health benefits counseling

Health Benefits Health Benefits Counseling Counseling

Health Benefits Health Benefits Counseling Counseling

By Michael RustBy Michael Rust

ABC for Rural Health, Inc.ABC for Rural Health, Inc.

ABC for Rural Health & HealthWatch 100 Polk County Plaza, Suite 180Balsam Lake, WI 54810(715) 485-8525(715) 485-8501 (fax)[email protected]

ABC for Health, Inc.

North Dakota FamNetHealth Benefits Counseling

Training

April 12, 2011Comfort Inn,

Bismarck


ABC FOR HEALTH, INC.• A Wisconsin-based nonprofit public

interest law firm dedicated to linking children and families, particularly those with special health care needs, to health care benefits and services.


ABC FOR HEALTH’S MISSION

• ABC for Health’s mission is to provide information, advocacy tools, legal services and expert support needed to obtain, maintain, and finance health care coverage and services.


What families face• Losing coverage due to loss of a job or

other circumstances.• Employment that does not provide

coverage• Coverage that does not provide

adequate benefits• Common policy elements such as ‘pre-

existing condition exclusions’.


Extra obstacles• Fragmented information on public

health programs• Patchwork network of providers;

complex referrals/PAs to specialists• Technology failures in assessing

eligibility • Intransigent or uninformed workers


Family needs• First priority is to provide counseling where

and when it will be of greatest benefit to the family.

• Extra support during times of intensive involvement with the health system; i.e. the birth of a child or a hospitalization.

• Reduce stress caused by worry about how medical expenses will be paid for.


Motivations for public and private health care denials

• From the public and private administrators’ perspective, the most important goal is to contain expense.

• Medical care is expensive—especially for medical equipment or treatment for long-term, chronic conditions.

• Private insurers want to maximize profit and public health administrators want to come in under-budget for the year.

• Seek to cut what they see as duplicative or redundant costs.


Family stress

• Reassure families that they are not alone in trying to find answers to their questions about health care financing.

• Move quickly to connect families to coverage, both to make sure that they meet the strict deadlines for applying for public programs and to allay their fears early on.


What is health benefits counseling?

Advocacy for patients/clients without health coverage, with inadequate health coverage or who are in a dispute with their insurer.

Also, advocacy for a better system of health care finance—broader benefits, more open eligibility, etc.


Health Benefits Counselor

• A professional position!

• Training and education

• Professional judgments


Client services in HBCClient services include: • health benefits counseling to inform families

of possible eligibility for programs or services;

• consultation about the patient’s rights and obligations under their managed care plan; assistance with filing grievances and appeals;

• legal assistance with filing hearings


Appealing denials• After discussing the case with the family, health

benefits counselors should appeal any denials that seem incorrect.

• Types of denials:– Medicaid under-assessment of coverage– Denial of Medicaid coverage– Denial of coverage by a private insurance plan– Denial of a Prior Authorization for a procedure,

therapy or for medical equipment


Other tasks of the health benefits counselor

• In addition to working directly with families, benefits counselors should also consider:– Conducting outreach– Disseminating information regarding state

and federal managed care and insurance laws (i.e. through brochures or press releases).

– Collecting information from HMOs; client demographics, special programs, etc.

– Collecting information from providers; demographics, charity care programs, etc.


Outreach to families• Families make extensive use of word-of-

mouth information. Parent support groups and associations can rapidly distribute information.

• Health care providers, community agencies, other advocates for families and children with special health care needs are other good sources of information


Common referral sourcesAgencies like these should be made aware of the

existence of your counseling program and given your contact information:– Health care providers– County public health departments– Disability rights organizations– Community-based service agencies– Disease-related organizations– Information and referral agencies– Schools and school nurses– Public interest law firms

Settings

• Free-standing• Health Care Providers• Health Departments• Service Networks• Tribal Clinics• FQHC’s/CHC’s


Why should providers have health benefits

counselors?• Increased third party

reimbursements (Up to $33/$1)• Improve customer service• Improve staff morale• Improve community image

Health Departments

• Core/Essential Service• Clients (WIC/FP/PreNatal Care)• Federal Funding

Service Networks

• Well-defined constituency• Common case patterns• Established partnerships

FQHC, etc.

• Clients• Federal Funding

Tribes

• Unique issues• Relationships• Preserve Contract Health Funds


WHY A LAW FIRM?• Families have problems accessing and

financing health care– Complicated public benefits program– Limited insurance coverage– Lack of understanding and accessible

information– Lack of assistance and support in navigating

the system, which is based on laws and regulation


The role of lawyers• Send letters of inquiry or demand

letters • Represent the family at hearings

(grievance, appeal, medical review).• Provide guidance, credibility and

leverage for the health benefits counselor


PARENTS AS ADVOCATES

• Parents are the child’s best advocate• Identifying the local and statewide

resources and supportive structures• Advocacy organizations, e.g.. Family

Voices, www.familyvoices.org

Systems/ND Equivalents

• Private Insurance• Managed Care• Medicaid/BadgerCare Plus• Social Security Disability• CYSHCN Programs (Children w

Medically Fragile Needs• HIRSP (CHAND & PPACA• Medical Debt

Commissioner of Insurance

What happens after I file the complaint form and how soon will I hear from the Department?Within a week after we receive your complaint, you will receive an acknowledgement letter from the investigator working on your complaint.

If your complaint does not require us to contact the insurance company or agent, you will receive written answers to questions you may have raised or an explanation of why we cannot handle your complaint.

What contact will be made with the insurance company?In most cases, the investigator will send the company a copy of your complaint, asking for an explanation of its position.

After the company responds, we should determine within three weeks whether we must take any further actions.

If the company agrees to resolve your problem, the investigator will send you a verification letter.

HEALTH INSURANCEHEALTH INSURANCEOVERVIEWOVERVIEW

Insurance Basics• Types of policies/structure

– ERISA– Managed Care

• Consumer Rights & Responsibilities• Underwriting/discrimination• Prior Authorizations/Referrals/Notification• Terminations & cancellations• Grievances & appeals (internal & external)• COBRA continuation and conversion• ADA/FMLA/HIPAA/Parity/FMLA

• Appeals


Health Insurance Law

• State v. Federal Regulation of Insurance

• ERISA • COBRA• Common Claim Denials & How to

Fight Them


APPLICABLE LAW• Health Insurance Regulation• State

– Statutes– Regulations, Office of the Commissioner

of Insurance– Case Law

• Federal-ERISA• State/Federal-ERISA


ERISA• Employee Retirement and Income

Security Act of 1974– Federal Law designed to address the abuses

in employee pension plans.

• Two major types of plans– Insured and self funded plans– Self funded plans are NOT regulated by state

law– What is the difference between insured and

self funded plans?


ERISA• The Plan Document

– The legally binding contract that contains the detailed information on benefits

– NOT JUST A BROCHURE– Employer is required to provide a

summary plan document– Reasonable copying costs may be

charged– Contact the plan administrator in writing.

(30 day response time or a possible $110/day fine)


ERISA• Claims

– Claims should be resolved within 90 days

– Decisions must be in writing and must state the specific reason for the denial

– Every ERISA plan must have a review procedure for denied claims (generally 60 day review period)


Choosing a policy

• Managed Care (HMO, PPO)• Fee For Service• Group or individual?


Remember!• North Dakota Law will not apply to

self- funded insurance plans


Consumer rights and responsibilities

• Know your policy – marketing materials, policy summary, and complete policy

• Follow the appeal process• Document your work!


Law of Insurance Contracts

• The insurance policy is a contract• Confusing or ambiguous language is to be

strictly interpreted in favor of the insured• The reasonable expectations of the insured

should be met• Exclusions must be clear and understandable• Get a specific reason for the denial• Go up the management ladder


Phantom clauses– These may be inserted in a policy

without a definition or without any accurate meaning. For example the phrase “services, care, or supplies that are not medically recognized by the American Medical Association” has no accurate meaning.


Insurance Company Wrongdoing

– Failure to acknowledge communications about claims

– Failure to finish investigating a claim with reasonable speed

– Failure to promptly provide claim forms, instructions and reasonable assistance

– Failure to give a prompt and reasonable explanation of why a claim is denied


Insurance Company Wrongdoing (cont’d)– Knowingly misrepresenting facts and

policy provisions– Failure to respond to a claim soon

after proof of loss


Common Claim Denials

Experimental treatments• Obtain a written definition of

experimental treatment from your policy or insurance company

• Obtain supporting literature from your physician (letters, articles etc.)


Common Claim Denials: Medical

Necessity• “Not Medically Necessary”

– How is the term defined in the contract?

– Obtain documentation of the need for the service

– Is the denial contradicted elsewhere in the policy?


Medical Necessity (cont’d)

• Medically Necessary– This term can be very ambiguous and

is often used as a “catch all”– Other terms include medical

necessity or medically indicated


Usual, Reasonable and Customary Charges

• Waivers that bind you to payment obligations

• Illegal billing issues


Pre-existing condition

• When is a condition a condition• Misdiagnosis?• Manifestation to the reasonable

person,


Educational verses medically related services

• Speech therapy• Physical therapy• Occupational therapy


Managed Care Issues • Limitations on providers and types

of services, care, equipment or drugs

• Referrals for specialty care• Cost difference for in-plan or out-

of plan services


Blanket Coverage issues

• Using Medicaid and your private insurance together

• Coordination of benefit considerations

Medicaid/CHIP Overview

• Eligibility categories and framework• Benefits• Prior Authorizations• Appeals• Special populations• EPSDT

Medicaid• Children in foster care or subsidized adoption • Children with disabilities (birth to 19) • Other children up to age 21 • Pregnant women • Women with breast or cervical cancer • Parents or caretakers of deprived children • Workers with disabilities • Other blind and disabled individuals • Individuals age 65 or older • Low-income Medicare beneficiaries (Medicare

Savings Programs).

Healthy Steps• Healthy Steps insurance is for

children who:– do not have health insurance coverage – are 18 years of age or younger – do not qualify for the North Dakota

Medicaid Program – live in families with qualifying incomes

Other Programs

• Social Security Disability• EPSDT (Health Tracks)• CYSHCN Programs (Children’s Special

Health Services, Children w Medically Fragile Needs)

• HIRSP (CHAND & PPACA)• Medical Debt


Tools of the trade• Health benefits counselors should have

copies of program and policy manuals relevant to his or her work.

• The most important in Wisconsin is the Medicaid Eligibility Handbook. Updates are regularly issued through a subscription service and Operations Memos are sent out by email.


Tools of the trade (cont’d)

• Other key references include:– Administrative Code (the rules

established by and followed by state agencies)

– State Statutes (laws passed by the legislature)

– Policy Manuals for specific programs (Katie Beckett, etc).


Tools of the trade: ND

In order for services to be payable under the provisions of the

Children with Medically Fragile Needs Waiver, the person receiving the service must meet all of the following:

1. Recipient of Medicaid Program under the State Plan for Medical Assistance as set forth in Service Chapter 510-05, Medical Assistance Eligibility Factors.

2. Between the ages of 3 to 18th birthday and be Medically Fragile.

3. Eligible to receive care in a skilled nursing facility (Level of Care).

4. Participate to the best of their ability or by representation from their Legally Responsible Caregiver in a comprehensive assessment to determine what services are needed and the feasibility of receiving home and community-based services as an alternative to institutional care.

5. Receives a score of 30 or above on “Level of Need” determination, from their primary physician and Family Viewpoint.

6. Have an Individual Case Plan, developed and approved by the applicant/client or legal representative and family’s team that adequately meets the health, safety, and personal care needs of the recipient.

7. Voluntarily choose to participate in the home based program after discussion of available options. This is documented by completion of Explanation of Client Choice.

8. Service/care is delivered in the recipient’s private family dwelling (house or apartment).

9. A waiver service (not including Case Management) must occur at least on a quarterly basis.

10. Not eligible for and/or receiving services through other Medicaid Waivers.

11. Payments that are in excess of what is authorized or are unallowable are recouped from the family by the Fiscal Agent.

12. Only 15 individuals will be allowed on the Waiver at a time. If more than the 15 are applying a waiting list will be maintained by the Program Manager.

Eligibility Criteria for Staying on Waiver:1. Continue to be a recipient of Medicaid

Program under the State Plan for Medical Assistance as set forth in Service Chapter 510-05, Medical Assistance Eligibility Factors.

2. Continue to meet Level of Care – annually.3. Continue to meet Level of Need – annually.

(requires a score of at least 30)4. A waiver service (not including Case

Management) must occur at least on a quarterly basis.

Eligibility Criteria for Waiting List:If there is a waiting list the following criteria will be

implemented.

1. Recipient of Medicaid Program under the State Plan for Medical Assistance as set forth in Service Chapter 510-05, Medical Assistance Eligibility Factors.

2. Eligible to receive care in a skilled nursing facility; Level of Care.

3. Child can be placed on waiting list at 2.9 months BUT – will not receive services until the age of 3, if an opening on the waiver occurs and if their score on Level of Need is the highest. Level of Care and Level of Need can be completed after 2.7 months of age. The child’s application date would be 2.9 month date.

4. Completion of Level of Need - the highest level of need score for child will be recorded.

5. Earliest application date. 6. A child can be placed on the waiting list up until their 18th

birthday. The Medically Fragile Children’s Program Manager will be responsible for the maintenance of list and for notification to families as to placement on waiver, quarterly.

Once opening on Waiver, is determined, applicant with the highest level of Need will be contacted by Program Manager and another Level of Care/Level of Need will be completed. This will ensure family is still eligible for services. Upon successful completion and determination, family will be introduced to a DD Program Manager for assistance with completion of Case Plan.

Covered Services• Case Management• Institutional Respite• Environmental Modification• Equipment and Supplies• In-Home Support• Individual and Family Counseling• Dietary Supplements• Transportation• Maximum Amount Per Family ($18,966)

Terminations/Denials of ServicesClosure: Reason for:1. Family has reached the allowable amount of Waiver

services. ($18,966.00)2. Family is not using a waiver service quarterly.3. Family is not following through with developed Case Plan.

ie. Not meeting quarterly, not following through with goals.4. All task/goals on Case Plan have been accomplished.5. No longer meet the eligibility requirements:

a. Does not pass Level of Care.b. Does not receive at least a 30 on Level of Need and Family

Viewpoint.c. Is no longer eligible for Medicaid.

6. Unable to assure health and safety of eligible consumer.

Denial:A denial to waiver services will occur if any of the

following is true.

1. Child is not eligible for Medicaid.2. Child does not pass the screening for Level of Care.3. Child does not acquire a score of 30 or above on the

Level of Need and Family Viewpoint.4. Waiver services are not appropriate to meet the

needs of eligible consumer.5. Unable to assure health and safety of eligible

consumer.

Appeal:A Legally Responsible Caregiver has

the right to appeal either the decision to terminate or deny services.

1. A Healthy Steps unit may be one individual, a married couple, or a family with children under twenty-one years of age, or if disabled under age eighteen, whose income is considered in determining eligibility for any member of that unit, without regard to whether the members of the unit all physically reside in the same location.

2. A parent or other caretaker of children under twenty-one years of age may select the children who will be included in the Healthy Steps unit. Anyone who is included in the unit for any month is subject to all Healthy Steps requirements, which may affect the unit. The financial responsibility of relatives must be considered with respect to all members of the assistance unit.

When a child is included in the Healthy Steps unit eligibility is pursued for the child unless:a. The child is or would be eligible under the Medicaid Program;b. The child is an ineligible alien;c. The child is ineligible due to having creditable health insurance coverage or

having creditable health insurance coverage available;d. The family terminated their health insurance coverage within the last 6 months,

without ‘good cause’.

When a caretaker chooses not to include a child in the Healthy Steps unit, the child is not included in the unit for any other purpose (e.g. in the budget).

3. When an adult is providing care to an unrelated child of a divorced, separated, or deceased spouse, the household may include the child if the child is expected to continue to reside in the household.

1. No support may be required of relatives other than from spouses and from natural or adoptive parents for children under age 21, or if blind or disabled, under age 18.

2. Under North Dakota law, a stepparent has no legally enforceable obligation to support stepchildren. Therefore, the stepparent's own personal income cannot be considered available in determining Healthy Steps eligibility for the stepchildren. The natural parent, however, is legally responsible for supporting the children. The income of the natural parent cannot be first applied to the children if by doing so other members of the family are deprived of basic necessities.

3. If a child resides with a caretaker other than the parent, and the parent’s whereabouts are known, an attempt must be made to obtain the parent’s financial information. If the parent’s income is made available, follow the budgeting procedures outlined in section 07-50-20, Budgeting Procedures for Financially Responsible Absent Parents. If unable to obtain the information, document the efforts made, and determine the child’s eligibility without the parental information.

1. Children through age 18, who meet the requirements of this program, are eligible for Healthy Steps. Coverage for eligible children who are 18 years of age continues through the last day of the month in which child turns age 19.

2. A child is not eligible for Healthy Steps if:a. The child would be eligible for full Medicaid benefits (no recipient liability)

in the month for which Healthy Steps eligibility is being determined;b. The child has other current creditable health insurance coverage;c. Coverage is available through the child’s parents’ or legal guardians’

employer at no additional cost; ord. The child had creditable health insurance coverage within the past six

months, unless the coverage was terminated:i. Due to involuntary loss of employment; orii. Through no fault of the family member who had secured the coverage; oriii. By a household member who is actively engaged in farming in a county which

was declared a federal disaster area within the last 12 months. This information is available in the Vision tables.

3. Children who are eligible to receive services through Indian Health services or through Section 638 Tribal contracts can be eligible for Healthy Steps.

4. If the Department estimates that available funds are insufficient to allow plan coverage for additional applicants, the Department may take any action it deems appropriate to limit enrollment in the Healthy Steps Program, including denying applications and establishing waiting lists.

1. Applicants or recipients of Healthy Steps who are dissatisfied with a decision made by the North Dakota Department of Human Services or the county agency, or who have not had their application acted on with reasonable promptness, may appeal to the North Dakota Department of Human Services. Refer to Service Chapter 449-40 for more information with regard to Hearings and Appeals.

2. A request to appeal must be in writing and not later than 30 days

from the date the notice of action is mailed. 3. When a recipient requests an appeal prior to the effective date of

an adverse decision, the recipient's Healthy Steps eligibility may not be terminated until a decision is rendered after the appeal hearing unless it is determined that the sole issue is one of Federal or state law or policy. The recipient must be informed in writing that eligibility will be terminated pending the final appeal decision.

4. The appeals supervisor normally decides whether an issue being appealed is one of federal or state law or policy and is not appealable. However, if Healthy Steps eligibility ends because a child is found to be eligible for full Medicaid benefits during an annual redetermination, the Eligibility Worker must determine that the issue is not appealable, and Healthy Steps eligibility will not continue.

5. When assistance has continued pending an appeal decision

and the decision to terminate benefits is upheld, the recipient’s eligibility must be terminated effective the end of the month of receipt of the notice of decision. Pursue collection of any Healthy Steps premiums paid during the period assistance was continued pending the appeal decision.

Categorically needy income levels.– Family Coverage group. The family

size is increased for each unborn when determining the appropriate family size.

Medically needy income levels are applied when a Medicaid individual or unit resides in their own home or in a specialized facility, and when a Medicaid individual has been screened as requiring nursing care, but elects to receive HCBS. The income level is equal to eighty-three percent of the poverty level applicable to a family of the size involved. The family size is increased for each unborn when determining the appropriate family size.

Application1. All individuals wishing to make application for

Medicaid must have the opportunity to do so, without delay.

2. A relative or other interested party may file an application in behalf of a deceased individual to cover medical costs incurred prior to the deceased individual's death.

3. An application is a request for assistance on: (list)4. A prescribed application form must be signed by

the applicant, an authorized representative or, if the applicant is incompetent or incapacitated, someone acting responsibly for the applicant.

5. The date of application is the date an application, signed by an appropriate person, is received at a county agency, the Medical Services Division, a disproportionate share hospital, or a federally qualified health center. The date received must be documented.

6. An application is required to initially apply for Medicaid, to re-apply after a Medicaid application was denied, to re-apply after a Medicaid case has closed, or to open a new Medicaid case for a child who has been adopted through the state subsidized adoption program.

7. A recipient may choose to have a face-to-face or telephone interview when applying for Medicaid; however, none are required in order to apply for assistance.

8. Information concerning eligibility requirements, available services, and the rights and responsibilities of applicants and recipients must be furnished to all who require it.

1. Current eligibility may be established from the first day of the month in which the signed application was received, . . .

2. Retroactive eligibility may be established for as many as three calendar months prior to the month in which the signed application was received.

3. An individual determined eligible for part of a month is eligible for the entire calendar month unless a specific factor prevents eligibility during part of that month.

• A decision as to eligibility will be made promptly on applications, within forty-five days, or within ninety days for individuals for which disability is pending, except in unusual circumstances. When these time periods are exceeded, the case must contain documentation to substantiate the delay.

• Applications for disability-related Medicaid should be made to both the Social Security Administration and the county agency. When the Social Security Administration denies an application because of lack of disability the application for Medicaid must also be denied. The Social Security Administration's decision with regard to disability is binding. The Medicaid application should not be held pending an appeal of the Social Security decision.

1. Applicants or recipients of Medicaid who are dissatisfied with a decision made by the county agency or the North Dakota Department of Human Services, or who have not had their application acted on with reasonable promptness, may appeal to the North Dakota Department of Human Services.

2. A request to appeal must be in writing and not later than 30 days from the date the notice of action is mailed.

3. When a recipient requests an appeal prior to the effective date of an adverse decision, the recipient's Medicaid eligibility may not be reduced or terminated until a decision is rendered after the appeal hearing unless it is determined that the sole issue is one of Federal or state law or policy.

Deprivation– Death of a parent;– Divorce or legal annulment;– Separation, legal or mutual, as long as there was no collusion

between the parents to render the family eligible;– Imprisonment of one or both parents. – Unmarried parenthood (when not residing together);– Abandonment;– A parent is age sixty-five or older;– Disability of a parent;– Incapacity* of a parent; or– Unemployment, or underemployment, of a parent.

* The county agency is responsible for determining all eligibility factors except for incapacity which is determined by the State Review Team. Since the State Review Team does not see the person, it must depend on the examining physician's medical report to document the individual's physical or mental condition.

Benefits Counseling Process

• Intake• Review• Documentation• Investigation• Negotiation• Appeal

Managed Advocacy1. Advocacy: through one-to-one health benefits counseling,

advocates help families with children with special health needs to solve their health coverage and finance issues.

2. Education and training: through education and training, parents, service providers, and advocates gain knowledge of health care and coverage issues, along with the tools to maximize private and public health insurance benefits.

3. Coalition building and policy development: local and regional HealthWatch Committees create grassroots-level partnerships that become forums for policy development and legislative action.

Other Benefits Counseling Tasks

• Obtaining timely and accurate information on public and private health care financing programs and supportive services

• Gaining an understanding of their coverage options, which empowers clients to make their own decisions

• Applying for Medicaid programs• Filing grievances and appeals• Taking actions that improve health care and

avoid depletion of family resources


Intake interview• First contact is often a phone call• Determine if the family’s coverage

problem falls within the purview of the benefit counselor’s services.– If not, give the family one or more

referrals to other potential sources of help. (asset mapping)

– If so . . .


Intake interview, cont’d• Information to obtain:

– Determine the urgency of the problem (although always move as quickly as possible to send in applications or appeals).

– Determine what exactly the family needs—they may not be able to express it in specific terms


Intake interview, cont’d

• Determine if the family has private or public health care coverage, or both

• Determine financial and non-financial eligibility for either purchasing a private insurance plan or for applying for public programs

• Get as much contact information as you can; work phone, email, fax, etc.

Intake interview, cont’d• Determine if a grievance or appeal needs

to be filed and the deadline for doing so.• Determine if other parties need to be

contacted and if you need a signed release of information.

• Explain what a health benefits counselor can and cannot do. Define the scope of assistance and do not raise expectations above what you can offer.


Gather documentationRequest every document that the family has on hand relating both to whatever coverage they have and to the issue they are currently facing.•Medical records•Statement/certificate of benefits•Billing records•Letters


Medicaid notices• Families applying for Medicaid will receive

notices detailing what coverage they can receive. Health benefits counselors should review these notices to make sure that the family is receiving the correct level of coverage.

• Human or computer errors have resulted in families receiving much less coverage than they deserve.


Release of information• Have the family sign and return a

Release of Information so that you can request information on their case from their provider or insurer.

Investigate• Make contact with other indicated

parties. (Phone, email, in writing)• Build the narrative.• Analyze and review• Determine specific decisions/actions or

other parts of the story that are incorrect or challengeable.

• Repeat


Document, Document, Document!

• Avoid problems by building a paper trail– Keep complete records of phone

contacts, procedures approved, names and titles of people to whom you speak

– Follow up in writing– Keep a journal


Case study• Case Study #1: • Sally Smith has a physical disability and

cannot get health insurance. She has applied for insurance several times and has been denied. She can only work part-time and therefore does not qualify for her employer’s sponsored health insurance plan. However, her income is too high for S.S.I. eligibility.

• What health insurance options exist for Sally?


Case Study• Case Study #2: • Tina works for a large employer. Her health insurance

is covered by a fee-for-service plan. Recently, Tina was denied coverage by the plan for surgery to remove a large growth from her ear. The surgery was denied because it was considered to be cosmetic. Tina works in the reception area of the company and was very self-conscious about the benign growth. She felt that the growth on her ear affected her job performance, self-esteem, and prevented her from moving up in the company.

• What are Tina's options to challenge this denial?


Case Study• Case Study #3: • Tim was recently diagnosed with a rare liver disease.

He needed to get specialized treatment at a hospital in California. Tim's insurance company, BestHealth, refused to pay for Tim's medical treatment in California because the services were considered to be experimental. The treatment was written up in the Journal of the American Medical Association three years ago and results were very favorable. Tim considers the denial by the insurance company to be unfair and feels that they have not conducted the necessary review to determine if his treatment is indeed experimental.

• What are Tim's options to challenge this denial?


Case Study• Case Study #4: • Danny belongs to a large HMO. His son, Aaron, has

multiple physical disabilities. He requires a lot of physical and occupational therapy. The HMO has refused to pay for the therapy services because they consider them to be the responsibility of the school district. Danny believes the school district is only responsible for some of the education-related services. Two months ago the HMO denied the claims for Aaron because they felt the services were not medically necessary. Danny believes that the HMO is changing their reason now to suit their own needs.

• What are Danny's options to challenge these denials?


CONTACT ABC FOR HEALTH

• E-mail [email protected]• [email protected] • Call or FAX our local or toll-free phone

numbers:– 608.261.6939– 800.585.4222– 608.261-6938 (FAX)

• Monday through Friday, 8:30 am - 5:00 pm


ABC FOR HEALTH WEBSITE

• www.abcforhealth.org• Information about ABC for Health

and its programs• E-mail contacts for staff• Fact sheets and PDF publications • Links to other sites• Meeting notices and minutes

ABC for Health’s Health ABC for Health’s Health Care Coverage PlanCare Coverage Plan

ABC for Health’s Health ABC for Health’s Health Care Coverage PlanCare Coverage Plan


Developing a Health Care Coverage Plan

• Start early!• ABC for Health’s Health Coverage Plan

offers a concise record of:– the client’s key health care or

coverage issues– ABC for Health staff’s analysis of

health care coverage options and considerations


Coverage Plans document:

– ABC for Health staff’s services and activity on behalf of the client

– Follow-up and next steps– Important dates and deadlines– Referrals to other health care coverage or financing

resources

• ABC for Health’s Health Coverage Plan provides an essential tool for managing the client’s personal health information, guiding the client and the provider to appropriate public and private health care coverage resources.

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