insurance question

[Guest guest]

This is not an uncommon situation. Most insurances do not cover WLS ,

as it is expensive and also a great many people would be eligible.

Do not exhaust your appeals! Save the last one for an attorney, if

needed. Most places give you 3, so if this is the second one, you're

fine. If you only get 2, I'd urge you to contact an atty now for his

help.

This is an impt area for you, since any band problems can be very

expensive, and you want coverage if at all possible.

steve kalman is a banded attorney who devotes part of his practise to

helping bandsters with issues like this. His consult is free, and he

often gets results with only a letter or two on your behalf.

Steve Kalman - techauthor@...

I think you're correct that they can not deny a pre-existing

condition, but it's sticky becuse it is in an area that they DO deny.

also, here is the Bandster insurance forum that might be able

to give you other ideas :

BandstersInsurance

Good luck! do not give up!

sandy r

sandy r

>

> I'm a lurker but I need help. I was banded in '04 and it was

covered

> by my insurance (through my employer). Fills, all follow-ups and

> even a revision surgery were covered (all under the same insurance

> provider MVP - they managed the plan for my employer who self-

> insures). I still work for the same employer but in '07, they

> switched to a new insurance provider (Aetna). Same situation, with

> employer self insuring and Aetna managing the plan. Unbeknownst to

> me, my employer requested that all weight-loss surgery be

> specifically excluded starting in '07. So, when I got a fill

in '07,

> I was surprised to be denied coverage. I have since appealed and

the

> appeal has been denied. So now I am getting ready to submit a

second-

> level appeal and want/need some advice. My position has been that

> since this was an approved procedure, paid for in '04 and with the

> understanding that it requires long-term followup success, that it

is

> not in good faith for them to deny these follow ups. Clearly it is

a

> pre-existing condition.

>

> Has anyone been in this position? Any advice on how to word an

> appeal so that it will be better-received? I am prepared to battle

> this for as long as it takes (including filing suit)but want help

> with looking at it from angles I may be missing.

>

> Thanks -

>

>

>

[Guest guest]

,

Sorry to hear of your difficulties. Here is alink to someone who may

be able to help some.

http://obesitylaw.com/

Good luck

SharonS

> Has anyone been in this position? Any advice on how to word an

> appeal so that it will be better-received? I am prepared to battle

> this for as long as it takes (including filing suit)but want help

> with looking at it from angles I may be missing.

>

> Thanks -

>

>

>

[Guest guest]

Simple answer: You're SOL. Sorry.

Wednesday, April 9, 2008, 2:39:44 PM, you wrote:

> Same situation, with

> employer self insuring and Aetna managing the plan. Unbeknownst to

> me, my employer requested that all weight-loss surgery be

> specifically excluded starting in '07.

Insurance policy is a three way contract. You, the employer, and the

insurance company. The contract, like any others, includes all the

things that the three parties agreed to. You DID agree to it by

signing up for, or continuing, the insurance you already had. You

probably didn't read the details of the fifty pages or so of the full

contract (almost no one ever does), but you still approved it by

signing up. Of course your only other option would have been to have

no insurance, which would have been even worse.

> So, when I got a fill in '07,

> I was surprised to be denied coverage. I have since appealed and the

> appeal has been denied. So now I am getting ready to submit a second-

> level appeal and want/need some advice. My position has been that

> since this was an approved procedure, paid for in '04 and with the

> understanding that it requires long-term followup success, that it is

> not in good faith for them to deny these follow ups. Clearly it is a

> pre-existing condition.

Unfortunately, it is a different contract with a different insurer,

and the new insurer has NO obligation to cover anything else. In

fact, since your company is self insuring, it may have been the costs

incurred due to your weight loss surgery (and those of any others)

that got them to drop that from the policy. At least you got some of

the benefit while it lasted.

> Has anyone been in this position? Any advice on how to word an

> appeal so that it will be better-received? I am prepared to battle

> this for as long as it takes (including filing suit)but want help

> with looking at it from angles I may be missing.

If you want to talk to a lawyer, here is one:

http://www.obesitylawyers.com/bandedlawyer/

If they give you any hope or satisfaction, I'll be glad to learn

about it, but basically both the employer and the insurer are holding

you to the contract you signed, just like Visa would if you didn't

want to pay your credit card bill.

One other thing to think about....is suing your employer....which can

end you up in a world of hurt, such as unemployment.

dan

--

" It's OK to be a little broken, everybody's broken in this life " Jon Bon Jovi

Dan Lester, Boise, Idaho, USA www.mylapband.tk

Banded 4/27/03, Dr. Ortiz, Tijuana

Started at 355, at goal in the 210-220 range for almost 4 years

Ultimate goal of 195 Tummytuck in Boise and SmartLipo in Tijuana

[Guest guest]

Dan, wouldn't the coverage for pre-existing conditions apply here,

though? It's not like she is asking for new, expensive WLS, but only

that they cover MAINTENANCE for one already approved, and requiring

regular care.

If she were diabetic, and on insulin, and the compnay changed to a

policy that allowed no diabetics, I believe they would be required to

still cover her insulin and other DM care, as a pre-existing condition.

I surely don't know the answer, but i hope she pursues it

Sandy r

>

> Simple answer: You're SOL. Sorry.

>

>

[Guest guest]

Thanks for the advice. One note, I was never provided a copy of a

policy prior to signing up for it. I only found out about the

exclusion by my doctor trying to get pre-auth for a fill. When it

was denied and I called the insurer, they stated that there is no

document they can send me that says it is excluded but that it is, at

my company's request, that I should have called them about it before

signing up for the coverage. This makes no sense to me because who

can think to call about all the possible procedures one might need

and make a call about each before buying the coverage. In addition,

several months after the coverage had to be selected, a summary of

coverage was made available on the company website. I read through

the whole thing and weight loss surgery was not listed as excluded.

Maybe I do have a chance here.

>

> > Same situation, with

> > employer self insuring and Aetna managing the plan. Unbeknownst

to

> > me, my employer requested that all weight-loss surgery be

> > specifically excluded starting in '07.

>

> Insurance policy is a three way contract. You, the employer, and

the

> insurance company. The contract, like any others, includes all the

> things that the three parties agreed to. You DID agree to it by

> signing up for, or continuing, the insurance you already had. You

> probably didn't read the details of the fifty pages or so of the

full

> contract (almost no one ever does), but you still approved it by

> signing up. Of course your only other option would have been to

have

> no insurance, which would have been even worse.

>

> > So, when I got a fill in '07,

> > I was surprised to be denied coverage. I have since appealed and

the

> > appeal has been denied. So now I am getting ready to submit a

second-

> > level appeal and want/need some advice. My position has been

that

> > since this was an approved procedure, paid for in '04 and with

the

> > understanding that it requires long-term followup success, that

it is

> > not in good faith for them to deny these follow ups. Clearly it

is a

> > pre-existing condition.

>

> Unfortunately, it is a different contract with a different insurer,

> and the new insurer has NO obligation to cover anything else. In

> fact, since your company is self insuring, it may have been the

costs

> incurred due to your weight loss surgery (and those of any others)

> that got them to drop that from the policy. At least you got some

of

> the benefit while it lasted.

>

> > Has anyone been in this position? Any advice on how to word an

> > appeal so that it will be better-received? I am prepared to

battle

> > this for as long as it takes (including filing suit)but want help

> > with looking at it from angles I may be missing.

>

> If you want to talk to a lawyer, here is one:

>

> http://www.obesitylawyers.com/bandedlawyer/

>

> If they give you any hope or satisfaction, I'll be glad to learn

> about it, but basically both the employer and the insurer are

holding

> you to the contract you signed, just like Visa would if you didn't

> want to pay your credit card bill.

>

> One other thing to think about....is suing your employer....which

can

> end you up in a world of hurt, such as unemployment.

>

> dan

>

>

>

> --

> " It's OK to be a little broken, everybody's broken in this life "

Jon Bon Jovi

> Dan Lester, Boise, Idaho, USA www.mylapband.tk

> Banded 4/27/03, Dr. Ortiz, Tijuana

> Started at 355, at goal in the 210-220 range for almost 4 years

> Ultimate goal of 195 Tummytuck in Boise and SmartLipo in Tijuana

>

[Guest guest]

OH yeah!

There is no written eclusion and your employer simply told them not

to pay YOUR costs ?? There is likely a very stong case.

But, again, be careful not to exhast your appeals.

I'd consult a couple of the attorneys we suggested, like NOW.

Sandy r

>

> Thanks for the advice. One note, I was never provided a copy of a

> policy prior to signing up for it. I only found out about the

> exclusion by my doctor trying to get pre-auth for a fill. When it

> was denied and I called the insurer, they stated that there is no

> document they can send me that says it is excluded but that it is,

at

> my company's request, that I should have called them about it

before

> signing up for the coverage. This makes no sense to me because who

> can think to call about all the possible procedures one might need

> and make a call about each before buying the coverage. In

addition,

> several months after the coverage had to be selected, a summary of

> coverage was made available on the company website. I read through

> the whole thing and weight loss surgery was not listed as

excluded.

> Maybe I do have a chance here.

>

[Guest guest]

Dan,

your post makes a lot of sense. the position of the new insurer was

very interesting to read.

i too, had a gnawing feeling that the appeal process could severely

affect the relationship between employee and employer with

unemployment being one of the side effects. moreover, one could get

a reputation for bucking the system which would not bode well for the

next potential employment.

i like the position you take on " be satisfied with what you have

already gotten. "

george

>

> > Same situation, with

> > employer self insuring and Aetna managing the plan. Unbeknownst

to

> > me, my employer requested that all weight-loss surgery be

> > specifically excluded starting in '07.

>

> Insurance policy is a three way contract. You, the employer, and

the

> insurance company. The contract, like any others, includes all the

> things that the three parties agreed to. You DID agree to it by

> signing up for, or continuing, the insurance you already had. You

> probably didn't read the details of the fifty pages or so of the

full

> contract (almost no one ever does), but you still approved it by

> signing up. Of course your only other option would have been to

have

> no insurance, which would have been even worse.

>

> > So, when I got a fill in '07,

> > I was surprised to be denied coverage. I have since appealed and

the

> > appeal has been denied. So now I am getting ready to submit a

second-

> > level appeal and want/need some advice. My position has been

that

> > since this was an approved procedure, paid for in '04 and with

the

> > understanding that it requires long-term followup success, that

it is

> > not in good faith for them to deny these follow ups. Clearly it

is a

> > pre-existing condition.

>

> Unfortunately, it is a different contract with a different insurer,

> and the new insurer has NO obligation to cover anything else. In

> fact, since your company is self insuring, it may have been the

costs

> incurred due to your weight loss surgery (and those of any others)

> that got them to drop that from the policy. At least you got some

of

> the benefit while it lasted.

>

> > Has anyone been in this position? Any advice on how to word an

> > appeal so that it will be better-received? I am prepared to

battle

> > this for as long as it takes (including filing suit)but want help

> > with looking at it from angles I may be missing.

>

> If you want to talk to a lawyer, here is one:

>

> http://www.obesitylawyers.com/bandedlawyer/

>

> If they give you any hope or satisfaction, I'll be glad to learn

> about it, but basically both the employer and the insurer are

holding

> you to the contract you signed, just like Visa would if you didn't

> want to pay your credit card bill.

>

> One other thing to think about....is suing your employer....which

can

> end you up in a world of hurt, such as unemployment.

>

> dan

>

>

>

> --

> " It's OK to be a little broken, everybody's broken in this life "

Jon Bon Jovi

> Dan Lester, Boise, Idaho, USA www.mylapband.tk

> Banded 4/27/03, Dr. Ortiz, Tijuana

> Started at 355, at goal in the 210-220 range for almost 4 years

> Ultimate goal of 195 Tummytuck in Boise and SmartLipo in Tijuana

>

[Guest guest]

Thursday, April 10, 2008, 11:03:23 AM, you wrote:

> Dan, wouldn't the coverage for pre-existing conditions apply here,

> though? It's not like she is asking for new, expensive WLS, but only

> that they cover MAINTENANCE for one already approved, and requiring

> regular care.

As to pre-existing, well.....that could depend on what is allowed for

that. And if it specifically excludes ALL things related to weight

loss (as mine has and does), it won't even cover an office visit if

the doc codes it with something about weight loss, like helping you

learn to eat healthy, exercise, whatever. Fortunately most docs would

never code something that way, but if they did, it wouldn't be covered

on my policy. I know my doc (who is as righteous and honest as the

day is long) would code that as a routine checkup, or something

innocuous, but I have a friend who is trying to lose who had a doc

(perhaps without thinking) code a visit as obesity related and it was

bounced.

> If she were diabetic, and on insulin, and the compnay changed to a

> policy that allowed no diabetics, I believe they would be required to

> still cover her insulin and other DM care, as a pre-existing condition.

Maybe.....but I sure wouldn't count on it.

> I surely don't know the answer, but i hope she pursues it

Oh, I'm all in favor of pursuing the appeal, and would do so, but it

would be with minimal expectations. I hope it didn't sound like I was

opposed to appeals, as that wasn't my intention. If it were, I

wouldn't have listed an obesity law firm.

dan

--

" It's OK to be a little broken, everybody's broken in this life " Jon Bon Jovi

Dan Lester, Boise, Idaho, USA www.mylapband.tk

Banded 4/27/03, Dr. Ortiz, Tijuana

Started at 355, at goal in the 210-220 range for almost 4 years

Ultimate goal of 195 Tummytuck in Boise and SmartLipo in Tijuana

[Guest guest]

Thursday, April 10, 2008, 1:45:51 PM, you wrote:

> Thanks for the advice. One note, I was never provided a copy of a

> policy prior to signing up for it. I only found out about the

> exclusion by my doctor trying to get pre-auth for a fill.

That won't do it for you, any more than signing up for a credit card

and not knowing what the interest rate is, etc, etc.

> When it

> was denied and I called the insurer, they stated that there is no

> document they can send me that says it is excluded but that it is, at

> my company's request, that I should have called them about it before

> signing up for the coverage.

As noted, you didn't have to sign up for the coverage....though

assuming it was the only option available (as is usually the case) it

is better than nothing, I'm sure.

I believe that by law (you'd have to check with your state insurance

commission) in most states, there MUST be a copy of the policy

available to the employees both before and after they have signed up.

I know that mine is available on the web, all 100 pages or so of it.

It takes a bunch of digging to find the exclusions, but they're there,

including no obesity anything, no experimental surgeries (which is how

some companies still exclude lapbands, even 6 years after FDA approved

them), etc.

> This makes no sense to me because who

> can think to call about all the possible procedures one might need

> and make a call about each before buying the coverage. In addition,

> several months after the coverage had to be selected, a summary of

> coverage was made available on the company website. I read through

> the whole thing and weight loss surgery was not listed as excluded.

> Maybe I do have a chance here.

There's always a chance, but there should also be the complete policy.

Can you send me the URL and let me look at it?

dan

--

" It's OK to be a little broken, everybody's broken in this life " Jon Bon Jovi

Dan Lester, Boise, Idaho, USA www.mylapband.tk

Banded 4/27/03, Dr. Ortiz, Tijuana

Started at 355, at goal in the 210-220 range for almost 4 years

Ultimate goal of 195 Tummytuck in Boise and SmartLipo in Tijuana

[Guest guest]

Private health insurance can deny anyone or accept anyone.

The laws vary according to each state. You may want to contact your

state agency for Insurance. (e.g. State of NH Insurance Department)

Here in NH, many large group policies for larger organizations and

agencies do accept people with Disabilities, because it cost less, the

more people who sign up on the policy. This may be the case in other

states as well.

The insurance that Matt was talking about, I believe was Life

Insurance. Yes, many life insurances will deny a person with dwarfism,

disability, and many medical conditions.

However, the organization I work for does have a policy where anyone

with any medical condition can sign up for life insurance. If the

individual wants a higher premium (I believe that's what it's called),

the individual would need to have a medical exam and wait to hear if

they have been denied or approved.

I hope I have given you further information.

~ a

>

> I was told something today that I had a hard time believing, but

don't know for sure.

>

> Are LPs (adults) generally not eligible for health insurance with

most employers? My bf's mom told that today. He has Federal Gov't

insurance, but she said that he would not be able to get insurance

otherwise. I find it hard to believe that someone would be refused

insurance simply for having dwarfism. He was also born in the 70's, so

things could definitely be different that what she experienced.

>

> Could anyone let me know if she's off the mark with this? I feel like

Matt Roloff said something about insurance on one episode, but I

assumed it was because he was self-employed and had nothing to do with

any dwarfism condition.

>

>

[Guest guest]

I work for Jefferson County, Texas, and this is how it works for us. Any

full-time employee is eligible for health insurance after 90 days of

employment; pre-existing conditions have a one-year waiting period for

coverage of charges having to do with that condition. However, if one does

not sign up for health insurance when hired (or does not sign up a

dependent), that person would have to qualify if they wanted insurance

later, and they could be turned down.

Laws have changed regarding " portability, " or the right to maintain

insurance after employment ends, but there are variations and exceptions.

Ask LOTS of questions!

Alyce :-)

On Fri, Sep 19, 2008 at 2:35 PM, a <quartznh@...> wrote:

> Private health insurance can deny anyone or accept anyone.

>

> The laws vary according to each state. You may want to contact your

> state agency for Insurance. (e.g. State of NH Insurance Department)

>

> Here in NH, many large group policies for larger organizations and

> agencies do accept people with Disabilities, because it cost less, the

> more people who sign up on the policy. This may be the case in other

> states as well.

>

> The insurance that Matt was talking about, I believe was Life

> Insurance. Yes, many life insurances will deny a person with dwarfism,

> disability, and many medical conditions.

>

> However, the organization I work for does have a policy where anyone

> with any medical condition can sign up for life insurance. If the

> individual wants a higher premium (I believe that's what it's called),

> the individual would need to have a medical exam and wait to hear if

> they have been denied or approved.

>

> I hope I have given you further information.

>

> ~ a

>

>

> >

> > I was told something today that I had a hard time believing, but

> don't know for sure.

> >

> > Are LPs (adults) generally not eligible for health insurance with

> most employers? My bf's mom told that today. He has Federal Gov't

> insurance, but she said that he would not be able to get insurance

> otherwise. I find it hard to believe that someone would be refused

> insurance simply for having dwarfism. He was also born in the 70's, so

> things could definitely be different that what she experienced.

> >

> > Could anyone let me know if she's off the mark with this? I feel like

> Matt Roloff said something about insurance on one episode, but I

> assumed it was because he was self-employed and had nothing to do with

> any dwarfism condition.

> >

> >

[Guest guest]

The laws also vary within states as far as who qualifies for state

help (e.g. SSI, Medicaid, etc.). The catch-22 is if you automatically

qualify for SSI, you're enrolled in Medicaid (in Ohio), but also you

can work and get Medicaid w/disability, but SSA's administrator has to

determine you're disabled (see the problem here)?

Anyway, a's right, there isn't any law that says you MUST be

covered (well, at least, not at the present time) by someone.

All politics aside though, if the global economy sinks like reported

in yesterday's newspaper here (The State - in SC), we will become an

entire welfare state (along w/the rest of the world).

> >

> > I was told something today that I had a hard time believing, but

> don't know for sure.

> >

> > Are LPs (adults) generally not eligible for health insurance with

> most employers? My bf's mom told that today. He has Federal Gov't

> insurance, but she said that he would not be able to get insurance

> otherwise. I find it hard to believe that someone would be refused

> insurance simply for having dwarfism. He was also born in the 70's, so

> things could definitely be different that what she experienced.

> >

> > Could anyone let me know if she's off the mark with this? I feel like

> Matt Roloff said something about insurance on one episode, but I

> assumed it was because he was self-employed and had nothing to do with

> any dwarfism condition.

> >

> >

[Guest guest]

Maybe I have somehow fallen through the cracks, or I haven't filled

out my insurance forms completely. But, I'm not even sure my health

insurance company knows I am an achondroplasia dwarf. I've never been

denied health care coverage in my years of work.

-Jeana

On Fri, Sep 19, 2008 at 4:50 PM, mrnatlfan00 <rrapert@...> wrote:

> The laws also vary within states as far as who qualifies for state

> help (e.g. SSI, Medicaid, etc.). The catch-22 is if you automatically

> qualify for SSI, you're enrolled in Medicaid (in Ohio), but also you

> can work and get Medicaid w/disability, but SSA's administrator has to

> determine you're disabled (see the problem here)?

>

> Anyway, a's right, there isn't any law that says you MUST be

> covered (well, at least, not at the present time) by someone.

>

> All politics aside though, if the global economy sinks like reported

> in yesterday's newspaper here (The State - in SC), we will become an

> entire welfare state (along w/the rest of the world).

>

>

>

>

>> >

>> > I was told something today that I had a hard time believing, but

>> don't know for sure.

>> >

>> > Are LPs (adults) generally not eligible for health insurance with

>> most employers? My bf's mom told that today. He has Federal Gov't

>> insurance, but she said that he would not be able to get insurance

>> otherwise. I find it hard to believe that someone would be refused

>> insurance simply for having dwarfism. He was also born in the 70's, so

>> things could definitely be different that what she experienced.

>> >

>> > Could anyone let me know if she's off the mark with this? I feel like

>> Matt Roloff said something about insurance on one episode, but I

>> assumed it was because he was self-employed and had nothing to do with

>> any dwarfism condition.

>> >

>> >

[Guest guest]

Thanks everyone! I should have known but she acted sooo sure! Even my bf looked

at me like I had 2 heads when I asked.

Sent from my Verizon Wireless BlackBerry

Re: Insurance Question

The laws also vary within states as far as who qualifies for state

help (e.g. SSI, Medicaid, etc.). The catch-22 is if you automatically

qualify for SSI, you're enrolled in Medicaid (in Ohio), but also you

can work and get Medicaid w/disability, but SSA's administrator has to

determine you're disabled (see the problem here)?

Anyway, a's right, there isn't any law that says you MUST be

covered (well, at least, not at the present time) by someone.

All politics aside though, if the global economy sinks like reported

in yesterday's newspaper here (The State - in SC), we will become an

entire welfare state (along w/the rest of the world).

> >

> > I was told something today that I had a hard time believing, but

> don't know for sure.

> >

> > Are LPs (adults) generally not eligible for health insurance with

> most employers? My bf's mom told that today. He has Federal Gov't

> insurance, but she said that he would not be able to get insurance

> otherwise. I find it hard to believe that someone would be refused

> insurance simply for having dwarfism. He was also born in the 70's, so

> things could definitely be different that what she experienced.

> >

> > Could anyone let me know if she's off the mark with this? I feel like

> Matt Roloff said something about insurance on one episode, but I

> assumed it was because he was self-employed and had nothing to do with

> any dwarfism condition.

> >

> >

[Guest guest]

I may be wrong, but I believe in the State of Massachusetts, everyone

must have health insurance. Please correct me if I'm mistaken...

~ a

>

> Anyway, a's right, there isn't any law that says you MUST be

> covered (well, at least, not at the present time) by someone.

>

>

>

>

>

[Guest guest]

Health insurance laws vary from state to state. Some states, like

Mass. and Oregon, provide a state health plan if you are not eligible

for private insurance. It works similar to Medicare. Unfortunately,

many state and federal plans (Medicare, SSDI) do not automatically

recognize dwarfism as a legitimate disability, and can deny coverage.

However, the trick is applying for coverage based on the disabling

conditions associated with dwarfism (orthopedic problems, sleep apnea,

etc.).

Private insurance companies are a different beast. They can deny a

person for a whole range of pre-existing conditions, including

dwarfism. This creates a frustrating Catch-22: you can't get private

insurance because you are " disabled " by dwarfism, but you can't get

Medicare because dwarfism is not that disabling.

If you work for a large company, federal or state government

institution, or university, you can usually get coverage on the group

health plan after a waiting period. Since insurance is a form of

" gambling " (i.e. the insurance company is betting that more healthy

people pay premiums than sick people receive benefits), a large group

plan represents less of a risk for the company since it is more likely

that a vast majority of the employees are " healthy. " The problem

comes when small business owners or self-employed people with dwarfism

(such as Matt Roloff) attempt to apply for coverage. There is not

enough average, " healthy " people buying policies to offset the risk of

someone needing medical services.

FYI, myself and Joe Stramondo have talked about writing a letter on

behalf of LPA advocating for both presidential candidates to use their

influence (if/when elected) to remove pre-existing clauses from small

business and private health plans.

Bill

On Sat, Sep 20, 2008 at 1:27 PM, a <quartznh@...> wrote:

> I may be wrong, but I believe in the State of Massachusetts, everyone

> must have health insurance. Please correct me if I'm mistaken...

>

> ~ a

[Guest guest]

She is incorrect. Because you state she is entering the donut hole makes me

think that she has medicare a/b and a D plan for meds. The pump will cost

her 20 percent which could run 3,000-5,000 dollars. When she has the pump

filled...she will not have a regular co pay but will have to pay 20 percent

of the cost which will likely be way more then a regular co pay. Because it

will be filled at a Dr office the refill will go under Med part b....and

there will be a 20 percent copay.

She is correct that the med will not be considered in the donut hole. But

she will most likely need to pay upfront the doctors office in order to fill

her pump. Because it is a special type of preservative free medicine it

could be very expensive. I am confused how she can have a supplemental plan

as well as a regular RX plan......unless her supp has nothing to do with

medicare....like from her spouse or from insurance ....

Deb RN

From: neck pain

[mailto:neck pain ] On Behalf Of jeannieboo1

Sent: Thursday, October 02, 2008 4:14 PM

neck pain

Subject: insurance question

Hi all,

I have a friend who is disabled also with back and neck problems, and

she has decided to have a morphine pump implanted. I don't know if

anyone in the group can help her out, but she says that everything is

being paid for by insurance, including the morphine. Is she getting the

right information? I would think that the morphine that will be put in

the pump would be counted as a medication that you would have to pay

for as if it were a regular pill. She has medicare with a

supplementalplan, as well as a regular prescription plan, she's had so

many medications during the year, she's entering the part of the plan

known as " the dough-nut hole " , where she's maxed out the amount they

pay, and she'll have to pay full price. Can anyone give me any info I

can pass on to her before she has this procedure?

Thanks

Jeannie

[Guest guest]

hi Debra

Thank you for your answer. My friend only has one rx plan-Humana, if I remember

right. But I also have a medicare supplemental plan, it covers more, and my

hospital deductible is much less. I've had to have a lot of surgery, and I don't

qualify for a lot of plans since I'm under 65. I get medicare because I'm

disabled, so does she. Oh man, she's going to be in shock when she gets the

bill. She still insists that they told her all she has to pay is the $30. office

bill. Well, I hope they can work something out as her husband just lost his job,

and there was no insurance through his job. Her appt. is at the end of the

month, she doesn't even know how long it will take, she thinks she'll just be

there a couple hours. I love her to death, but I think her brain is fried from

all the medication she's already on.

Thank you again, I'll let you know what happens

 

Jeannie

[Guest guest]

Jeannie,

There are no age requirements if you are disabled. You could still apply

for medicare thru say AARP. You are able to enroll in any plan that someone

that is 65 can.

Put it this way...my co pay with straight medicare for three ESI is closed

to 500 dollars. I am assuming my stimulator could be 4 to5 thousand

dollars.

Deb

From: neck pain

[mailto:neck pain ] On Behalf Of Abbott

Sent: Friday, October 03, 2008 11:58 PM

neck pain

Subject: Re: insurance question

hi Debra

Thank you for your answer. My friend only has one rx plan-Humana, if I

remember right. But I also have a medicare supplemental plan, it covers

more, and my hospital deductible is much less. I've had to have a lot of

surgery, and I don't qualify for a lot of plans since I'm under 65. I get

medicare because I'm disabled, so does she. Oh man, she's going to be in

shock when she gets the bill. She still insists that they told her all she

has to pay is the $30. office bill. Well, I hope they can work something out

as her husband just lost his job, and there was no insurance through his

job. Her appt. is at the end of the month, she doesn't even know how long it

will take, she thinks she'll just be there a couple hours. I love her to

death, but I think her brain is fried from all the medication she's already

on.

Thank you again, I'll let you know what happens

Jeannie

[Guest guest]

Hi Susie,

My question is on the same line but regarding the SB101 bill that was

passed. It sounds like a great law, but doesn't seem to benefit many

families. Everyone I know that would benefit from the new law work for

companies that are self insured.

Thanks,

Kathy

_____

From: IPADDUnite [mailto:IPADDUnite ] On

Behalf Of DDudasik@...

Sent: Monday, March 09, 2009 3:43 PM

IPADDUnite

Subject: Insurance Question from PASSAGE

The PASAGE group of Palatine has a question. Could you please explain the

benefits of the new Autism Insurance Law in Illinois and its limitations on

age and on those who work for companies that are self insured.

Thank You!

In a message dated 03/08/2009 6:32:56 P.M. Central Standard Time,

jeruefamily@ <mailto:jeruefamily%40comcast.net> comcast.net writes:

Just a friendly reminder, our insurance guest expert starts tomorrow, so get

those questions ready to post. In the subject line of your post, put

'Insurance Question' or 'Question for Susie' so that she can more easily

scan thru

the volumes of posts we tend to generate on a weekly basis.

Topics: Any insurance-related questions, including the new Autism

insurance law in Illinois

Guest: Susie Dressler of Health Claim Assistance, Inc.

When: Monday March 9th to Thursday March 12th

Post your questions and Susie will repond to them online within 24 hours. We

can all learn from one another's questions!

Laurie

**************Need a job? Find employment help in your area.

(http://yellowpages.

<http://yellowpages.aol.com/search?query=employment_agencies & ncid=emlcntusye

lp00000005>

aol.com/search?query=employment_agencies & ncid=emlcntusyelp00000005)

[Guest guest]

Hi all:

Just know that all questions to Susie will be passed on just as soon as

possible.

Ellen

Ellen Garber Bronfeld

egskb@...

Insurance Question from PASSAGE

The PASAGE group of Palatine has a question. Could you please explain the

benefits of the new Autism Insurance Law in Illinois and its limitations on

age and on those who work for companies that are self insured.

Thank You!

In a message dated 03/08/2009 6:32:56 P.M. Central Standard Time,

jeruefamily@ <mailto:jeruefamily%40comcast.net> comcast.net writes:

Just a friendly reminder, our insurance guest expert starts tomorrow, so get

those questions ready to post. In the subject line of your post, put

'Insurance Question' or 'Question for Susie' so that she can more easily

scan thru

the volumes of posts we tend to generate on a weekly basis.

Topics: Any insurance-related questions, including the new Autism

insurance law in Illinois

Guest: Susie Dressler of Health Claim Assistance, Inc.

When: Monday March 9th to Thursday March 12th

Post your questions and Susie will repond to them online within 24 hours. We

can all learn from one another's questions!

Laurie

**************Need a job? Find employment help in your area.

(http://yellowpages.

<http://yellowpages.aol.com/search?query=employment_agencies & ncid=emlcntusye

lp00000005>

aol.com/search?query=employment_agencies & ncid=emlcntusyelp00000005)

[Guest guest]

This is from the article:

The autism coverage requirement applies only to insured plans. It does not apply

to self-insured plans. It applies to insurance policies and contracts delivered,

issued, executed, or renewed on or after the effective date of the law which is

180 days after August 13, 2009--on or about February 9, 2010.

>

> I live in NJ and am delighted that the law passed requiring insurance

companies to cover treatments for autism. Does anyone know the timing of when

the law actually will be put in place? I just want to get an idea -- are we

talking months or years? Thanks.

>

[Guest guest]

February 9, 2010

Yvette A.

I live in NJ and am delighted that the law passed requiring insurance

companies to cover treatments for autism. Does anyone know the timing of when

the law actually will be put in place? I just want to get an idea -- are we

talking months or years? Thanks.

[Guest guest]

Hello,

 

I am wondering if anyone has any information or experience they can share

related to insurance and changing jobs.  I am considering a change and am

concern that I'll lose insurance coverage from my current employer and be denied

for " pre-existing conditiion " for my daughter with ds  under the new

company plan.

 

Thank you,

Carol and (15 mos.)

 

[Guest guest]

If there is no break in coverage HIPAA (Health Insurance Portability &

Accountability Act) laws will protect you from any denial based on any

pre-existing conditions. You may need to purchase three months of Cobra

that can negotiated with your previous or future employer if there is a wait

period for health benefits. Even if worse comes to worse and there is a

denial of pre-existing condition, HIPAA laws say that they cannot deny you

out right. They can only deny it for a length of time (6mo-1yr) usually,

and then the law says they have to cover it.

I have allot more detailed information on the HIPAA laws if anyone is

interested. I wish the general public was more aware that there are already

laws on the books that protect us from being denied health insurance

coverage based on pre-existing conditions. But alas, the crisis could not

be hyped as much.

Nolan-6

Phoebe Ds & Cf-4

Don't Question Authority, they don't know either

Lipstick

_____

From: [mailto: ] On Behalf

Of Carol Middendorp

Sent: Wednesday, October 21, 2009 10:38 PM

Subject: Re: Insurance Question

Hello,

I am wondering if anyone has any information or experience they can share

related to insurance and changing jobs. I am considering a change and am

concern that I'll lose insurance coverage from my current employer and be

denied for " pre-existing conditiion " for my daughter with ds under the new

company plan.

Thank you,

Carol and (15 mos.)