People with disabilities often have health care needs that vary in type and intensity over time. The challenge for you, as a consumer, is to find a health care plan that best meets your needs. This requires understanding how the health insurance that you choose will work for you and your family members.

Medicare, Medicaid, Worker’s Comp, an HMO, PPO, or traditional health plans all come with a policy. Some plans are traditional fee-for-service programs with few restrictions on choice of doctors, while some are preferred provider organizations (PPOs) that require the equipment or treatment to come from specified providers. Others are health maintenance organizations (HMOs) that restrict your choice of providers.

With the various insurance plans, some rules you’re likely to encounter may include:

• Required letters of medical necessity
• Required pre-approval, exclusion of certain equipment
• Yearly deductibles (the amount of money you have to pay before insurance will cover costs)
• Limits on care provided out-of-state

One claims representative emphasized that policies have rules. "We don’t buy sports chairs; we don’t buy multiple chairs; we don’t buy hearing aides; we don’t buy vans; we’re not liable for quality of life things. Our guidelines clearly state that equipment must address functional capacity and activity of daily living."

When choosing a health insurance plan, consider the following questions:

• Are pre-existing conditions covered?
• Do I need to choose a primary provider to coordinate my care, or can I obtain care from any provider?
• How will the health plan treat my health condition? What are the plan’s clinical protocols regarding the treatment of my particular condition?
• Can I go outside of the health plan network to seek care from a non-network provider?
• Will I have to pay a co-payment or deductible for visits to my provider? For tests? How much?
• Will the plan pay for the prescription drugs I need?
• If I need care in a hospital, which one does the plan use? How much of the cost is covered?
• Can I see a specialist when needed? How do I do that?
• Does the plan cover allied services like therapies?
• Does the plan cover medical equipment, medical supplies, orthotics, prosthetics and assistive technology?
• If I have a problem with the plan, what is the process for handling my complaint?

• Talk to others with a similar disability or health condition for advice.
• Check the NC Institute of Medicine web site at <http://www.nciom.org/hmoconguide/backh.html>
• Call the NC Department of Insurance at 800-622-7777 or 800-546-5664.

Richard Holicky, writing in the March 2000 issue of New Mobility, said, "Medical insurance, regardless of who provides it, can be a source of stress. Most of us have been there, trying to deal with the logic of being denied a shower/commode chair because it’s not ‘medically necessary.’ It’s a jungle out there, and what once was the domain of medically trained and knowledgeable personnel is now the dominion of bean counters entrusted with cost containment."

Annette Lauber with the NC Assistive Technology Program offered these survival tips:

• Policies are different. Know your policy, its limits, inclusion and exclusions. Make sure you know if you have a fee-for-service or HMO plan.
• Justify and document the medical necessity of all requests.
• Be polite and businesslike, and don’t take denials personally.
• If your claim is denied, find out why it was denied; then appeal it. Include letters of medical necessity from your provider.
• It is not unlikely for things out of the ordinary to be denied after the first claim.
• Refer to your insurance benefits materials which will outline the appeal process.

"Form letters just don’t work anymore," according to a hospital counselor who advocates for patients. What gets funded is dependent on the wording of the policy and the wording of the requests. People are usually more successful if they use medical terms to justify their requests. When "getting out of bed" becomes "skilled transfer or posture positioning," when a " bowel program" becomes "administering of medications (suppositories)," when "bathing" becomes "monitoring for skin integrity," case managers tend to be more receptive, the counselor said.

Another valuable tactic is to point out the long-term prevention aspects of both care and equipment. For example, explain the cost of skin-flap surgery when requesting a replacement cushion. Work with your provider to write a letter of medical necessity for what you need.

Once you understand that a denial is simply a business transaction, you won’t let it discourage you. Keep a key statistic in mind: 70% of denials are never appealed. And it’s likely for things out of the ordinary to be denied after the first claim.

No matter who you talk to, one piece of advice always comes through loud and clear: always appeal denials. And if you feel you’re on sound footing, don’t stop with simple appeals to the insurance company. You have other options. Write letters; make phone calls; put your tax dollars, public employees, and elected representatives to work. Write your state insurance commissioner. Exhaust all avenues.

Say it with me: "Always appeal denials."
 

This article includes excerpts from NC Institute of Medicine web site, "Questions to Ask Your Plan: People with Special Health Needs <http://www.nciom.org/hmoconguide/backh.html> and "Insurance Tips" from New Mobility magazine, March 2000, by Richard Holicky, health counselor and free lance writer.