Re: NJ prosthetic insurance coverage mandate - anyone heard about this?

[Guest guest]

Very interesting. I'm not in NJ so I don't really know. I do know that something similar has happened in our state with regards to insurance companies being required to cover hypoallergic formula (which is hundreds of dollars a month). Up until now, parents were forced to pay out of pocket for these. I found out because I was told to supplement my daughter's diet at 13 months with one of these formulas since she was only eating one solid food and not gaining weight well with only that and breastfeeding alone. Luckily, she started gaining weight well before I had a chance to purchase any and the doctor said that we could wait a little bit. Anyway, I looked up the cost and was astounded at what I'd be paying. Imagine the insurance companies saying that this wasn't medically neccessary for my daughter. At the time, that was their stance. The law went into effect a few months later.

Maybe this indicates that this will soon be happening for helmets. One can only hope. We won't benefit, but hopefuly others will.

Good luck with figuring all of this out.

NJ prosthetic insurance coverage mandate - anyone heard about this?

Our insurance company denied our claim to cover Evan's helmet and we are in the process of starting an appeal. When I spoke to someone at Cranial Tech for tips, she mentioned that there is a mandate regarding coverage if the treatment and your employer are both in NJ. I researched online and found that there is a law N.J.S.A. 17:48E-35.30 that:"requires health benefit plans that provide benefits for orthotic and prosthetic devices to provide coverage for expenses incurred in obtaining orthotic and prosthetic appliances from any licensed orthotist, prosthetist, or any certified pedorthist if determined medically necessary by the physician. When prescribed by the member's physician, eligible appliances may not be subject to any prior surgery or authorization requirements, medical necessity determinations and/or utilization management."I also found an article (http://www.njbiz.com/article.asp?aID=73338)stating that "The legislation signed last month requires private health care insurers in New Jersey, together with the State Health Benefits Program, to cover the cost of any orthotic or prosthetic device when a doctor deems it medically necessary. The State Health Benefits Program provides medical, dental and prescription drug coverage for New Jersey state workers and retirees.The mandate doesn't allow the insurers themselves to review whether the devices are medically necessary. Decisions are left solely up to the doctors who refer patients to orthotists and prosthetists—caregivers who custom build and fit devices such as leg braces and artificial limbs for patients. The legislation does not apply to self-funded insurance coverage, typically provided by large employers."Has anyone in NJ heard about this mandate? If what I found is true, why is BCBS saying that Evan's helmet isn't medically necessary (despite a craniofacial surgeon saying it is)?