Insurance Caps, questions?

Discussion in 'General Parenting Archives' started by totoro, Oct 19, 2009.

  1. totoro

    totoro Mom? What's a GFG?

    OK I am having major brain fart today... but I just found out that K maxed out on her psychiatrist and therapist.
    I think we may be able to ask them to change the apts. to family.
    Right? We can do this, if the Doctors are willing?
    Also what is the protocol you take to ask for extended number of visits? I think we have 20?
    But K maxed out the $ amount.
    Is it that your child has a "Chronic Condition" that she will have for life? She must have a psychiatrist and therapist to enable her to function.

    My head is spinning with bills and insurance not paying claims etc.... they are pretty good usually, but Jeff had some blood work that was unnecessary according to them!
    It was for his gout and arthritis. Looking for allergens that might be triggering inflammation, which they found.
    Plus some other unnecessary speech testing for K. BLECH :sad-very:

    Any ideas would be very appreciated. :whiteflag::D
    We have United Health Care.
  2. totoro

    totoro Mom? What's a GFG?

    Also how does the Health Parity law work? Is it the state you live in? Or where your insurance company is located? Or where you pay your insurance?
    We live in AZ, company is in IN, but bank and Insurance where we pay is in IL. But United Health Care is nation wide.
  3. SRL

    SRL Active Member

    Totoro, by maxed out do you mean she's used her alloted number of visits for this calendar year? I have BCBS and I've not known them to budge with this but hopefully someone else can give you better news. For instance I have $1500 alloted to me for chiropractic per year and when it's gone, it's gone. That's the coverage that's included in my plan and anything beyond that is my responsibility.
  4. smallworld

    smallworld Moderator

    Like SRL, my understanding is that it's by calendar year, not lifetime, but you should call your insurance company and check. Fortunately, it's mid-October and January is coming . . .

    I also think the mental health parity law is slated to begin January 2010, but I'm not 100 percent certain about that.
  5. DammitJanet

    DammitJanet Well-Known Member Staff Member

    I think there is also a lifetime cap on insurance but she should not be near that yet. I think when I had BCBS I had a million dollar lifetime cap. Sounds like a lot but it really isnt if you have a chronic illness.
  6. slsh

    slsh member since 1999

    If the company is self-insured and UHC just administers the plan, call the HR dept of the company. The co. can make exceptions.

    I feel your pain. I used to spend at least a couple days a week (seriously) dealing with- insurance company issues (esp with- UHC) and my kids' bills. Keep good records and notes. ;)

    Hang in there!
  7. Josie

    Josie Active Member

    Do you have an EAP you can use? We have UHC and they only pay for 20 visits but we also have EAP benefits that cover 8 visits.

    I also make sure that insurance pays for all of the psychiatrist visits and the visits over the 20 are the therapist (or which ever one is cheaper). Probably too late for that this year, but next year you can do that, if you have to.

    I call UHC regularly to question them about why they denied some of our claims (not mental health ones though). A lot of the time, they will then pay some of it. Sometimes they even pay things that they didn't pay for before. Either the same exact claim if I file it again or the exact test on a different date that was denied. I think they just deny things hoping we will go away and they won't have to pay. I don't think it would work on the mental health but might work on your husband's test.
  8. SRL

    SRL Active Member

    I haven't looked at our policy recently but when I was teaching I remember there was a lifetime cap on medical, plus a seperate lifetime cap on mental health that was considerably lower.

    I have a friend who had maxed out her lifetime mental health benefits through one employer.
  9. rlsnights

    rlsnights New Member

    "The federal Mental Health Parity and Addiction Equity Act of 2008 (Public Law 110-343, Subtitle B) goes into effect for large group health plans (51 or more employees) issued or renewed on or after October 3, 2009. In summary, the federal law includes the following:

    A health plan may not apply annual or lifetime limits for mental health or substance use disorders that are lower than those for medical/surgical benefits
    A health plan may not have higher deductibles, copayments, coinsurance, out-of-pocket expenses or more restrictive treatment limits (limits on the frequency of treatment, number of visits, days of coverage, or other similar limits on the scope or duration of treatment) for mental health or substance use disorders than those for medical/surgical benefits
    A preferred provider plan may not require that mental health or substance use disorder services be available solely from network providers
    The federal Departments of Labor, Treasury and Health and Human Services are responsible for implementation and enforcement of the federal mental health parity law."

    You have no protections currently under AZ law but you now (as of 10/3/09) have federal protections for policies ISSUED on or after 10/3/09.

    If your policy is coming up for renewal you should see new/different language in your EOC on mental health coverage.
  10. Wiped Out

    Wiped Out Well-Known Member Staff Member

    Have you looked into applying for Medicaid through the Katie Beckett program? They look only at the children's income and not the parents. Elijah qualifies and it has been amazing. Anything our regular insurance doesn't pay for they pick up the co-pays or pay it in full.
  11. smallworld

    smallworld Moderator

    Mental Health Parity Rules Delayed Until January 2010

    HHS Secretary Kathleen Sebelius said in an October 2 letter to lawmakers that the Administration aims to issue regulations for the 2008 mental health parity law by January 2010. The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (Pub. L. No. 110-343) required that regulations be issued by October 3, 2009, but HHS and the Labor and Treasury departments are still working to develop them. The letters were in response to queries from Senator Al Franken (D-MN) and Representative Patrick Kennedy (D-R.I.) who spearheaded efforts from Senate and House members regarding proper implementation of the regulations. For most insurance plans, the law goes into effect January 1, 2010, and concerned lawmakers and mental health advocates have said the absence of regulations could lead to misinterpretations of the law. The House and Senate letters also highlighted areas that members said the agencies must take careful care to address such as scope of services, medical management, treatment limitations, and the use of "separate but equal" deductibles.

    HHS has stated that insurance plans should make reasonable efforts to adhere to the law's intent in the absence of regulations and a spokesman for America's Health Insurance Plans, a trade association representing health insurers, said that health plans have already made changes to come into compliance with the law though they are seeking further guidance on some technical questions.

    DGR continues to monitor the regulatory process and provide any assistance possible to the Administration, in addition to helping provide guidance to employers, insurance plans and physicians on how to properly implement the law.
  12. totoro

    totoro Mom? What's a GFG?

    Thanks you guys.
    My dollar amount for in network was maxed out for psychiatrist for the year for K.
    For therapist the 20 visits were out of network and that maxed out.

    The psychiatrist was what confused me? I know we haven't reached our lifetime CAP.
    But when I looked at K for in-network psychiatrist the $ amount for the year has maxed out.

    Our company is only 5 people. Plus the kids and wives.
    I talked to our therapist today and she said she would do what she could. Our psychiatrist had said in the past she would also.

    I wish things would change.
    W.O.- When I had tried for Katie Beckett before I was told that her 529 plan kept her from being approved? This was set up by her grandparents in her name.
    This was in Idaho, the moron in the dept up there could have been a moron...

    HOPE- What is an EAP?
    Last edited: Oct 19, 2009
  13. LoveMyDuke

    LoveMyDuke Guest

    I know a bit about insurance...I've worked in the industry for 10 years. Mental health parity at the Federal level does go into effect 1/1/10 and supercedes State mandates (assuming the State mandates is less--if more, then State prevails). However, MHP only applies to certain employer groups based on size and funding status (fully insured vs. self-insured. It basically says that mental health and medical coverage must be equal, ie., if medical has a 90% coinsurance mental health has to be equal to or better than that benefit.

    If your employer group is only 5 or so people, I'm betting your benefits include only what the State your group is domiciled in requires. And if it's a max $ amount per calendar year...then you are probably out of luck until January. :( I hated telling that to members when I was in Customer Service!

    In Wisconsin, where I live, we have State mandates that most insurance policies stop at. A few self-funded plans exceed the mandate, but not many. I believe it's currently a $7,000 combined max for inpatient, outpatient and transitional treatment. When the max is met--the max is met. No amount of pleading or appealing will change that. Now, if you are self-insured...then there's a remote possibility the employer will take sympathy and agree to pay extracontractually. But with a group of only 5 or so, no way are they self-insured.

    EAP stands for Employee Assistance essentially acts as a referral service for mental health. They are all different and are usually free. Sometimes the EAP benefit is in addition to insurance benefits, but usually it's fairly limited (eg., 3 visits). EAP's are a good starting point but not a long-term benefit.

    Hope that helps. It's difficult to respond to insurance "stuff" sometimes without knowing all the is a complex beast!
  14. susiestar

    susiestar Roll With It

    I don't have specific knowledge of your plan. I DO know that many plans seem to ahve the "deny it first time and only pay if the client makes a fuss.

    The savings they find this way is phenomenal. I know my husband would accept what they said the first time because it wouldn't occur to him that they would actually do this.

    There is a Grisham novel about this. Sadly it rings true about most of the insurance dealings I have ever had.

    I hope things can be resolved.

    Is there any way the grands can dissolve the 529 plan or allow it to be used for healthcare/mental health payments?

    It won't hurt to apply for SSI or medicaid for the girls. Just remember to appeal if they deny it becasue, at least here, that is when most are accepted.
  15. totoro

    totoro Mom? What's a GFG?

    Thanks LMD and Susie!
    It is our company, so we pay for insurance. Well we being my Husband and his 2 partners. He started the company with his Dad and Brother, so it is family and they are understanding of our issues.
    There are 2 other employees in Gary, IN. Actually 3 now that I think of it.
    So all of the bills and statements etc. Go through Indiana and I never actually see them until I get "our" bill for payment for everything denied or not in-network or when we have maxed out etc.
    The company pays the premiums and we pay everything else.

    I have been trying to figure this out for such a long time over the phone and computer, but because I don't control the account I don't get very far. :(

    husband tries but just doesn't explain it or ask the questions the way "I feel" he should to get the right answers! LOL
    And I document... like most women do, everything.

    I am going to both therapist and psychiatrist this week, I will see what they think and go from there.
    Thank ladies, you rock!!!!
    Right now K needs her therapist it is keeping her semi stable. AND ME ALSO!
  16. GoingNorth

    GoingNorth Crazy Cat Lady

    LMK how you get it worked out. I am currently hassling with ChampVA and Medicare to figure out how gets billed for what and in what order.

    I have a stinking feeling I'm going to get stuck with some lab bills, but I hope like hell I don't get stuck with drug bills