DD reached limit on medical insurance, ideas??

[PatMcDuck]

Oh, jeez, it looks like our nightmare got worse....... DD has been VERY sick, needing multiple hospitalizations and surgeries in the last 3 years. Almost lost her twice. She had another double knee surgery a couple of weeks ago, and now they stopped paying her claims, and say she is maxed out...... Yes, I knew there were limits of course. I thought she was ok; I may have miscalculated and misunderstood. I am beside myself with guilt, and anger, mostly at myself. Did I screw this up for her, my not understanding the fine print? We have the situation under review, maybe they have it wrong. They even pre-certed that last surgery. But now they say that does not mean she was covered for it. (then what does pre-cert mean? ) It is a complicated set of limits, and rules, for both hospital days allowed, and major medical benefits. The insurance co seems to be saying she maxed out both, which seems impossible, to have that happen at the same time. They also say that they do NOT send out letters letting you know that the benefits are maxed out. They just start kicking them out, not paying. Arghh. She just turned 18 in February, and begins community college in September. She actually needs some minor surgery, that we were going to do this summer. (carpal tunnel is severe in both hands, likely a side effect of all the treatments or from on of her diagnosis')

I am getting various suggestions from friends. One thing they say, she is 18, and has no $$ (can't even work PT, she has been too ill). So, are we legally responsible for her unpaid medical bills? Our finances are a MESS, largely from paying other (uncovered) medical bills for her. I have not been able to work FT, we go to doctors, therapy, etc and I need to be home for DS after school, he is 20 with Downs and Autism. (I do work 2 PT jobs) I do not feel comfortable with these bills not getting paid, but I feel so conflicted. We will have to sell the house very soon, things are that bad already, we are drowning in bills. Looking forward, we were going to try and get her on SSI, which would give her Medicare at least, but that takes 6 months or more, excluding appeals. Another option might be the medical insurance that the community college offers? Does anyone have any experience with using that type of insurance? (I will call and ask too, of course). Of course that means she must keep FT student status, which will be a challenge with her health, but we are hopeful/ she needed to be FT for our family policy as well. I will also see if the hospital has any programs that could help us. The NJ kid care program will not help, she is already 18, and our family income is a few thousand over the limits. I also will see if I can somehow work FT to get family medical benefits.

For those of you who are dead set against the new health plans, welcome to my nightmare. I have a chronically ill daughter, who has multiple pre-existing conditions, and may suddenly have no medical insurance...... I can barely sleep. So if you have a chronically ill family member, read that fine print!

 

[JenSop]

I have nothing but sympathy for you. I can't even imagine how difficult it must be for your family. I would say try to contact your representatives? Insane long shot, but you never know. Maybe even alert the press? Health care is a hot issue right now, and your situation might be able to get some attention, and as a result, maybe get some help?

This is why I am 100% for universal socialized health care. (I am not saying that to get anyone started on a debate - this is not the forum for it. I'm a socialist - deal.)

I really hope things work out for you. I'll try to sent some good vibes and prayers your way.

 

[SnowWhite2]

I thought that starting in January you can keep the kids on the policy until 26 and the limits go away. Not that it would help you today, but maybe in a few months.

Pixie dust to you...

 

[Sadie22]

A special needs/elder law attorney could assist you in navigating the social services maze. If DD is an adult she could be eligible for services on her own income.

 

[jgates]

In some states you can keep the kids on policy already if they are not FT students, but it can be very pricey as they have to charge you taxes on the value of that policy. We had considered adding son back on ours when Wisconsin started this early. However, even though premium did not change as we already had family coverage, we would have been taxed on approximately $600 value per month for his policy. So he elected to keep the policy he got thru the alumni association.

My son & his fiance both took a student policy (son when he lost job & was no longer on ours thru alumni group). But watch policies. May have high deductibles & may not cover all. So just read the terms carefully. But at least it is something.

In this situation it sounds like their family policy is of no value in daughters situation any longer & will no longer pay if I am reading it right.

 

[wdwfan16]

I agree with the PP. The limits and 26 rule are in effect but I am not sure of the exact date.

Per: http://www.healthreform.gov/reports/keyprovisions.html

EXTENDS COVERAGE FOR YOUNG PEOPLE UP TO 26TH BIRTHDAY THROUGH PARENTS’ INSURANCE—Requires new health plans and certain grandfathered plans to allow young people up to their 26th birthday to remain on their parents’ insurance policy, at the parents’ choice. Effective 6 months after enactment.

BANS LIFETIME LIMITS ON COVERAGE—Prohibits health insurance companies from placing lifetime caps on coverage. Effective 6 months after enactment.

 

[wdwfan1]

Depending upon your daughter's status and your financial situation, she may be eligible for Financial Assistance (reduced medical bills) or Medicaid.

In New York State, Financial Assistance is based on family income, family size and monthly bills. The amount of assistance granted is based on the federal poverty level. The co-pay could be figured as a sliding scale, which would greatly reduce any $$$$$ owed.

Assistance may be different in other states, but you should inquire at the hospital to find out what is available. If the hospital can't help, inquire at a local Medicaid office.

I hope your daughter gets all the medical help she needs.

 

[Mary•Poppins]

I have nothing but sympathy for you. I can't even imagine how difficult it must be for your family. I would say try to contact your representatives? Insane long shot, but you never know. Maybe even alert the press? Health care is a hot issue right now, and your situation might be able to get some attention, and as a result, maybe get some help?

Even if your representative can't help you, perhaps they can direct you to an agency that could help you through this?

This is why I am 100% for universal socialized health care. (I am not saying that to get anyone started on a debate - this is not the forum for it. I'm a socialist - deal.)

Right there with you!

I really hope things work out for you. I'll try to sent some good vibes and prayers your way.

My thoughts and prayers are with you and your family. As bad as this is, you sound like a strong women.

 

[Tinker'n'Fun]

Definetely not my area of expertise but I think you could use a and a few more , and a friend. Come and vent anytime.

 

[wannago]

My thoughts are with you. I can only imagine the stress that your entire family must be enduring. Don't know if this will help but I believe that all states have some form of emergency Medicaid. Speak with your local social services as to the application process.

Any avenue may be a catastophic illness fund. Do a google search for this (I can't post links yet )
You may also find some assistance through your states Vocational Rehabilitation.

 

[Halbleib1]

One thing they say, she is 18, and has no $$ (can't even work PT, she has been too ill). So, are we legally responsible for her unpaid medical bills?

Once a child turns 18 parents are no longer responsible for their medical bills. Any bills before she turned 18 would be your responsibility though. In PA once a child turns 18 it is easier for them to get medicaid as they usually only use the child's income and not the whole household's income. Any assets that they have are used however. Such as bank accounts and vehicles.

Example: When I was 19 and in college I was still covered under my parents health insurance however I qualified for medicaid to cover anything that the insurance did not such as co-pays etc.

Check into the requirements in your state. Most states have the information online.

Good luck. I hope everything works out for you and your daughter.

 

[debbiemomto4]

Yes. When you have a special needs child at 18 you still seem to walk a fine line. My dd has Crohn's Disease and numerous other autoimmune diseases. Thankfully she can keep being covered as long as she can maintain a full-time status at college. She realizes the need for this since she is medically "uninsured " on her own. I pray the new laws will be on her side with these issues.
We live in NY so our back up plan has been she can apply for SSI and Medicaid. In the mean time go onto an extremely expensive Oxford plan while these things are in motion. My ds who is 10 had cancer and I am on several cancer boards and this is what always needs to happen. Remember once she gets approved for SSI they backpay to the date you began your application.
She also needs to pick up insurance right away I believe the key is 60 days. So if they are dropping her get her on a COBRA plan right away. Obama's health plan should eventually help(probably not for her now) with this but the problem is the low ceilings on some medical plans. $1 million dollar limit is low for a special needs child.
Some pages to check out- you mentioned NJ
www.njspecialneedschildrenlaw.com
www.healthplanone.com/healthinsurance/newjersey/ (this page looks like you can buy ins through them but it has the links you need to get to all sites.
Remember she is still considered a minor until out of high school plus you will need to act quick.
Good luck also there are attorneys and social workers that can point you in the right direction.

 

[megsters]

no advice, but lots of

 

[DisneyokwSSR]

If your daughter becomes eligible for SSI she will receive Medicaid, not Medicare. The new legislation is a big tangle of problems and you most likely will not see the provisions that interest you in effect until at least January 2011. There is already a safety net in place for people like your daughter. Even before she receives a decision about SSI she should apply for Medicaid through the state. That is traditionally what people in this situation do. Usually the big problem is hitting the limit before the individual turns 18 and then it is much more difficult to qualify for assistance.

 

[ML_LovesDisney]

Oh, jeez, it looks like our nightmare got worse....... DD has been VERY sick, needing multiple hospitalizations and surgeries in the last 3 years. Almost lost her twice. She had another double knee surgery a couple of weeks ago, and now they stopped paying her claims, and say she is maxed out...... Yes, I knew there were limits of course. I thought she was ok; I may have miscalculated and misunderstood. I am beside myself with guilt, and anger, mostly at myself. Did I screw this up for her, my not understanding the fine print? We have the situation under review, maybe they have it wrong. They even pre-certed that last surgery. But now they say that does not mean she was covered for it. (then what does pre-cert mean? ) It is a complicated set of limits, and rules, for both hospital days allowed, and major medical benefits. The insurance co seems to be saying she maxed out both, which seems impossible, to have that happen at the same time. They also say that they do NOT send out letters letting you know that the benefits are maxed out. They just start kicking them out, not paying. Arghh. She just turned 18 in February, and begins community college in September. She actually needs some minor surgery, that we were going to do this summer. (carpal tunnel is severe in both hands, likely a side effect of all the treatments or from on of her diagnosis')

I am getting various suggestions from friends. One thing they say, she is 18, and has no $$ (can't even work PT, she has been too ill). So, are we legally responsible for her unpaid medical bills? Our finances are a MESS, largely from paying other (uncovered) medical bills for her. I have not been able to work FT, we go to doctors, therapy, etc and I need to be home for DS after school, he is 20 with Downs and Autism. (I do work 2 PT jobs) I do not feel comfortable with these bills not getting paid, but I feel so conflicted. We will have to sell the house very soon, things are that bad already, we are drowning in bills. Looking forward, we were going to try and get her on SSI, which would give her Medicare at least, but that takes 6 months or more, excluding appeals. Another option might be the medical insurance that the community college offers? Does anyone have any experience with using that type of insurance? (I will call and ask too, of course). Of course that means she must keep FT student status, which will be a challenge with her health, but we are hopeful/ she needed to be FT for our family policy as well. I will also see if the hospital has any programs that could help us. The NJ kid care program will not help, she is already 18, and our family income is a few thousand over the limits. I also will see if I can somehow work FT to get family medical benefits.

For those of you who are dead set against the new health plans, welcome to my nightmare. I have a chronically ill daughter, who has multiple pre-existing conditions, and may suddenly have no medical insurance...... I can barely sleep. So if you have a chronically ill family member, read that fine print!

I am so sorry to hear about your DD. I will say a prayer for you all. "Precert" means they call and verify with a clinician (medical professional) if the person actually NEEDS this surgery. They give a little disclaimer before every call or before they authorize it, and say "this is not a guarantee of payment, this is based on medical necessity and not an available benefit". Insurance companies SUCK! Have you tried to apply for public assistance for your child? I know with people I work with, even if they normally wouldn't qualify, if something is wrong medically, public assistance through your state will pick them up as a secondary insurance. Public assistance takes about 30 days, as opposed to 6 mths for SSI. Also, in regards to the bills, if you sign a little piece of paper they sneakily put in front ofyou before doing a procedure and your daughter doesn't sign, you would be responsible, its a financial responsibilty form. If you didn't sign it, I would assume she is responsible.

 

[gandycat]

I'm so sorry your daughter has to go thru all of these medical issues and that it's causing such stress for all of you. My kids have minor issues that have caused lots of money paid out for prescription copays and treatments that aren't covered and it causes stress, I can't imagine what you guys are going through. ((hugs))

As people have said, she may qualify for a MA card on her own. Where I am, even if it takes a few months, they can be billed retroactively so it may cover some things she has done in the month or two before she qualifies. I would suggest talking to the medical social worker at the hospital where the money is going to be owed. They may be able to help you decide what route is best to take. They deal with similar issues everyday.

Good luck to your family.

 

[disney1990]

I thought that starting in January you can keep the kids on the policy until 26 and the limits go away. Not that it would help you today, but maybe in a few months.

Pixie dust to you...

Yes, help is coming. And, thankfully, when she is eventually on her own policy, the new law will also make sure that she can continue to have health insurance.

 

[LilyWDW]

Another option might be the medical insurance that the community college offers? Does anyone have any experience with using that type of insurance? (I will call and ask too, of course). Of course that means she must keep FT student status, which will be a challenge with her health, but we are hopeful/ she needed to be FT for our family policy as well.

I wanted to reply to this part of it as it seems you are getting some good advice on some of the other points.

I currently have a health insurance package that is offered by my University through Pearce & Pearce. In my experience, these packages are not very good if you have a chronic issue that requires a lot of expensive care. It's really meant for general medical (yearly exams and sick visits) and an occasional emergency situation. The limits are pretty low and they have high deductibles. The reason I currently have it is so that I would have something between when I left my job and until I could find a private plan that worked better for me. I didn't want a lapse in coverage.

 

[blondietink]

Depending on your daughter's disability diagnosis, many states have medicaid "waivers" that will disregard the parents income in qualifiying the child or young adult for medicaid. Although, since your child is 18, she should be able to qualify on her own income.

 

[SandrA9810]

You mentioned your son has chronic illness too, what do you do for him??

My brother has sydrome G, and for his entire life he's recieved SSI and medicaid. My mom has never had to pay out of pocket for his medical expenses. When he was younger he went to see a lot of specialists for various reasons to see if certain problems could be fixed. Unfortantly it never paid off.

Usually if you go to a hospital for something, and you can't afford to pay it. There's some lengthy paperwork that can be filled out to help reduce the amount owed and set up payment plans. And I think this also sets you on the path for applying for medicare.