No Denying it, babies are expensive and the bills will keep coming for the next 18+ years. A baby with special medical needs can cause many sleepless nights. Understanding your medical insurance will help you prepare for the bills. Here are a few pointers:
Enroll your baby in your insurance plan as soon as your baby is born. If your insurance is through your employer, you can ask your human resource department for help. Some plans will cover newborns under the mother’s insurance for the first 30 days but it can take that long to get the paperwork complete.
The good news is that the state of Texas (Insurance Code Chapter 1367.153) mandates that health insurance include coverage of children with a cleft lip and/or palate. Most congenital conditions are covered. However, like most laws, there are exceptions that may apply to you (e.g. small group or individually purchased plans may be excluded). Policies may exclude coverage of a specific condition for a set time period if you are newly insured or if there has been a gap in coverage.
Health insurance is usually purchased by your employer, through a small group, or individually. Health Insurance Exchanges are expected to offer a variety of plans and prices. Other health care programs such as Medicaid, Children’s Health Insurance Plan (CHIP), and Children with Special Health Care Needs (CSHCN) are government programs that have eligibility requirements for family income limits. Whichever type of coverage you have be sure to understand your rights and responsibilities.
Application for insurance: When completing an application for insurance, answer all questions completely and honestly. Do not withhold information. Failure to answer a question correctly can mean denial of coverage even after the service is provided. This will leave you with the debt.
Select a Plan: If you have a choice, choose a plan that includes the specialists on your cleft team. ALWAYS talk to the Team Coordinator before making a selection or changes. Contracts between providers, hospitals and insurance companies change frequently and may not be current on their websites.
Read your policy carefully. Pay attention to “exclusions”. If you are not clear about the interpretation, you should call the insurance company and ask specifically about your child’s treatment. For instance an insurance company may pay for speech therapy for a child with a cleft palate but may also set a limit on the number of treatment sessions. Some plans specifically exclude coverage of a molding helmet for plagiocephaly.
Read your policy to understand “limits on coverage”, “deductibles”, “lifetime maximum” and “co-pays”. This will help you budget how much money you will need to pay. After the first year, you will be better prepared to predict the treatment needed for the cleft and can plan for the expenses.
Referrals: If your insurance requires referrals to other doctors it is your responsibility to obtain the referral from your primary care physician (PCP). This is requirement of your insurance, not the doctor. You should call the PCP to ask how much time is needed to process a referral. Always give the PCP the name of the specialist, address, phone and fax numbers to expedite it. Make sure the specialist’s office has received the referral prior to your appointment or you will be responsible for the bill.
Prior Authorizations: Hospitals and doctor offices will request prior approval from the insurance company for certain procedures. If prior authorization is received, it usually comes with a disclaimer saying that the pre-authorization is not a guarantee of payment. Insurance companies can refuse to pay because they did not issue a “prior authorization” and yes, they can deny payment even for a service that they previously authorized.
Explanation of Benefits Letter (EOB): This is a letter from the insurance company stating what claims for services (charges) were received, what was approved, and what you may have to pay. There are explanation codes that explain the reasons for not paying any or all of the charges. You should respond to this in writing if you disagree.
Appeal Denials: When you are told by a provider or insurance company that your insurance will not authorize treatment, call and ask the insurance company to send it to you in writing. The denial letter should tell you why they denied it and how to appeal the decision. Be clear that making the appeal is your responsibility. Always appeal denials in writing and before the deadline (usually 30 days). An appeal is a statement from you saying why you disagree with the denial. Ask the Team Coordinator if you need help to compose your appeal letter and obtain letters describing the medical necessity.
Continuity of coverage: Apply for COBRA if you expect a gap in coverage as when changing jobs. The job you are leaving should give you the information and documentation necessary to purchase this temporary coverage. Your new employer may have a waiting period before covering an existing condition. This waiting period may be waived if you had continuous coverage.
Problems with your insurance company? Ask if you can have a case manager for complex cases. These are usually people with more knowledge about certain diseases or birth disorders. Some insurance companies will assign a case manager for children who were discharged from neonatal intensive care units. The case manager may help you navigate the insurance obstacles.
If you still are not getting the assistance that you think you should be getting and you have an employee sponsored health insurance, you might approach your benefits department at work. Your employer is the insurance company’s customer since they are purchasing the product. If you purchased the plan through an insurance agent, you should advise them of your difficulties.
Consumer Complaints: If you believe you are being treated unfairly by your insurance company, file a complaint with the Texas Department of Insurance Consumer Protection Division. This complaint can be filed on line at http://www.tdi.texas.gov/consumer/complfrm.html or by calling (800) 252-3439.
Medicaid, CHIPS and CSHCN
These are government assistance programs that currently require families to re-submit proof of eligibility every six months. You will lose coverage, if you do not get the paperwork in the mail or if they do not get your re-submission in time. Be your child’s advocate and track the due dates for applications, confirm that the program received your paperwork and that the supporting documents are acceptable.
If you do not have insurance, you should check your eligibility for one of the government programs by going to www.state.tx.us or by contacting your local Medicaid office. The CSHCN program will cover children with cleft palates but need a physician affidavit form (PAF). Let us know that you are considering applying so that we can give you the form.
Children will age out of some eligibility programs such as medicaid. They will also age out or lose eligibility to be covered by their parent’s insurance. When teens reach facial growth maturity, they may decide that they want additional treatment. The best chance of getting this paid for by insurance is while they are still covered by your plan. You will want to take care of this before your child ages out of your insurance plan. Coverage for adults may differ from that offered to children.
Dental insurance plans place limits on what they will pay for and how much they will pay. You should read the plan to determine what you can expect the plan to pay for and what the upper limit of coverage is. If you have a Dental Health Management Organization Plan (DHMO) you may find that you have access to many group practices but not to a pediatric specialty dental practice.
If the dental work is being done in preparation for a surgery, it may be possible to get your medical insurance to pay for it. Be patient with your dental providers because they do not usually deal with medical insurance. Ask them to re-submit the claim with a “Letter of Medical Necessity” attached to the claim. If you get a denial submit a written appeal with a “Letter of Medical Necessity”, ask the Team Coordinator for help obtaining this letter.