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Health insurance benefits are often confusing to read and difficult to appeal, especially for a family with a child with special healthcare needs. Health insurance terms such as "medical necessity" and "skilled nursing" are difficult to understand and may be interpreted differently by each insurer. Families often lack the expertise, experience and clout to successfully deal with insurance issues and this can add significant emotional and financial stress.
Ask to see your entire policy online or in print. This detailed document often provides information that better explains and occasionally contradicts what you thought was covered. Medications are often covered by a separate policy and the covered medications and copay may change during your coverage. Most policies cover all medications used in the hospital or emergency room as part of your medical coverage. However, medications prescribed for you as an outpatient are controlled by the “pharmacy” part of your policy and thus a medication that was fully covered and working well in the hospital may not continue to be covered or have a high copay once you are discharged. You can ask your physician to submit all medications and other treatments such as therapies to your insurance company prior to discharge so that you know what is covered or how much your total “out of pocket” cost will be.
Your physician, social worker, discharge coordinator, and hospital financial aid office can assist you in this process. Their knowledge can be extremely useful but sometimes you have to personally seek their assistance.
Information included throughout our directory can help you understand the process, realities, rights, and available resources. You can find sources of financial assistance including how to obtain free or discounted medications.
The Complex Care Center at Cincinnati Children's connects patients and families with web sites that provide general information, checklists, strategies and sample letters to assist you with health insurance issues.
Health organizations often provide current information on disability information, health policies, useful statistics and news items of special interest.
Find additional information on health insurance programs under Financial Assistance.
Many families depend on their insurance company to pay for expensive treatments, assistive technology and adaptive devices. Insurance denials can be appealed since decisions are sometimes made by an individual who may not be an expert on the condition or recommended treatment. It is important to know the fine details of your insurance policy.
A strong letter of medical necessity or appeal can often make the difference in what an insurance company will cover. The physician or health care specialist writes the letter emphasizing how the individual's life will be affected by permitting or denying treatment. There are also rare situations when an attorney is needed. Alternative sources of funding may be available if the insurance coverage is inadequate or denied. These web sites provide sample letters, checklists, strategies and appeals process information.
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