Insurance
From ShortGut - Wiki
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Primary Insurance
- Review your primary insurance to see what benefits are covered under your primary insurance. Your insurance company may dictate anything and everything from where you receive treatment, to which home health health care company you use, to which home nursing company you use and which products (ostomy products, etc) are covered.
Secondary Insurance
- A secondary insurance can be obtained for many children with short gut syndrome. Obtaining secondary insurance is not dependent on your financial status or income, but the severity of your child's health issues. Generally, you must document, through a child's diagnosis and a forms completed by your child's primary physician, that your child has a chronic and serious illness. The manner in which you word your child's limitations and illness can impact whether or not your get approved, so you may want some advice from someone experienced in doing this such as the hospital social worker or your pediatrician.
- The process of applying for and obtaining secondary insurance can be somewhat complicated. You may want to try to get assistance from the hospital social worker or request a case manager through your primary insurance company. Alternatively, you can call your local county social services/county assistance office (where someone would apply for SSI, food stamps, etc) and request the forms. The process varies state to state. In PA, we had to apply first for SSI (which is income dependent), get denied and then apply for medical assistance (secondary insurance). Again, if you speak to a worker who is not familiar with medically ill children, they may tell you that benefits are dependent upon income, but that is not the case.
- What are the benefits of secondary insurance? Secondary insurance covers a huge portion of what your primary insurance doesn't cover. That might mean co-pays for doctors visits and medications to deductables for hospitalization to formula. They may also cover services such as therapy (in addition to EI) and private duty nursing. It's well worth the hastle of getting it. With AustinRath, our secondary insurance has paid 100% of all our therapy, nursing, medications, hospitalizations, etc. We haven't paid a cent for anything since he was born.
- Medicaid Waiver Data by State
- In Michigan, special needs kids automatically (no income or assets test for parents) get secondary from Michigan Children's Special Health Care. This policy explicity excludes private duty nursing (but does include respite care; the max you can get approved is 180hrs for the whole year). Medicaid, on the other hand, may include PDN. If your kid is in-patient for 30+ days, your child automatically should apply for and receive Medicaid for one year. After that year has passed, you must reapply. There is income/assets test, and you have to be low income to get it, at that point, unless you qualify for one of the waivers. There are 4 paths to Waiver-Land: get your kid who is 18+ SSI and automatically qualify for Medicaid (no SSI for kids under 18 unless parents, again, meet income/asset test), get The Children's Waiver (kid must be DD), get the TEFRA (Katie Beckett in other states) waiver- very rarely used and most public health people are even confused how to apply, or get the HBCS (1915) Waiver (which may be the same as one of the other waivers mentioned, but we're in the thick of it right now, and aren't clear about that). We'll update when we have news.
Problem Solving
- "Writing Winning Insurance Appeal Letter" - Article from the May/June 2008 Oley Lifeline Letter
- Benefits, everything from going out of state for treatment, to therapy services, to private duty home nursing care, to a particular brand of ostomy products, may be denied by insurance companies. And all these denials can be appealed. There are often multiple steps to an appeal and you may need to appeal a denial several times before something is covered. You may need provide additional information or a letter from the doctor, justifying what you are trying to get covered. Insurance companies like logic - and what is going to save them money. So consider doing the background research to justify coverage for something. For example, if the insurance company is refusing to cover the particular central line cap that you want to use, look for studies (ask your home health company or hospital) indicating that the cap you want to use has lower rates of line infections. Then write a letter to your insurance company, with the study attached, stating that covering the cap will likely result in few line infections and costly hospitalizations. If you have a case manager, you can request that they assist you with this process. See also LegalAdvocacy for organizations that can help families through insurance struggles.
Insurance Coverage for Omegaven
- Blue Cross Blue Shield has a tendancy to honor the precedence of other BCBS coverage in these grey areas. BCBS-MA and BCBS-NJ policies have been known to cover Omegaven. In our case (BCBS-NJ), we did not have to appeal for coverage. We were in constant contact with our Complex Case Manager, though.
- After appealing to our insurance company, Humana, twice and being denied, we appealed a third time. The third and final appeal must be made to the TPA (Third Party Administrator), the company who chooses your benefits for you. My "TPA" is my employer, a large hospital organization in Louisville, Ky. I submitted a letter requesting them to cover the Omegaven. I included graphs and labs of his bili levels since he had started the Omegaven and pictures. It was this package that made them decide to tell Humana they had to cover the Omegaven for John, because they felt it would be unethical to not let him have it anymore (he has been getting it through charitable donations). We just got the official letter from Humana this week stating they would pay for it. We received our first home health delivery of John's Omegaven on May 20th...2 mos worth.
