Need Advice


<font color=red>Steve Irwin, taking care of Heaven
Nov 1, 2001
Sorry this will be long

Dh lost his job in Dec. We were planning on paying the cobra ins(800). Turns out we are having problems already with them okaying anything. We have 3 Ds one who is 4 has developmentald disabilities. Ranges are a few months to almaot 2 years and that is the speech. We have him in 2 hours a week in private speech therapy and 3 afternoons a week in a early childhood special ed. paid for by the school district.

We've tried to get other ins. for us but so far don't want to insure for pre exsisting conditions. Or they are either the same price. We are looking into getting medicaid for the boys but they also suggested that we get John(ds) on SSI benefits. Is this a good idea or is there anything else out there that we can do to help him? Any help/advice offered would be appriecatied. We are kind of new at this.

Oh I forgot to add the private speech therapy place wants to do a pt/ot evaluation on John. We did with the school and he did not qualify. Feel free to ask any questions.

Well, by what criteria did the school district determine that your son does not have a motor control problem that would interfere with academic performance? Did they do a formal screening assessment, or did they just say, "Oh, I don't think he has a problem with that..." or something lame like "He is too young for that kind of assessment" and let it go from there? You should request a formal assessment, in writing, by certified mail. You should contact your local disabilities advocacy group - I am sure Sue knows the right links for Parent groups in Minnesota.

I can't help you with the insurance questions, that is a tough one.
They did an evaluation about a month ago. The felt he did have a motor control and balance problem but it wasn't enough for the school district to pay for it. We know he needs some kind of therapy for it but the ins has a 25 visit limit per year. That also goes for the speech and he'll meeet the limit in early March. So even if we stay with this ins we don't know what will happen after the limits are met. With Tim out of a job it would be impossible to paay the bills ourselves.
Welcome. Sorry to hear about your problems. I do know from my days of working as a school nurse and in Public Health that a lot of kids who are behind don't qualify for some programs because they are not far enough behind. It's kind of a viscious cycle though, because if they get far enough behind to qualify, it will take more to catch them up.
Here's a link to The PACER Center. They are a parent advocacy group in Minnesota and they know all the ins and outs of the education system. They have advocates who can help you over the phone or even come with you to school if you need that.
They also have people who can help you with insurance problems, appeals and getting into the different health programs in Minnesota (including questions about SSI).
Good luck to you.

For readers who are not in Minnesota, the PACER Center in Minnesota is one of the national models for programs like this. Their website also has links to similar programs in each state.
Thank you Sue. I knew that you woukd be able to help. This place is the best.
You're welcome. The people at PACER are really nice. I have called a few times just for moral support and a second opinion. Hope they can help you out.
Boy oh Boy these woman know their stuff! :)
I have one idea on your current insurance..
it comes from a previous experience I had with my diabetic care and being on Cobra for a short period.

If the current insurance you have with COBRA is the SAME insurance who originally paid/ok'd the speech therapy and ds is still in the SAME RX/care plan.. then the insurance has no reason to deny coverage. However it all changes if there was a lapse in coverage or if a new Rx was ordered. In most cases changing to a new insurance will have the pre-existing condition clause.. it is absurd...but it is the way the insurance co. gets around.

Also being on the PT end of things, do the letter as suggested by Teri. In it state why you feel that the motor/balance problems will be a deficit to your ds education. Be objective and to the point. If they still refuse to enter him into the PT program at school, you may want to request a "home program" as part of his homework. This is a way to get your foot in the door before they completely close it BECAUSE... if they feel he needs a home program.. then darn it, he needs a PT to supervise the progression of the program. ;) ah beuracracy.. ain't it grand! Either way your son will get some exercises that will be of benefit.

Hope this helps a little, I am sure Sue's links will be the best.
Best wishes and a extra dose of PD.. so dh can re-enter the work force
Actually going from COBRA to a new insurance with no lapse should mean that there is no preexisting clause. At least that is what my husband tells me is the law now. I know that when we switched the preexisiting clause did not come into effect. We will be changing again in JUly and it again will not be aproblem then either. The determining factor is continuous coverage. You cannot allow the insurance to lapse. If it does lapse then the ppreexisting clause will come into play.
Another thing that might make a difference is if the insurance at your your dh's job was a self insurance program. If so, there are differnt rules, but you can get help from PACER on that.
Thank you so much you guys. I don't feel as lost or confused anymore. The problem with our ins is that they are the Worst in the state. Everytime I make a appointment somewhere I feel like I have to apolgize for having them. Right now we paid the $800 for the month of Jan. and everything is coming back rejected. We not in the system yet but they cashed the check.

Anyway I talked to a few people yesterday about getting them on Medicaid during our layoff time. It sounds like that is the way we will go for the kids but We are planning on getting with Pacer also to see what else we can do.

Its just very frustrating to pay this much and get nothing in return. We even paid early so this wouldn't happened. I just hope that we wouldn't have to switch doctors if we go on medicaid. His speech place that they would prefer medicaid than our ins.

Basiclly when we take John anywhere we get "he is a puzzle." I'm thinking of making him a shirt that says that. It certainly isn't something I disagree with either. But he is an a sweetie and we love him to death.

Thanks for listening/reading my rants and answering my questions. You are the best!
I just wanted to add a note of encouragement to you. Some of the prettiest pictures I ever seen were made from puzzles! :)

Hopefully you've been able to get somewhere with your insurance problems already, but the whole idea of COBRA is that it's a "Continuation of Benefits." Whatever you had while your husband was working is what you, by law, still have (as long as you didn't select a lesser-coverage when you signed on for it). If they were paying for this stuff before, insist that they provide an answer as to why they would pay for it back in ________ (December, or whatever), but now they've refused to pay. The fact that you're now on COBRA shouldn't even be an issue. When I worked in HR, both our regular employees and our COBRA people were on the same contract. Do you make your COBRA payments to the insurance company, or to the former employer? If it's the former employer, see if you can get someone there on your side to intercede for you with the insurance carrier.

Try the sugar and honey approach first, but if that doesn't work, get firm (but not rude), and then keep talking to the next person up the food-chain as far as you have to go to get them to treat you fairly.

Good luck.

Tammy, A normal person would think that was the case but not this company. As for now were dumping them and putting our son in State health care. They will cover so much more and I was so surprised about how much there was for us. I don't know if that would continue when Tim(Dh) gets another job something we will be finding out this week.

Right now John is talking more at home but hardly at school. The school will be doing evaluations to see about sending him to kindrgarten next school year. We have a ot/pt evaluation coming up to see about that. Meeting with Ssi in a couple of weeks and waiting to hear about other papers we filled out.

Thanks again for everyones advice. I think part of my problem was I was thinking that if we could just get John to talk he will be fine, Now its time to get our heads out of the sand and get that best help we can for him.

The DIS is really a blessing in so many ways.


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