Resource CenterInsuranceInsurance GuideInsurance Maze

2.5. Insurance Maze

Recommended Steps:

  • Obtain a copy of the full (not abbreviated or summarized) explanation of insurance benefits. Read your policy carefully and thoroughly, including fine print, definitions, exclusions, etc.

  • Find out if you have been assigned a case manager and contact that individual; if not, request that you be assigned to a case manager or benefits advisor. To be your own best advocate, you should educate this individual about your SCI/D and your particular needs to preserve the integrity of your body and health.

  • Determine the rehabilitation benefits: inquire about the number of allowed days of coverage for inpatient acute and sub-acute rehabilitation, outpatient and home health rehabilitation; is there an annual maximum number of days; is there a lifetime maximum number of days (these need to be differentiated according to the above categories of service)

  • Inquire about rehabilitation in a SCI/D-accredited rehabilitation facility; does this include both an in-state or out-of-state facility

  • Know the benefits re: durable medical equipment (DME); is there a lifetime maximum amount of dollars for DME

  • Select a doctor: Your choice will depend upon the type of insurance plan that you have. You will need a doctor with expertise in SCI/D; can this person be your primary care physician (PCP) or will your PCP consult with your SCI/D doctor in the management of your health care? The following will apply:

    1. HMO: must use a physician who is part of the HMO
    2. PPO or POS: Choose a doctor within the system; if your doctor is not on the given list, you may choose to go out of network; you will probably have to pay all or a larger portion of the fees

  • Contact your insurance representative for issues and/or concerns that relate to your health insurance and whenever you have been denied a service that you believe to be covered

  • Remember to always document/record all conversations with your insurance company: include date of the call, the reason for the call, the person with whom you spoke and the outcome of the call.

  • Keep all correspondence that has anything to do with your health insurance coverage! All written communications should include your Name, Insurance Identification (ID) and/or Group Number, Social Security Number and your date of birth; require that all actions regarding health benefits coverage be in writing.

Frequently Asked Questions

Can I go to a doctor with SCI/D expertise?
Consult the provisions of your insurance policy; if your PCP does not have this knowledge, ask him/her to consult with a SCI/D physician in the management of your health care
Can I continue my health insurance that I had through my employment, even though I cannot return to that place of employment?
COBRA, the Consolidated Omnibus Budget Reconciliation Act of 1986, is a federal law that gives certain employees and dependents the right to "continuation coverage." This means that they can temporarily continue to keep the same coverage they had through a group health plan, even after they are no longer entitled to stay in the group health plan. The benefits will be the same, but the premiums will probably be higher. COBRA continuation coverage is only available when coverage is lost due to certain qualifying events, such as losing a job, death, divorce, or other life events. Under certain circumstances for the person with SCI/D, this continuation may be extended an additional 11 months beyond the initial continuation.
What is durable medical equipment (DME)?
Equipment such as wheelchairs, walkers, commode and shower chairs that must be ordered by your doctor, accompanied by a 'certificate of medical necessity' (CMN), for long term use, and for use in the home.
Who is responsible for a 'certificate of medical necessity'?
Your physician must complete and sign, in his/her own handwriting, a CMN. This form should accompany any DME request to your insurance company or Medicare; it should specify that your diagnosis is permanent, that the requested item will be used over time and that it contributes to your health by preserving the integrity of your paralyzed muscles, wellbeing and/or functional independence.
Will my insurance pay for experimental or research procedures?
For possible consideration for access to and coverage for experimental medications or procedures: Ask the plan administrator for a "Compassionate Use Waiver" from the FDA. If the waiver is granted, the health insurance plan may permit access and coverage 13
What can I expect if I become acutely ill?
Prior to an acute illness, you should request a consultation appointment with your PCP during which you discuss your immediate needs regarding urinary tract infections (UTI's), spasticity, autonomic dysreflexia (AD), pressure sores and other possible urgent health care needs. Ask about "standing referrals" to a specialist such as an urologist, procedures and policies when you become ill after office hours and/or have an urgent care or emergency need.
What should I do if I am too ill and weak to wait for care in an emergency waiting room?
Call your health insurance provider advice or hotline. Ask that they make arrangements for you to be seen, or at least placed, in an emergency patient room as soon as you arrive at the ER or arrange for your doctor's office nurse/staff to assist with such arrangements or contact your hospital trauma or SCI nurse specialist and ask for this assistance
What should I do if I require urgent or emergency care?
Call your PCP or insurance advice/hotline if your situation is non-life threatening. If your situation is life threatening, go immediately to the nearest ER; take your insurance card with you; take information about AD and any allergies, if these are risk(s) for you. Following your emergency, immediately contact your health insurance case manager.

Guidelines When a Health Service or an Insurance Claim is Rejected or Denied

All health insurance plans have some form of appeals procedure. It is not unusual for medical procedures, medications, therapies, 'length of stay' days and durable medical equipment to be denied to individuals covered by healthcare plans. Over 70% of those persons, who have been denied coverage, do not attempt to appeal the decision. It is strongly recommended that you should appeal all denied or rejected insurance decisions or claims. Decisions are reversed in 43% to 80% of cases that are appealed, according to recent reports.

Recommended steps:

  • Contact your insurance representative immediately; ask for an explanation of the action
    1. If needed information was not provided with the original request, resubmit your request with the pertinent or necessary information.
    2. If the action is a denial, request the reason(s) for each denial in writing

  • Read your policy carefully:
    1. To discover which type of dispute resolution mechanism (appeals process) is available to you
    2. To determine if your insurance carrier has mistakenly denied coverage 14
    3. To determine if the service, that has been denied, is deemed "medically necessary"

  • Document/Record all conversations:
    1. Include name, date, time and actions, of anyone related to the problem/issue, with whom you have spoken
    2. Keep copies of all correspondence that has anything to do with the initial denial of coverage, and anything that pertains to your appeal
    3. Keep copies of all claim forms and bills

  • Submitting an appeal: Be your own best advocate!
    1. Be familiar with appeals procedures
    2. Know deadlines to file claims and appeals
    3. Inquire as to when a hearing will be scheduled. (Most plans have a maximum number of days in which to set a hearing date.) Make repeat phone calls until you get concrete answers to your questions. Be insistent, consistent and persistent!
    4. Base the contents of your appeal in relation to the reason for the denial:

      • Learn and be informed about your own health impairment, level of injury, care required to preserve the integrity of your paralyzed body, risk of secondary complications.
      • Enlist the cooperation and collaboration of your doctor in providing supporting documentation as to the need for a reversal of action
      • Submit supporting statements from experts in the field with your appeal
      • Submit published articles that substantiate the necessity of the service or durable medical equipment that was denied with your appeal

Be your own best advocate - when uncertain or dissatisfied – Appeal!

  • Should you feel that you have not been treated fairly by your plan provider or that the appeals process has become too lengthy, contact your state Insurance Commissioner. Each state has an agency whose sole responsibility is to regulate the insurance industry within that state. No two states have exactly the same insurance regulations; you must contact your state insurance agency to learn your rights about the appeals process.
  • Health Insurance Ombudsman: Twenty states now have these government-paid intermediaries to help the consumer navigate the health care system and resolve health insurance problems. Contact your state insurance agency to find out if this is a service offered within your state.

This page was: Helpful | Not Helpful