Approved for Medicaid-What's Next?

[Poohnatic]

My 10 year old DS has Asperger's Syndrome, along with several other issues.

After applying for SSDI in 2002 and getting turned down, we reapplied this past August. On Friday, we got a Christmas present from the state of Florida-a letter saying that he has been accepted into the Medicaid program.

This is a HUGE relief, as many parents of disabled kids can understand. The older my son gets, the more obvious it is that he's got issues that won't get better. In addition to the AS, he's been diagnosed OCD, ADHD, Sensory Integration Disfunction and possibly Bi Polar (doc is teetering between that and ODD).

Group insurance is a blessing and a curse-as many therapies that our doctor has recommended, insurance would not cover. Finally, we'll have those services.

As we breathe a sigh of relief, my DH and I now have a ton of questions. I turn to the great people here at DISabilities to see if you can point me to resources. The questions I have regard reimbursement of expenses. When I was interviewed, I'd been told that if DS is accepted, he is eligible from the date of application (8/25) and that it was possible that he'd also be retroactively enrolled for the previous 18 months.

From May until last month, we had no insurance-and paid for all of his meds (to the tune of 1300 a month) out of pocket. I think it's obvious why I want to find answers!

So, any resources on the net that can help? I'll probably be posting on OASIS as well to get some help from other parents of Aspies. Googling hasn't turned up much that is helpful so far.

Thanks in advance for any help that you can offer.

For the first time in many years, I am relaxed about my son's situation-I finally feel like we're going to be okay!

Suzanne

 

[dclfun]

I hope you are able to get the therapies you're hoping to get....the state of Florida isn't really that great for disabled children and even worse for disabled adults, as far as what is approved and what isn't. As for the meds though, at least those should be covered. As long as you have receipts or can get them from the pharmacy, if the Medicaid is retroactive then Medicaid will reimburse at their level, what was paid out of pocket. Good luck with everything and I certainly hope your son gets the services he deserves. ---Kathy

 

[spotdog]

I was a young adult with mental illness when I could no longer "afford to support myself" with group insurance. This lead to homelessness and welfare.
Fortunately, I was assissted in applying for SSDI, SSI and WA state Medicaid. I was fortunate and was accepted on the first try.

As I look back, the outpatient services which Medicaid (and Medicare) payed for were not very good. My medications and hospitalizations were covered and this is better than what many people can get.

It's a long story, but I still consider myself a success. I still live with my mental illness only now I work full-time, have my own small apartment and can barely get by with the insurance offered by my union.

Check into all of the services for your child that Medicaid can offer. If some of his limitations are due to mental illness, contact your legislature representatives about Mental Health Parity laws in your state. This is what made a huge differance for me.

Good luck

 

[Poohnatic]

Thanks to both of you!

Kathy, I'd heard Florida was not the best. However, I'm a pretty persistent person and will keep going at them. His psychiatrist did tell me that the social skills therapy group she'd like him to participate in is covered by Medicaid.

We're very fortunate-his doctor has and will really advocate for us. I have a feeling she'll be giving us tons of info that wasn't really neccessary before.

Tampa is slated to get a Charter school for Asperger's/HFA. The school got approval for Charter status. I'm cautiously optimistic about this. If it's not as good as the program he was in back in Maryland, then we'll stay with his self contained program.

Spotdog, great suggestion on Mental Health Parity. I will keep that in mind if our needs require it!

Suzanne

 

[SueM in MN]

I don't know how things are handled in Florida, but my DD (in MN) has 2 caseworkers assigned to her case. One is the Financial caseworker and is responsible for making sure they have what they need to stay eligible. The other caseworker has been much more useful to us; she's actually found programs DD might fit into and has helped us with choices on programs.

 

[dclfun]

Sue- I wish things went so well in Florida, but the services here are dismal. I'm glad the OP has her physician to recommend programs for her son. Sometimes school-based therapists may also be aware of programs supported by Medicaid and can thus make a referral. ---Kathy

 

[barkley]

on the granting letter you received there should be the name of the worker assigned to your son's case along with their phone number. call that person and inquire as to the status of the retro-active (18 month) application to make sure it was evaluated (if you applied for it you should receive a letter granting or denying that as a separate portion of the case). also inquire what the process is for reimbursement/billing to the state (i'm assuming your ds was approved for the state run program) for your out of pocket medical expenses. you will likely not get the full amount back-because the amount pharmacies and doctors charge for cash paying is not the same as the contracted rate they agree to accept from medicaid or medicare. it may be that you have to contact each of the medical providers/pharmacy and provide them with proof of coverage and have them submit billings-and in those instances where they are paid they will refund that amount.

just as an asside-if you are pursing social security for your son-if he is denied again DO NOT REAPPLY. APPEAL the denial for as long as it takes/the process allows-only file a new application after you've exhausted this process. by appealing you will protect his 'begining date of aide' (bda) such that if the case is ultimatly granted it will go back retro-activly to the date the application was originaly filed. i worked in the california version of the medicaid program and we had lots of clients that used our services while a social security case was being evaluated-it was not unusual for a won appealed case to go back multiple years resulting in thousands of dollars in cash benefits.

btw-i just looked on the internet-there's a site called myflorida.com that links to the medicaid information site for floridians. it seems to be a good resource for questions on coverage, providers and procedures within their state's program. it might be a good place to get some answers.

 

[Poohnatic]

Just popped back in and figured I'd give an update:

As is typical for the government agencies, the letters I recieved came out of order. We got a small SSI check, but no documentation. Three days later, my son's Medicaid card showed up, then the letter explaining the program. The Friday before New Years, we got another small check and two more letters. The second check said SSI Jan, so we were able to figure out what the first check was. Yesterday's mail brought another letter-his SSI determination.

It ends up that we're told to submit ALL medical receipts from his date of eligiblity (8/1/06), along with any for services/prescriptions up to 90 days prior. Except for his psychiatrist, I've got them all ready to go. Being organized pays off on this front. Now, let's see what the state decides to cover.

Barkley, thanks for the aside, lol. I wish I'd known that 4 years ago. Then again, we may not have been approved on an appeal back then. While we and the school were pretty sure what we were dealing with, the doctors were not. It sure helped to go into that meeting with Social Security with a list of all his schools, doctors, and day care providers and a few letters from those who worked with my son.

I feel like that load I've been carrying isn't that bad anymore. I'm already learning a few quirks of Medicaid. My son's current dosage of Abilify is a half tablet (7.5mg), because the doses go from 5mg to 10mg. Medicaid won't okay the script as written-so doc resubmitted it as one pill every other day. We know what the dose should be, he doesn't get it at school. Apparently, we can't get away with half pill dosing anymore.

Thanks again for the input.

Suzanne

 

[disneytraveler]

My sil and i applied submitted a medicaid application for my mother in December. The process seems like it will never end.
We have 2 women who are making the application for us and submitting the information to medicaid. Medicaid last month gave us 30 days to submit some missing information which they were not aware they already had. I contacted
the the women and asked them if they needed anymore information from me.It was mine information that they needed. They told they did not and the information was fine. Now medicaid contacted them and needs some of the same information or an update on the information. What more of an update do they want when my data was updated from 8/2006-to 3/31. Now the process is going to may and in june i have an operation .

Noone is contacting me ,myself but thru my sil

 

[PrincessSuzanne]

Hi Suzanne, is there an Easter Seals programs in Florida? My cousin has a son, 5 years old that has Autism that has been in "daycare" at Easter Seals for about 1 1/5 years. When he went in he wasn't speaking very well, but they have done wonders for him, he is even going to be able to possibly go to regular school in the fall, I don't understand why, because he is only at a 2 year old level. I know she said that there are children there of all ages, some even up to I think about 18 years old. They offer Speech Therapy, OT, and PT, as well as other services. You might want to check into it.

Suzanne

 

[SueM in MN]

Medicaid last month gave us 30 days to submit some missing information which they were not aware they already had.

We've run into that too.
DD just had to be renewed and they needed some information that we had discussed with her last caseworker late last fall/early this year. Now, she has a new caseworker who doesn't have that information and of course, the old caseworker didn't make any notes.

PS. I'm going to move this to the disABILITIES Community Board.

 

[PrincessSuzanne]

My sil and i applied submitted a medicaid application for my mother in December. The process seems like it will never end.
We have 2 women who are making the application for us and submitting the information to medicaid. Medicaid last month gave us 30 days to submit some missing information which they were not aware they already had. I contacted
the the women and asked them if they needed anymore information from me.It was mine information that they needed. They told they did not and the information was fine. Now medicaid contacted them and needs some of the same information or an update on the information. What more of an update do they want when my data was updated from 8/2006-to 3/31. Now the process is going to may and in june i have an operation .

Noone is contacting me ,myself but thru my sil

It should take no more than 45 to 60 days to process a Medicaid application (I work for a company that assists people with the medicaid application process/Disability application process in hospitals, and we work closely with the Medicaid offices). Someone is not doing their job if they still haven't approved or denied it. You or your SIL need to contact the Caseworker and demand to find out what is going on. Depending on the program she is eligible for, you may have to provide updates every 30, 60, or 90 days, and some program only check updates once a year. There are also states that have a Spenddown program, where the person has to meet a minimum of medical bills before Medicaid pays.

Good Luck

Suzanne

 

[disneytraveler]

The application for my mother was denied once because the caseworker
thought he/she did not have all the information. Then it went into pending stage after the person saw the information. This happened in March . Now still waiting for acceptance of the application. The people who helped us with the application want it to be denied because of the transfers.

Still no word on the application being accepted yet. Then i receive a bill
from the nursing home . It is about" medicaid surplus' for 571.20 each month.
I paid for one month already back in March. I called the nursing after to inquire about the bill. They told me the application is pending but they dont
have a total bill to give me so disregard the notice .Their computer generates it. Now iam wondering about the recent bill.

 

[disneytraveler]

Anyone have information on the medicaid appeal process. The company that made the application filed an appeal on the denial so that we can preserve
the original submission date and go back to 10/06 for coverage. It was first
denied because the caseworker thought he/she did not have the information but they did. We dont have go thru with the appeal i was told. And somehow they are still not getting some information. Not sure if SIL has already sent her updates or not.

 

[barkley]

Anyone have information on the medicaid appeal process. The company that made the application filed an appeal on the denial so that we can preserve
the original submission date and go back to 10/06 for coverage. It was first
denied because the caseworker thought he/she did not have the information but they did. We dont have go thru with the appeal i was told. And somehow they are still not getting some information. Not sure if SIL has already sent her updates or not.

are you certain this is a medicaid application and not a medicare (i administered my previous home state's medicare program and private companies did'nt generaly file applications for clients-i've only heard about those types of services for medicare/ss apps because the companies get a portion of the cash benefit as payment).

if it is a state program, then i would suggest you just let the appeal run it's normal course and not withdraw it. if the issue is resolved prior to the formal appeal hearing you will get a letter stateing that the appeal issue has been denied due to the issue no longer existing, however-if the issue is not resolved by the time the appeal hearing is held it will force the issue and get it resolved. generaly alj's (administrative law judges) oversee appeals (if they even reach the hearing stage-many are resolved by appeals specialists prior to getting to that point) and they put strict time lines on enacting a decison. by not withdrawing your appeal you have it still in the case record to protect that begining date of aid should whomever told you the appeal was unnecessary be wrong (and sadly that happens way too often).

state run programs generaly work under a 45 day processing rule-the application must be granted or denied within 45 days from the date of application (the date they receive it and date stamp it in). some states with fed funding however have successfully gotten temporary waivers when circumstances are such that they cannot process apps timely (staffing shortages, unanticipated emergency increase in apps). you can check with your state (or if yours goes county to county-that county) to find out what their processing rules are. it should also be contained in the informational sheets that came with the application.

my suggestion is if possible-keep a copy of every item you send to your caseworker, and get your doctor to provide you with the same. file them in the date order they were submitted (you can put a post it on each to keep track)-then if you are told something is not in your file you can easily refer to your 'dummy case record' and advise the worker of the submission date as well as provide another copy.