Insurance question - Update

[Goldie]

I have been following this forum since I discovered it a month or so ago -- right about the time my 19-year-old gfg was on the verge of agreeing to go into rehab, out of state. He is there now, and so far, so good, as far as his progress.

But I did get word from the facility last week that our insurance has refused to certify gfg's treatment, on the grounds of medical necessity. The insurance carrier believes our son would be better off in Intensive Outpatient Treatment.

I will be working with the rehab facility on an appeal, but I thought I would post here and ask if anyone has done such an appeal and actually prevailed. I'm afraid this appeal will be an exercise in futility, but I'm hoping to hear that it is not impossible to reverse this kind of decision.

TIA for any insight you can give!

[Nancy]

Grrrrrrr of course they feel it is not a medical necessity and he would do just as well in outpatient because it's cheaper for them. I'm glad the facility is helping with the appeal. We have appealed insurance ruling in the past (not related to rehab though) and were successful in getting them overturned. The doctor's opinion carried a lot of weight. So don't give up.

Our insurance only paid for five days detox and five days of inpatient out of 60. Since we had $10,000 deductible they ended up paying $3,000 out of $25,000. They paid nothign for intensive outpatient since we exhausted benefits.

The rehab center our gfg was in did have scholarships available for people who did not qualify for insurance. Does your son's have anything like this?

Nancy

[Goldie]

Thanks for the encouragement, Nancy -- we will not give up!

As far as a scholarship goes -- the facility website does mention scholarships, but we paid up front (for a 30-day stay), so I assume that we would not qualify. I might ask them anyway, but I would think that the scholarships would be for people who could not otherwise afford treatment. For us, it is a hardship, but it is not impossible.

[Kathy813]

Hello and welcome!

My GFG is 26 and had no insurance when she went to a 30 day inpatient rehab. She went to a community health center rehab and they charged on a sliding scale based on her income (which was zero). So she was charged $700 for a normal $7000 stay.

Of course, we had to pay the $700 since she didn't have any money. The point of this, though, is that since your GFG is an adult, the scholarship should be based on his income . . . not yours.

Good luck and keep posting! We are glad to have you here.

~Kathy

[DDD]

Our insurance did not give us any grief about admission (he was a minor teen) but then after five days or seven the insurance company determined he was free of substances and should be released to go to community outreach. Yikes, that blindsided me. Appealing worked for a few more weeks and then, ugh, we ended up out of pocket. The second facility (we did three) had a generous sliding scale as they had sizable endowments etc. I had not explored the 2nd one at first because it was "top drawer" and I knew we didn't have the resources to pay what very wealthy families paid. What a shock it was to find that they were less expensive for us than the first. Do check all your options. Fingers crossed that your insurance company comes through. Hugs DDD

[Nancy]

We had to pay out of pocket too Goldie. What this all forced us to do after we paid over $30,000 including aftercare, was to drop her from our insurance and then being an adult without insurance and no income she would then be eligible for sliding fee scales or scholarship opportunities. Our treatment center told us their scholarships are for those who are currently in treatment and whose insurance has run out and cannnot self pay.

It's a shame that there is so little help out there unless you have unlimited funds. We used most of our savings over the years trying to get her help and then the treatment center exhausted all the rest. The only good thing was on last years taxes we were able to deduct over $30,000 in medical expenses. Our accountant called to verify that amount was correct and we said sadly it was. I was almost hoping we would get auditted.

Nancy

[Goldie]

I just checked in here for the first time since last night. Thank you so much for your responses!

Nancy, it just occurred to me yesterday that we might have a sizable medical deduction on our taxes next year. I pointed that out to my husband, but for some reason, the thought did not excite him! But, hey, whatever helps, financially . . ..

DDD, I am glad to hear that appealing bought you a few more weeks. It does give me some hope.

Kathy813 (and the other posters), I appreciate the information about the advantage (scholarships, sliding scales) of not having gfg on our insurance; that had not occurred to me. I hesitate to do that, though, for a couple reasons. For one, our mental health coverage is usually pretty good. For example, gfg had a 10-day inpatient stay at a psych hospital last summer, for a major depressive episode with suicidal ideation. The charge was over $7000, but insurance paid every penny of it. We are also reimbursed pretty well for gfg's out-of-network psychiatrist. It is only now, in rehab, that we are running into a real challenge.

Another reason I hesitate to drop gfg from our insurance is the worry about unexpected medical expenses. Gfg himself is a great example of that kind of surprise, as he was born 10 weeks prematurely. (The unexpected cause: my appendix ruptured. Not fun!) He spent four weeks and a day in the NICU, and the cost of that was way, way more than the cost of his current 31-day stay in rehab. We were very relieved that insurance covered everything. (Fyi, he was a trooper, and came home a healthy and happy baby!)

On the other hand, I can already see that this has the potential to get really, really expensive, especially if the current rehab place recommends (as I expect they will) extended residential rehab. I keep saying to my husband that this had better work, because I can't imagine affording any more rehab after this year! (We did recently receive an inheritance, which helps a lot, but it is still a limited resource.) But I know that relapse is part of recovery, so -- well, we may have to consider the option of dropping him from our insurance at some point, despite my worries about that.

My husband and I will be going to the rehab facility for four days starting this Saturday, for a family program, and at some point we will be meeting with our financial contact person there, to discuss insurance appeal strategies. Thanks to all your suggestions, I will ask her about scholarships and sliding scale payment arrangements. It may not help us, but it sure can't hurt to ask!

Thanks again for the feedback and suggestions. I am glad I found this forum!

[Ephchap]

Hi Goldie.

Our situation was a little different, as my son had just turned 17. It was one of those gray areas, where the police and court system considered him an adult, but the health insurance and hospitals and rehabs considered him an adolescent.

He did go to an adolescent substance abuse hospital, and our insurance (which he was still covered under at the time) did cover his stay. However, even though we had agreed to 21 days with the director of the program when he was admitted (as we told her we were looking for a long-term placement), he was released on day 12, as the insurance carrier said he now had all the tools and could do outpatient. That night he went out the window of our home, was arrested and has an adult felony on his record to this day. Yeah, thanks insurance carrier. He was really ready. Ughhh.

We did end up having him evaluated once again, and found a place after making what seemed like a hundred phonecalls. I finally got someone at one of the hospitals substance abuse floors for adults that recommended I contact a certain agency that dealt with our county's MHMR. They evaluated him and agreed he needed dual-diagnostic (both psych and substance abuse) long-term residential care. Our insurance carrier would not pay for anything that was considered a residential stay. The agency had us fill out paperwork to apply for SSI for him. It was based on his income (zero). As a minor living in our house, however, they also had us fill out paperwork, and they determined what we could pay. We appealed that and had the amount lowered, as by then I was not agreeable to throwing more money out and we had two other children had home. He was placed in a great facility about 2 hours from here, and he stayed there 10 months - just up until his 18th birthday. He could have stayed longer since he was already in there before turning 18, but they (and at that point, we did too) felt he was ready to transition home.

Again, this was all very different since he was a minor. However, there are agencies that will help and that deal directly with MHMR and other agencies. The hard part (sometimes futile) is finding someone or some agency that will help.

It should not be this difficult when someone is finally ready to get help. Unfortunately, the sad reality is that it is. Many fall through the cracks and never get the help they need because of the way the system is set up (or, in my opinion, not set up).

My heart goes out to you. I know what a difficult situation it is to be in.

Hugs to you and yours,
Deb

[PatriotsGirl]

Hello and welcome!

My GFG is 26 and had no insurance when she went to a 30 day inpatient rehab. She went to a community health center rehab and they charged on a sliding scale based on her income (which was zero). So she was charged $700 for a normal $7000 stay.

Of course, we had to pay the $700 since she didn't have any money. The point of this, though, is that since your GFG is an adult, the scholarship should be based on his income . . . not yours.

Good luck and keep posting! We are glad to have you here.

~Kathy

Kathy - since we live so close by - can you PM which facility this was so I can have it on standby? I would SO gladly pay $700 for GFG to get into a program!!! (Course she has to want to help first!)

[Goldie]

Thank you, Deb! This is all so strange for me. A year ago, I was immersing myself in the intricacies of applying for financial aid for college. I would not have thought that a year later, I would need to learn all about affording rehab. But you do what you have to do, I guess!

I wish there were a book or a primer about this topic, though, the way there is for paying for college. I have now googled SSI benefits, but I realize I have a ways to go before I have a real handle on how we can afford this. Our insurance does not pay for extended residential rehab, so even if we eventually get reimbursement for this 31-day primary care stay, we are on our own for any subsequent care, other than IOP. So I guess -- I'd better get focused on this now!

Anyway, we are leaving this evening for a four-day Family Education Program (FEP) at gfg's rehab facility, and will be meeting on Tuesday with the financial person there who is helping with our insurance appeal. I'll post again next week about that.

I don't think we get to see gfg too much at the FEP, but we do have lunch with him two of the days, plus he will be performing an original song at chapel on Sunday. (I wish I could link to a video of him performing this song back in September at Student Talent Night at his college, but I guess that would be a problem, privacy-wise! But I have to say, the boy can compose and sing; whenever I'm down in dumps, I watch that youtube video.)