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.