My son, Michael is scheduled for the mod quad in May (just scheduled the surgery last week) and I just had a bit of shock. I was browsing TCH's website and came across the list of insurance providers. Mine isn't on there. When I spoke with Angel last week, she took all my insurance info and I never had the slighest thought that my insurance didn't/doesn't participate. *Obviously* I should have asked up front (she did say that an Insurance Coordinator would be calling me, so I never thought twice about it. I should know better!)
My question is: I seem to remember reading on another site (iVillage's BPI board) about a loophole law that allows a *child only* to receive financial assistance if it is needed (I think that it had something to do with the child being physically disabled?). Does anyone know anything about this (how to apply, is there a limit, is there a wait to get assistance, do I have to get his surgery pre-authorized with someone, etc)? I looked into it briefly last year when we were waiting to see if he was going to need the primary, but I couldn't figure out how to apply for just him (as a family, we make just a bit too money - never thought I'd say that! so I can't apply as a family). I live in Maryland - if that makes a difference.
I would very much appreciate any advice.
Thanks!
Sally
BTW, I did leave a message for Angel and Lisa Thompson, but I'm trying to get as much info as I can.
? about "loophole" law?
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A gentleman named George will be calling you about your insurance info and he is pretty helpful...he will call your insurance company and try to help arrange things beforehand. TCH and its surgeons accept my insurance, but they have "aggreements" with their insurance companies on charges from what I understand. George tried to "negotiate" a price with our insurance and it didn't really do much good. TCH was $6000 higher than "reasonable and customary" and that was with a $500 discount. The end price ended up being $9600 higher, but we are filing an appeal and it will go up for medical review,etc. We found out about all of this 3 days before we left for TCH, talk about freaking out:) I called my insurance and they explained everything and we went ahead and went anyway. The way I look at it, I have the rest of my life to make money and find a way to pay for this(insurance always ends up picking most of it up), but the time to try to help my child is now and can't wait. I feel rather calm now, but last week when I opened up my "explanation of benefits", I was a total basketcase. Everything involved with this injury is overwhelming sometimes.
713-798-1186 is George Fleites' phone number. He takes care of the insurance info for Baylor surgeons.
Good luck.
713-798-1186 is George Fleites' phone number. He takes care of the insurance info for Baylor surgeons.
Good luck.
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Sally - the loophole law is specifically for PA residents. The loophole law is 355.14 in the medicaid booklet that says basically that if your child is disabled at birth, then they have access to medicaid without having anyone look at the parent's finances. This is about to change. There will be a cap of $100K earnings. Any family earning more than $100K will not be eligible for Medicaid for their children.
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Hi, Sally. We have Medical Assistance for Nicole. When Francine posted about the assistance in PA, I checked into it too. It is different here, as is every state I imagine, but it is quite possible that there's some type of assisance that you too might be able to get for Michael. Basically, it is Medicaid, but with an income waiver. That means we get all the benefits of Medicaid, but don't have the same income criteria. The only financial criteria is that Nicole has less than $1,000 in assets (no problem!). We did have to include our financial info. on the lengthy application, but there is a waiver that disregards it in the qualification process. I'm really not sure how they determined eligibility specifically. I didn't even know who to call about it. Thankfully, when I asked Nicole's Early Intervention PT / Svc Coordinator about it, she was able to act as a liasion for us. She got me the application and then submitted it after I completed it. The organization that it falls under here is the DMR (Dept. of Mental Retardation). However, the child doesn't not have to be MR to take advantage ot it. We've had it for about 9 months now and it has saved us so much money already. Basically, it has covered the therapy co-pays for Nicole and co-pays for in-state dr. visits. I believe that any benefits paid are limited to drs / therapists, etc. within the state as well as those that accept Medicaid. We also use it as a secondary insurance for prescription co-pays for Nicole (not a big deal though since she's only needed meds post-op pretty much, but every little bit helps). I believe that our coverage will also pay for 100% of therapy visits when the insurance benefits are exhausted, but we haven't gotten to that point yet b/c last year we were able to get our insurance co. to approve extended therapy visits and we have a different insur. co this year so we haven't hit our max. visits yet.
I don't know if the medical assistance that might be available in your state will cover out of state surgery and the application might take a while to get processed. I would still look into it though b/c regardless of what they approve for surgery, it will still help you -- esp. with all the post-op therapy that Michael will need. BTW, our coverage was approved for one year, so I will soon findout what renewing entails. I don't see why she wouldn't be approved this year too. Also, I've been told that this assistance only covers children until they're around 5+ y.o. and at that point we will have to try other alternatives.
As far as getting the surgery covered by your insurance, regardless of Medical Assistance, I would also very actively pursue this. Talk to George at TCH and see what he says and if he's ever dealt with your insurance co. before. Also, call your insurance co. and request to get in touch with a case manager so that you can establish a relationship with one individual there (who will also be more knowledgeable and qualified than a rep. who you'd first speak to when you call there). Compile lots of info. on the Mod Quad and the benefits of the surgery. If TCH is out of network, then the insurance co. might want you to at least seek an opinion from an in-network dr. If they require that, then you will NEED to go and at least let the dr. examine Michael and give an opinion. Try to findout how the dr. feels about TCH and see if you think the dr. might be able to give you a referral there. Being that you live in MD, they might want you to go to Johns Hopkins. I know that there's a dr. there with BP experience (Dr. Belzberg?). I don't know how much BP experience he has and esp. with the Mod Quad type procedure in particular though. I think it's always good to get at least 2 opinions so you might want to go ahead and schedule to see him anyway.
If you findout that you're going to have to go to an appeal process with your insurance co. then it might not happen before you go. That leaves you in a difficult situation b/c if you go ahead with the surgery before getting approval, then they might never pay for it b/c you did it w/o approval. However, if timing isn't too critical and you can postpone surgery if necessary in order to hopefully get it covered, that's something to think about too. Only you all can make that decision if you're willing to take that financial risk. We postponed surgery and eventually got it approved, but had we gone I'm quite sure it wouldn't have been covered. This was primary surgery and I still (and always) will feel badly about it and wonder how much of an impact those 7 weeks had on Nicole's recovery. At the same time, I don't work and we would've had to sell our house to pay for the surgery and knowing that there would likely be future surgeries (and there have been -- 3 to be exact), we didn't think that was wise. It took a lot of tears and prayers to come up with a decision.
I will leave you with a couple more tips. Contact your state dept. of insurance if you think you're going to have problems in dealing with your insurance co. I never got timely calls back from ours, but maybe you'll do better. Also, contact your state attny general's office and ask to speak with the individual / area that handles insurance problems. Our asst attny gen'l was VERY helpful to us and was EXTREMELY instrumental in helping us to get the surgery approved finally -- after a hearing. I got advice from a friend 2 days prior to our hearing and while the asst A.G. couldn't make the hearing on such short notice, he participated via teleconference; plus in the meantime, he'd contacted the in-network dr. and the insur. co. Sometimes I think the insur. co's are more cooperative just by knowing that the A.G.'s office is involved. Health insurance co's haven't gotten a lot of good press these past few years.
Well, sorry this is so long. I hope some of this info. helps. Feel free to email me if you'd like. It's good that you're doing this now and not waiting until the last minute. Try not to get too stressed and have confidence that it'll likely workout well one way or another. Take care. Keep us updated please.
-Tina (rosesmom315@juno.com) :0)
I don't know if the medical assistance that might be available in your state will cover out of state surgery and the application might take a while to get processed. I would still look into it though b/c regardless of what they approve for surgery, it will still help you -- esp. with all the post-op therapy that Michael will need. BTW, our coverage was approved for one year, so I will soon findout what renewing entails. I don't see why she wouldn't be approved this year too. Also, I've been told that this assistance only covers children until they're around 5+ y.o. and at that point we will have to try other alternatives.
As far as getting the surgery covered by your insurance, regardless of Medical Assistance, I would also very actively pursue this. Talk to George at TCH and see what he says and if he's ever dealt with your insurance co. before. Also, call your insurance co. and request to get in touch with a case manager so that you can establish a relationship with one individual there (who will also be more knowledgeable and qualified than a rep. who you'd first speak to when you call there). Compile lots of info. on the Mod Quad and the benefits of the surgery. If TCH is out of network, then the insurance co. might want you to at least seek an opinion from an in-network dr. If they require that, then you will NEED to go and at least let the dr. examine Michael and give an opinion. Try to findout how the dr. feels about TCH and see if you think the dr. might be able to give you a referral there. Being that you live in MD, they might want you to go to Johns Hopkins. I know that there's a dr. there with BP experience (Dr. Belzberg?). I don't know how much BP experience he has and esp. with the Mod Quad type procedure in particular though. I think it's always good to get at least 2 opinions so you might want to go ahead and schedule to see him anyway.
If you findout that you're going to have to go to an appeal process with your insurance co. then it might not happen before you go. That leaves you in a difficult situation b/c if you go ahead with the surgery before getting approval, then they might never pay for it b/c you did it w/o approval. However, if timing isn't too critical and you can postpone surgery if necessary in order to hopefully get it covered, that's something to think about too. Only you all can make that decision if you're willing to take that financial risk. We postponed surgery and eventually got it approved, but had we gone I'm quite sure it wouldn't have been covered. This was primary surgery and I still (and always) will feel badly about it and wonder how much of an impact those 7 weeks had on Nicole's recovery. At the same time, I don't work and we would've had to sell our house to pay for the surgery and knowing that there would likely be future surgeries (and there have been -- 3 to be exact), we didn't think that was wise. It took a lot of tears and prayers to come up with a decision.
I will leave you with a couple more tips. Contact your state dept. of insurance if you think you're going to have problems in dealing with your insurance co. I never got timely calls back from ours, but maybe you'll do better. Also, contact your state attny general's office and ask to speak with the individual / area that handles insurance problems. Our asst attny gen'l was VERY helpful to us and was EXTREMELY instrumental in helping us to get the surgery approved finally -- after a hearing. I got advice from a friend 2 days prior to our hearing and while the asst A.G. couldn't make the hearing on such short notice, he participated via teleconference; plus in the meantime, he'd contacted the in-network dr. and the insur. co. Sometimes I think the insur. co's are more cooperative just by knowing that the A.G.'s office is involved. Health insurance co's haven't gotten a lot of good press these past few years.
Well, sorry this is so long. I hope some of this info. helps. Feel free to email me if you'd like. It's good that you're doing this now and not waiting until the last minute. Try not to get too stressed and have confidence that it'll likely workout well one way or another. Take care. Keep us updated please.
-Tina (rosesmom315@juno.com) :0)
Re: ? about
P.S. (as if I didn't write enough of a novel already LOL), go to http://www.nichcy.org/ and click on State Resource Sheets and then select your state and print the list of contacts. I'm sure someone on the list can point you in the right directions you need for Medical Assistance and insurance problems. Bye! -Tina