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Insurance/Appeal question

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    Insurance/Appeal question

    I'm not sure where to put this...

    We currently have United Health Care through COBRA, which is ending tomorrow. There are two DME products (a standing frame and FES Bike) which my son's rehab tried to order for him, but were denied by our insurance (they said the standing frame was experimental and the FES bike wasn't DME). My question is, does anyone know if an appeal can be done even though we wouldn't have insurance with UHC by the time it was approved (assuming it will be approved). In other words, it would be like retroactive coverage, because it *should* have been approved in the first place.

    I have asked several people about this: at UHC, the vendors, US Dept of Labor and OH Dept of Ins. and get varying answers.

    It has been a nightmare trying to get these things ordered, and I would keep appealing as many times as possible...if I knew that there was a chance they would cover the items retroactively (say, as of the date it was initially ordered).

    If not, we will have to try and order the items through OH Medicaid, as that's all my son will have now. Apparently, no insurance will take him since he's eligible for Medicaid. Another very frustrating thing!

    Thanks for any suggestions or advice!

    If you or your son's father are eligible for group health coverage through an employer, they have to allow your son to be covered. Age limits are also eliminated for disabled children. If either of you has coverage now, you son can be added immediately as expiration of COBRA is a qualifying event.

    If neither of you has group coverage at this time, your son can go on as soon as you can get said coverage. I know that Medicare is only primary if the group is a "Small Group" plan but I believe Medicaid is always secondary (could be wrong on this). When does your son become eligible for Medicare?

    To say that a standing frame is experimental is crazy. If it is, the experiment has been ongoing for more than forty years-one of Ryan's therapy places had one that old. We did not even try to get insurance to pay for ours (probably should have) but bought a used one and took a tax deduction.

    Have you gotten your son's doctor involved in the appeals? Appeals should be effective when the claim was initially submitted. I would sick the state insurance commission on UHC. I know that this has worked for members in Virginia in the past. UHC (like most/all carriers) counts on you not fighting it. They have a precedent of denying claims and taking their chances. If a FES bike is not DME, what is it? A toy? I do not think do.

    Another thing you may want to try is to have your DME provider submit it to Medicaid immediately and let them fight with UHC. You will amazed how things are different when the state submits it.--eak
    Elizabeth A. Kephart, PHR
    mom/caregiver to Ryan-age 21
    Incomplete C-2 with TBI since 3/09


      Thank you SO much for your support and advice. It's very much appreciated!

      My husband and I don't have any insurance at the moment. He is still unemployed, and we are looking at purchasing private insurance for us. My son wouldn't be eligible under any of those though, because he has Medicaid.

      As COBRA just ended 30 Jun 2011, I understand we have 63 days to find us insurance without showing a drop in coverage. Do you know, if my husband finds a job with a group insurance plan, within that time, does the same rule apply? Also, would my son then be eligible for that coverage, even though he has Medicaid? I know his age (20) wouldn't be an issue. I'm wondering if his diagnosis (quadriplegia) would be though?

      We are dumbfounded that the standing frame wasn't covered. Experimental?? Are they crazy?! And I saw all the information that was sent for the FES bike, and there was tons of documentation supporting its use as medically necessary. Sigh.

      Yes, his doctor signed the letter that his PT wrote. I'm not sure if she was involved anymore than that.

      I am really hoping the appeal would be effective when the claim was originially submitted. That way we could keep appealing. Does it make a difference that we don't actually have the item(s) yet though? It is just for a preauthorization. One of the vendors doesn't even want to do an appeal because our UHC has ended.

      Do you know how I go about getting the Ohio insurance comission involved? It looks like that would be the same number I've spoken to at the Dept of OH Insurance, and they told me they have nothing to do with issues like this. Maybe I've spoken to the wrong department though?

      Finally, I like your idea about the DME submitting it to Medicaid and having them fight UHC, but how does that work exactly? Would I have to explain that I want them to try and get UHC to cover it, or would they do that automatically? I'm worried they would just try to process it through Medicaid, and then we'll just get a denial letter from them, lol.

      Thanks again for all your help!


        Oh, one more thing. I just spoke to the woman who is our case manager with OH Medicaid. She helps with the Home care waivers - the aide, nurse, home modifications etc. Anyway, she said she has never heard of Medicaid trying to get a private insurance (UHC etc.) to cover something.


          Group coverage from a "Large group" will always by primary coverage over any government plan (Medicaid or Medicare). The group has to allow coverage with no exclusions for prior conditions provided the break in coverage is less than 63 days. If a Plan has more than 100 participants at the beginning of the plan year, it is a large group plan. They have to allow coverage with no pre-existing condition exclusion provided said coverage can be obtained before the 63 days has passed. After that, they can "and will" exclude coverage for anything related to your son's SCI or anything else your family has been treated for.

          I am shocked that Ohio Medicaid does not do everything possible to get other coverae to foot the bills. I know that I have to submit annual reports about Ryan's other coverage. He has been covered by a large group health plan all his life. They were better than the carriers when Ryan went off COBRA and onto the new group health plan. Our situation was different in that we decided to COBRA Ryan only since a mid,year change, while he was inpatient in the Trauma center and facing rehab, would cost us more in new deductible and out of pocket max. Medicaid and the state department of Insurance were instrumental in getting the new carrier to acknowledge the prior coverage documentation that waived the pre-existing condition exclusions for Ryan.

          Tell your DME provider to submit the claim to Medicaid with a copy of the statement from UHC that they consider this equipment to be not covered. This will have the date and give the state the opportunity to fight the carrier. The response from the state will be very telling.

          I wish I could help with the Ohio State Insurance office. I had to spend hours to find the person who was willing to make a phone call to my carrier. I think that if you find someone willing to press the issue, the carrier will cave. We did not try to have these items paid for by insurance because we knew we maxed out the DME allowance with the power chair. I know others have had insurance cover the items. Fight for it out of principal even if the state will pay for it.--eak
          Elizabeth A. Kephart, PHR
          mom/caregiver to Ryan-age 21
          Incomplete C-2 with TBI since 3/09



            PLEASE PLEASE...

            READ a post of mine from 2010 I think...I give a brief history of my long 34yr experience with my c4/c5 injury age 16. My mom's insurance, United Healthcare, had to cover me as a minor child and as long as I don't marry...ALAS, I digress...

            UNH fully covered my 1ST ERGYS FES bike in 2/1985. Yes, that's 1985. It took about a 9 months of back-and-forth. They are about to cover my 2nd this year.

            UNH fully covered my 1st tilt-table [Midland Manufacturing, SC] in 1986 after about 1 yr fighting. When that table died in 2005, they fully covered a new one.

            POINT IS: Once they cover it, they are on the hook to 'replace it' from wear and tear.

            READ MY EARLIER POST in this forum...

            Need more? PM me..

            I live in NY