Insurance Caps, questions?

[totoro]

OK I am having major brain fart today... but I just found out that K maxed out on her PDOC and TDOC.
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 PDOC and TDOC 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


Any ideas would be very appreciated.
We have United Health Care.

[totoro]

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.

[SRL]

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.

[smallworld]

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.

[Dammit Janet]

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.

[slsh]

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 w/ insurance company issues (esp w/ UHC) and my kids' bills. Keep good records and notes.

Hang in there!

[Hope]

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 pdoc visits and the visits over the 20 are the tdoc (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 DH's test.

[SRL]

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.

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.

[rlsnights]

"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.

[Wiped Out]

Totoro,
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.