Health Insurance Issues
Health insurance benefits are often confusing to read and difficult to appeal, especially for a family with a child with special health care 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.
The Center for Infants and Children with Special Needs at Cincinnati Children's Hospital Medical Center connects patients and families with web sites that provide general information, checklists, strategies and sample letters to assist you with health insurance issues.
General Resources | BCMH | Medicaid / Medicare | Pre-Existing Conditions | Appeals / Writing Letters of Medical Necessity
General Resources
- American Academy of Child & Adolescent Psychiatry provides information about understanding mental health insurance.
- Catalyst Center provides information on improving health care insurance coverage for children and youth with special health care needs.
- Centers for Medicare and Medicaid Services provides comprehensive information on eligibility and coverage.
- Children and Youth with Special Health Care Needs are supported in each state through Title V government funding. A directory of local contact information and services is available.
- Children's Health Insurance Program (CHIP) is federally funded health insurance designed to provide support to families and children up to the age of 19.
- Cincinnati Children's Financial and Medical Assistance Programs for Families has counselors who can help arrange for payment plans, discounts and financial assistance for eligible patients and families. The Hamilton County Tax Levy provides medical coverage for indigent care through the University of Cincinnati Hospital and Cincinnati Children's. For further information and an application, please contact Patient Financial Services at Cincinnati Children's, 513-636-4427.
- CoverCincy provides information on health insurance coverage, paying hospital bills, help with prescription medication and local community health centers.
- Cover the Uninsured provides guides for finding health insurance coverage in each state.
- Georgetown University Health Policy Institute offers a consumer guide to getting and maintaining health insurance. Guides summarize consumer protection by state, including Ohio, Indiana and Kentucky.
- Health Insurance Finder provides information about a variety of health insurance issues, including understanding health insurance terms.
- Kaiser Family Foundation publishes A Consumer Guide to Handling Disputes with Your Employer or Private Health Plan.
- Medical Economics offers a series of handouts for patients and families, including "Translating Insurance-Speak."
- National Center on Financing for Children with Special Health Care Needs has compiled a glossary of managed care terms for consumers.
- National Health Law Program provides publications, notices of current and upcoming legislation, information on advocacy all related to health care issues.
- Ohio Department of Insurance provides information on Health Mainenance Organizations (HMO) as an alternative to traditional insurance. An HMO will accept individuals during their Open Enrollment Period regardless of any pre-existing health conditions. They also provide a Health Insurance Guide that explains different types of coverage.
- Ohio State University: Office of International Education offers basic information about the health insurance system in the United States.
- Patient Advocacy Foundation published "The Managed Care Answer Guide" with information about understanding managed care terminology, a consumer guide to selecting an insurance plan, and understanding the provisions of a health care plan.
- United Healthcare Children's Foundation offers assistance grants for children's medical services not fully covered by health insurance.
Find additional information on health insurance programs under Financial Assistance.
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BCMH
Bureau for Children with Medical Handicaps (BCMH) is a tax-supported, state-administered program through the Ohio Department of Health. The mission of BCMH is to assure that children under age 21, with special health care needs, obtain comprehensive medical care and services in Ohio that are family centered and community based.
Medicaid / Medicare
Medicaid is a publicly funded health insurance program that provides health coverage to families with low incomes, children, pregnant women and people who are aged, blind or who have disabilities. Individuals must first apply for Social Security benefits (SSI / SSDI) prior to applying for Medicaid. Ohio Department of Job and Family Services provides information about income eligibility requirements and the application process including:
Find the Medicaid agency in your state.
Medicaid Buy-In for Workers with Disabilities (MBIWD) begins in Ohio on April 1, 2008. MBIWD is an Ohio Medicaid program that provides health care coverage to working individuals with disabilities. Historically, people with disabilities were often discouraged from working because their earnings made them ineligible for Medicaid coverage. MBIWD was created to enable Ohioans with disabilities to work and still keep their health care coverage. The program has eligibility and financial requirements. Applications are available from your local county office of Ohio Department of Job and Family Services.
Medicare provides qualified adults with disabilities with publicly funded health insurance. This site provides general information about the Medicare program and has an online "eligibility tool."
Pre-Existing Conditions
The Health Insurance Portability and Accountability Act (HIPAA), effective July 1, 1997, provides certain protections for people who have pre-existing medical conditions. A pre-existing condition is any medical condition that a person has before being enrolled in an insurance plan. This law helps protect your health insurance benefits by:
- Limiting exclusion periods for pre-existing conditions.
- Lowering your chances of losing your existing coverage or of being discriminated against because of your health.
- Providing protections for you when you change jobs.
The length of time coverage can be denied for a pre-existing condition under HIPAA is limited to no longer than 12 months (18 months if you are a late enrollee). This time can be reduced or eliminated if you were covered by previous health insurance (which qualifies under HIPAA as creditable coverage) and if there was not a break in coverage between the plans of 63 days or more.
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Appeals / Writing Letters of Medical Necessity / Prior Authorization
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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If your questions are not fully answered by our Special Needs Resource Directory and its links, please contact us via email.
Rev. 4/08
