MICHAEL BRYANT / Staff Photographer
Phil Venezio sits in his wheelchair at the door to his N.J. home. Last year, at 55, he got sick, and lost his job. He was rejected for a Medicaid program called Global Options Nursing Facility Transition because his disability check is $77 over the qualifying limit. He has appealed.
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A fall through insurance-coverage gap
Phil Venezio worked for 30 years before he got sick and lost his health insurance. The he missed qualifying for Medicaid by $77.
"We have a big, big problem and it's about to get much, much worse."
Venezio applied for a Medicaid program called Global Options Nursing Facility Transition. This is designed to keep people out of nursing homes and in their own homes.
This program has the highest income eligibility limit of any welfare program, $1,911.
Venezio was denied on June 30.
"Client found financially and medically ineligible for Global Options," said the letter from the county's Medicaid Long Term Care Unit.
Venezio appealed in person.
He summarized his argument: "I'm crippled and in a wheelchair. There's nothing more that I'd like tomorrow morning than to get up and be a positive person in the workforce and go to work. But I could not function. I could not do what I did in the past. I don't want to be on disability and in this situation. It happened and I'm dealing with it. All I'm trying to do basically is to exist. I've worked hard all my life. And I don't feel that $77 should be a determining factor whether I get Medicaid or not."
Venezio expects a ruling any day.
But the state's expert on Medicaid eligibility, Elena Josephick, who runs the Medical Assistance and Health Service division in the Department of Human Services, said the $1,911 limit is "hard and fast."
"It's an income established by the federal government," she said.
Venezio also applied for another Medicaid program, Medically Needy, which in some cases will pay medical bills. But he would have to pay at least the first $10,000 in unpaid medical bills. This fall, Venezio sought legal assistance from the Community Health Law Project, a nonprofit that helps disabled New Jersey residents navigate the insurance maze and get coverage. It couldn't represent him.
"He is over income for our program, too," said Brian Smith, a senior staff attorney. "Take that for working all of your life!"
When he called the hospital to say he just couldn't pay his bills, Venezio was referred to the Charity Assistance Program at AtlantiCare Regional Medical Center in Pomona. He was approved for 100 percent coverage of hospital costs until Dec. 31, when he must reapply.
Venezio goes there for tests and to have his catheter replaced monthly.
In terms of trying to get outpatient physical therapy, Sandy Gubbine, director of patient accounts at AtlantiCare, had this advice for Venezio:
"Contact facilities and wheel and deal. It's like buying a car. Compare and try to get the best deal. If you're uninsured, that's where you are in the health-care arena."
Venezio's struggle for health insurance should end in 2010 - that's when he will be eligible for Medicare, the federal health-insurance program for the elderly and disabled.
When Congress expanded Medicare in 1972 to cover the disabled as well as people 65 and older, it established a two-year waiting period to keep costs down, according to the Medicare Rights Center.
At any one time, a spokesman said, about 1.5 million Americans are in this gap - eligible for disability, but waiting for Medicare. About 25 percent are like Venezio - without any health insurance.
Venezio is still dizzy from the way his life turned around.
