

Finally on slide 54, the – did I cover everything here? I think it is. As the beneficiary expands health coverage options with paid work remind the beneficiary that new plans may have further reporting requirements and procedures. And again, that reinforces the validity and why we recommend the benefits binder.

Benefits planning is not a one-shot deal. You all know that from your training and the work you do. And the benefits binder can keep that person's life organized while things change. They have a new job and then all of a sudden they get married or they move, and that can affect the benefits as well.

Moving forward, part of health coverage planning is understanding and exercising rights, including rights to appeal and rights to a second medical opinion. So we've talked more about what the plans are called and what they look like but a big piece of healthcare counseling is understanding that many decisions and many health coverage features have protections, and they're appealable protections.

So, if a decision comes down that is adversarial to the client, they can appeal it. If they appeal it timely, as described in the notice of action, then that benefit will stay the way it is while they appeal that decision. But healthcare counseling does include a component of knowing what people's rights are and how to appeal when adversarial decisions occur. They are bound to occur.

And a practical tip that I have referenced once before that I'll repeat here, is it does not help you or the beneficiary to make up your own terms. There are dedicated terms of art in the world of private health coverage, Medicare and Medicaid, that the more often you use those terms of art, the better your communication skills will be with the program, with the plan, with the beneficiary and the better educated that the beneficiary will be with interacting with the program on their own. It's used the terms of art of the program that explain their features rather than making up the names or the rules as you go.

Finally, we'll cover more of this next week, don't do it alone. There are legal organizations. There is CNA for beneficiaries of Social security. There is the SCHIP program, State Health Insurance Counseling and Assistance program, that's on slide 55. And there is a link in there, if you have this electronically that'll take you to the SCHIP program in your state. These are trained volunteers in the Medicare universe. They can be invaluable support to the technical interface between Medicare and employer-sponsored health coverage.

SCHIPs are legally required to serve all Medicare beneficiaries, right that in your margin. SCHIPs are not for seniors. Seniors are for Medicare beneficiaries, every single one of them. They are your friend and many of them do excellent, excellent work and they've had extensive training on how Medicare works in the state where they are operating. So they can be very, very helpful.

And with that, I've got seven minutes left, which I am relieved and thrilled to offer back up for more Q&A. Laura?

Laura Coffey: I have one question in the text chat and while I read this, (Steve), if you want to go ahead and give the instructions one last time to queue up calls for questions?

Operator: Again, if you would like to ask a question over the phone, please press star then the number one on your telephone keypad.

Laura Coffey: OK, thank you. And I have a question from (Flow). What's the difference between VA health coverage and TRICARE?

Bryon MacDonald: Fabulous question, fabulous question. TRICARE is limited to current active military personnel, their dependents, and military retirees. It is a smaller bucket, quite frankly, than VA healthcare services. The main thrust of TRICARE is for current active service duty and their families. It will also cover military retirees. Veteran's benefit is for any U.S. veteran who is discharged from the military. And that's a bigger group of people, and having said all that, you can access TRICARE and VA benefits at the same. So you can be a military retiree and get veterans benefits as well as TRICARE.

But the TRICARE's main emphasis is on current active duty military and their families. Also, military retirees can access it, and TRICARE is administered by the Department of Defense, not the VA Services Administration – the Veterans, the Office of Veterans Affairs. VA coverage is administered by Veterans Health Administration and covers all U.S. veterans who are eligible who have been honorably discharged. Those are the distinctions. Many people mix and match and have both. Next?

Laura Coffey: That's everything I have in the text chat box. (Steve), do you have anybody lined up?

Operator: There are no current questions on the phone here.

Bryon MacDonald: OK. Did (Alisson) – did we get the date and the time for the second half of this training?

Laura Coffey: I just responded to (Alisson), but...

Bryon MacDonald: OK.

Laura Coffey: Just as a reference to anyone else, you've heard mention of the second part of this training which there was a separate registration for, that will be happening next Tuesday, June 15th, from 1:00 to 3:00 Eastern Time, and materials and a link will be sent out in advance.

If you haven't already registered for that, we may or may not have room for you, but you could send me an email at lcoffey6@ and I can see if we can squeeze you in.

Bryon MacDonald: Laura, I would just like to point out, as we close, we had a lot of input from our trainings last year and we have adapted this training from it. And I think we've been largely successful in taking a lot of people's good input to heart because believe it or not, although we went quickly through some of the slides, we've actually finished time with enough space for people to have Q&A; which I'm very, very glad that we have.

At the end of the PowerPoint itself is a roster of information resources at the federal and the state level on the topical areas we've just covered. So please have a look at that when you have some time, all of you who are on this call. And then, Mason went to trouble of numbering the other handouts which is very, very useful. The seven other handouts, besides the PowerPoint, are really helpful resource documents for those terms of art and the place to find out the state rules around COBRA.

All the stuff that we sort of hit on lightly, you have tools and resources to get at the second page of the information so to speak, by using the PowerPoint and the seven other handouts as a tool all in one place. So, if you guys could put all these stuff into one three-ring binder that might be very helpful as a desk reference.

Mason O'Neil: And I'd like to just mention that if you're unable to attend the second webinar training but you'd like the materials, please email myself at mason@ or (over) Coffey and we can send you some of the materials that you can look over at your own pace. And as example, one of the handouts there is three pages of healthcare counseling tips and tools for CWICs. So that might be valuable to have even if you're not able to attend the second webinar training.

Bryon MacDonald: And as a just by way of closing, content-wise, two of the main features that are coming online with healthcare reform by September or in September is that for folks who are working with youth, for folks who are working with youth and they are still on their family's health coverage plan, that youth maybe would be able to stay on their family's health coverage plan until the age of 26. You may want to write that in your margin, that is in the healthcare reform summary.

And also, the high risk tools that Mason referenced in his sections of the training. Those high risk tools are undergoing a significant amount of change over the next couple of years, depending on what a state decides to do in relationship to high risk tools and their involvement with the new ACA or Affordable Care Act. So, those two things are front page news in terms of implementation of healthcare reform.

And one final note on content, healthcare reform did not give us single-payer healthcare. Healthcare reform, as signed into law in large, gave us a tweaking in a significant way in very, very many different places of the interactions between employer-sponsored health coverage, Medicaid and Medicare. The complexities and the crossover between these three types of benefit programs will increase because of healthcare reform.

So this training lays the threshold for a better understanding of how to even understand healthcare reform because healthcare reform will tweak Medicaid, and is tweaking Medicare already, and will tweak private employer-sponsored health coverage with the state having a major responsibility of implementing the new healthcare provision that expand healthcare to more populations over the next five years.

And with that, I'd really like to thank Mason for all the prep work he's done to make this a success. And I'd like to thank Laura, and hopefully we'll see many of you next week.

Laura Coffey: Thank you, everybody. And please don't forget when the evaluation comes in your email inbox to please fill that out and send it on back to us. Your feedback is invaluable. Thank you all for your great questions, for attending today, and hopefully we will see many of you next week. Have a great day.

Bryon MacDonald: Thanks, Laura.

Operator: This concludes today's conference call, you may now disconnect.

END

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