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General Parenting
Is there a way to get more than the approved
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<blockquote data-quote="bigblueagain" data-source="post: 4098" data-attributes="member: 909"><p>the carrier would not have to continue to pay if you have maxed out your benefits for the calendar year. If the preferred care is thru a self insured employer group the employer could be approached to make an exception and allow continuing coverage. That would have to go thru their human resources department as a benefit appeal. IF is not self insured, the employer could still ask on your behalf, but usually does not wish to get involved in the middle. This is because the risk is on the carrier, not the employer, and the employer's covered lives basically get only what the employer has set up to pay for. It is sort of like a savings account if you want to think of it in that way. Your employer if fully insured by a carrier pays a certain fixed amount to that carrier to pay what is forecasted claims for a certain time period. These are based on prior "experience" of the group, meaning the amount of utilization the employees have done previously. If paid claims go over the set amount, the employer usually does have some responsibility for covering them, but the insurer has the most responsibility. Hence the reason the employer does not like to get too involved. A self insured employer has more say over how the money is spent, as they are taking the risk themselves.</p><p>One thing I would suggest is to ask your mental health provider to write a letter of appeal on your behalf. You can call the preferred care carrier, ( I am assuming is BC/BS if is called "preferred care"), and ask for the steps in an appeal of benefits. There is some medical necessity to your appeal, but when a benefit is maxed it usually doesn't matter if it is medically necessary or not.....the benefit just isn't there. Let me check your state regs too on mental health coverage.......but I really need to know if your employer is self or fully insured, as self insured employers are exempt from the regs. BLUE</p></blockquote><p></p>
[QUOTE="bigblueagain, post: 4098, member: 909"] the carrier would not have to continue to pay if you have maxed out your benefits for the calendar year. If the preferred care is thru a self insured employer group the employer could be approached to make an exception and allow continuing coverage. That would have to go thru their human resources department as a benefit appeal. IF is not self insured, the employer could still ask on your behalf, but usually does not wish to get involved in the middle. This is because the risk is on the carrier, not the employer, and the employer's covered lives basically get only what the employer has set up to pay for. It is sort of like a savings account if you want to think of it in that way. Your employer if fully insured by a carrier pays a certain fixed amount to that carrier to pay what is forecasted claims for a certain time period. These are based on prior "experience" of the group, meaning the amount of utilization the employees have done previously. If paid claims go over the set amount, the employer usually does have some responsibility for covering them, but the insurer has the most responsibility. Hence the reason the employer does not like to get too involved. A self insured employer has more say over how the money is spent, as they are taking the risk themselves. One thing I would suggest is to ask your mental health provider to write a letter of appeal on your behalf. You can call the preferred care carrier, ( I am assuming is BC/BS if is called "preferred care"), and ask for the steps in an appeal of benefits. There is some medical necessity to your appeal, but when a benefit is maxed it usually doesn't matter if it is medically necessary or not.....the benefit just isn't there. Let me check your state regs too on mental health coverage.......but I really need to know if your employer is self or fully insured, as self insured employers are exempt from the regs. BLUE [/QUOTE]
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