Insurance Concerns

Social Security Home Page

This is were to start when looking for information from the Social Security Administration (SSA).  This page has many great LINKS to sections dealing with virtually every concern you could have.   Some examples:
Qualify and apply for SS benefits
Disability and SSI
Reporting a death

FREE 20+ Medical Necessity Letter Templates in PDF | MS Word

The following site has free templates for create Medical Necessity Letters. This can help you and the doctor get the information needed so you get your supplies covered by insurance.
https://www.template.net/business/letters/medical-necessity-letter/

AARP Insurance options
AARP has a lot of information on Medicare, Medicaid and other health insurance options at the following website:
https://www.aarp.org/benefits-discounts/healthcare/?cid=VanityURL-Health-79E-DM-21-050119&migration=rdrc

Suggestions from our members:

1. I am on disability. I started my procedure online and followed up at the local SS office. My advice is to keep a copy of all correspondence to and from Social Security as it takes time and memory fails. Having that record helps when they can’t find what you sent and you can give them a copy. Talk with your Doctor/therapists and go for it. My problems have grown since getting disability so start now if the need is there. It is a lengthy process.
David

2. My personal dealings with this government agency: With my recent Lary (June ’08) and being 64 years young I was in a position to an take earlier retirement than I had planned. I was a property manager who leased warehouse space to large and small companies. This required lots of phone work and speaking with customers and the public in general. I also taught at the University of Hawaii so my podium time would be difficult. After my surgery this was no longer a viable option.

So I went on line with the SSA and within a week I had an appointment to produce my original documents. When you go to their website they will tell you all you need to know. You can save tons of time by doing this all on line. Hint: If you have any military time at all be sure to bring your DD-214 since you will get a few bucks more. You can mail in your documents if you want, but the SSA office is not too far for me. I had my first SSA check within 10 days…and after I completed my disability application, again on-line, I was approved and had my first check in 3 weeks. and they even paid me for the 4 months not covered by my prior employment.

Have all your contact names and addresses, phone numbers, at hand as you do the on line appl’s. The website will assign you a number so you can enter some info…take a break.. and then go back to it when you’re ready. All in all it seems to be a secure site and fairly friendly to use.

Please try this before you spend money on an attorney…whom you’ll likely not need.

Frank…in NJ

MEDICARE PRIMARY with MEDICAID SECONDARY

If you have Medicaid as a Primary insurance but become eligible for Medicare, you will likely be eligible for both, if you are still at an income level to qualify for Medicaid.  The rules vary considerably from state to state, but usually when Medicare becomes your Primary insurance, Medicaid becomes your secondary and picks up the 20% balance. There are no doubt variations from state to state about the way the $100 deductible is handled.

Medicare Part B takes care of doctor’s visits and also equipment and supplies. It will pay for 80% of the cost of artificial larynges, TEP prostheses, stoma filters and some of the other equipment and supplies that you might need. For the purchase of equipment and supplies from a national vendor, you might have to pay some or all up front. Each state has its own rules and it is a paper nightmare for most of the vendors to handle the paperwork and rules for 50 different states without hiring more people and raising prices. But in many states, if you have had to prepay, Medicare will pass the claim on to Medicaid automatically and you will be reimbursed by both. Some of the vendors will sell to a local medical equipment dealer of your choice who is able to handle Medicaid in your state if you have a problem with having to prepay. For the rules in your own state, get in touch with your Medicaid representative. Check with a laryngectomy club in your state. As everyone in WW knows, people who have been through it can often give practical advice that the official representatives don’t think of.

People who are not on Medicaid or other special assistance programs that will supplement Medicare will probably want to have their own secondary health insurance policies through other sources.

Dorothy Lennox
Luminaud, Inc.

SOCIAL SECURITY DISABILITY

BENEFITS PLANNING

The Benefit Planning page can help answer questions on what to do and what benefits apply to you.

QUESTIONS BEFORE YOU START
How much time will it take to answer all the questions?
What types of questions will to ask?
Do I have to answer all of the questions?
What if I already get benefits from the Social Security Administration?
Who will see the answers I give?
What if I don’t understand a question?
What if I am helping someone else?
What happens when I finish answering the questions?

The Benefits Planning can be found at:

https://www.ssa.gov/planners/index.html

The Simple Dollar

We recently looked into the Social Security Disabilities Benefits and found that most people who have become or already living with disabilities are not fully aware of the benefits and resources that are available to them. So, our team spent weeks reviewing the US Social Security Administration’s documentation to develop our 2016 Disability Benefit Guide. This guide breaks down qualifications and the application process, as well as a calculator that can help estimate monthly and annual benefits.

You can see the entire guide along with some of its features here:

http://www.thesimpledollar.com/disability-benefits-guide/

Veterans Administration

UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

HOME PAGE

http://www.va.gov

THERE ARE LINKS ON THIS PAGE TO THE FOLLOWING:

Quick List
Veterans ON–line Application (VONAPP)
Enroll/Update Medical Benefits (10–10EZ)
My HealtheVet
eBenefits
Life Insurance Online Applications
VA Forms
Careers
Notices

Highlights
State and Local Resources
Post 9/11 GI Bill
Prescriptions
VA Strategic Plan FY 2011 – 2015
VA 2013 Budget Submission
Veterans Crisis Line 1–800–273–8255, Press 1

Special Programs
Returning Service Members (OEF/OIF)
Vocational Rehabilitation & Employment
Homeless Veterans
Military Service Benefits
Minority Veterans
Surviving Spouses and Dependents
Women Veterans
Adaptive Sports Program

BENEFITS

1. Where to find VA benefits

https://www.ebenefits.va.gov/ebenefits-portal/ebenefits.portal

This is the best place I’ve found for VA benefits. This major heading has every sub-heading listing all of the benefits that a person could want. The nice thing about this is that the veteran can enroll him/herself right there to see if they qualify.

Randy Lemster

2. Refill Prescriptions From Records on VA Site

http://www.myhealth.va.gov/

For all of you who are veterans, have VA benefits, and use the VA medical facilities, here is a web site you might want to take a look at.  It allows you to look at your medical records and to refill prescriptions. It is easy for me to order my meds and I now get all of them from the VA.

Logan Grayson

3. Some additional info to our Vets.

The toll free number 1-800-827-1000 is in Milwaukee and I have found those folks to be magnificent in handling this Lary whose voice is a real bear on the phone. I have not had to call them often, but when I do, I can tell that they are making every effort to take care of me and they always have.

Here is the number I use to re-order meds: 1-800-379-8387. Remember I am in Lakewood, OH (just west of Cleveland) so I don’t know if it works everywhere. But that is how I re-order the meds and you do not have to speak, just enter your SSAN and the prescription number, and then the ‘voice’ will tell you that it is re-ordered and when it will be shipped or whatever else is appropriate. So simple. It is a great system. And just so you know, I not only get my treatment from the VA and all the meds I need, but also any equipment. The VA has provided me with a humidifier and a suction machine. In fact, they just replaced the suction device. I use it often every day and the original just plain wore out.

I am getting absolutely magnificent care from the VA, not only with the throat but eyes and teeth and everything else. This is one satisfied dude, let me tell you.

John Shepley
Lary Since Oct 2005

4. There are two very important benefits for veterans that are not included in your library. For your consideration…….

(1) Veterans’ Aid and Attendance.

This allows for veterans and surviving spouses who require regular attendance of another person to assist in eating, bathing, dressing, undressing, medication dosing, and taking care of the needs of nature to receive monetary benefits up to nearly $2000 per month. Any local VA can provide complete information on this valuable benefit.

(2) While the number of WWII veterans is rapidly diminishing,there are probably some (like myself) who still carry their National Service Life Insurance (NSLI). VA Pamphlet 29-14 describes a valuable provision known as “Waiver of Premiums”. In a sentence, if the veteran had a laryngectomy before their 65th birthday they can apply for this benefit. Disability in this case is defined simply as organic loss of speech by removal of vocal chords. Not only are the premiums paid, but annual dividends on the face value of policy are paid in by treasury check.
29-14 provides full details.

Harry Wintemberg, Ormond Beach, Fla. Class of 1982.

5. In reading some of the emails on Military Claim, This is what I have to offer to WebW. Not all ships are covered under AO below is the newest list out on Naval Ships that are covered under AO These Ships are know as Brown Water Ships,If you served on any of these Ships you are eligible for AO disabilities.

There are two current Bills in Washington Senate Bill S. 1629 and House Bill H.R. 3612 which if passed will help the many other Naval Ships that were in Vietnam these Ships are know as Blue Water Ships hence the name of the Bill – Blue Water Navy Vietnam Veterans Act of 2011. Also there are TWO ways your spouse can keep your benefits – if you pass away from the illness or you live longer than 10 years with the illness. There are currently a group of us helping our Congressman and Senators get these Bills passed by sending emails asking for cosponsors. I will pass on the attch: of the Bills………… Bob Hug WW

An updated list of the new ships can be found at:
https://www.benefits.va.gov/compensation/claims-postservice-agent_orange.asp

VA Dental Benefits

Here is a VA site with some information on dental benefits for those that are eligible.

https://www.va.gov/dental/

VA DISABILITY issues

INFO ON ALL DISABILITIES

http://www.publichealth.va.gov/index.asp

Military Exposures,Diseases, Health, with the latest in studies and data. If you are a veteran, you should make this site one of your favorites and check there often for the latest information.

DISABILITY – LARYNGECTOMY

10/2/12

Just a heads up to those that may not be aware. The VA now includes pretty much automatic disability approval for laryngectomy if you served in Korea from 1968 – 1971, and were stationed in certain DMZ camps/stations. It is presumed (as in you don’t have to prove anything except that you were there) that you were exposed to Agent Orange just by being stationed there. Previously only Vietnam vets were presumed to be exposed. Other areas may
also qualify but the burden is on you to prove exposure…a hard thing to do.

Jack Henslee

DISABLITY COMPENSATION

Any veteran, with service from WWII to the Afghanistan fiasco,who believes they have a service -related disability that is endorsed by their personal physician, should obtain VA Form 21-526, “Veterans Application For Disability Compensation”, and file it with the VA.

Disability payments can be quite substantial, so anyone eligible should apply.

Harry Wintemberg ’82

Blue Water Benefits

Friends: I am a Vietnam Veteran who served aboard ship in 1966 off the coast  of South Vietnam. My laryngectomy surgery was in 2010. Prior to the passage  of the Blue Water Navy Act, only veterans who served on-shore were compensated for cancers caused by exposure to the Agent Orange herbicide. I filed my claim September 2021 and just received notice of a very nice monthly settlement , which included a lump sum from the date of filing. The act states that cancers covered are presumptive, so the veteran does not have to prove the cause.  I encourage any Vietnam Navy sailors who might qualify to check this out. Please reply directly to me for additional information, as needed.

Pete Meuleveld

Salem, Oregon

AGENT ORANGE HERBICIDE

The U.S. military sprayed millions of gallons of Agent Orange and other herbicides on trees and vegetation during the Vietnam War. Several decades later, concerns about the health effects from these chemicals continue. Find out more about Agent Orange.

http://www.publichealth.va.gov/exposures/agentorange/basics.asp

NEW ONLINE CENTER  AGENT ORANGE – 4/18/12

http://www.publichealth.va.gov/exposures/agentorange/

ASBESTOS RELATED CANCERS

http://www.warrelatedillness.va.gov/education/factsheets/asbestos-exposure.pdf

Explains exposure to asbestes

Tells the main cancers and then adds: Other Cancers.

Research studies have looked at the risk of getting cancer in parts of the body other than lungs. An Institute of Medicine (IOM) committee determined that asbestos exposure might be related to cancers of the pharynx, larynx, stomach, and colon and rectum.

Another resource for Ship workers and Military is the following:

https://www.asbestos-ships.com

VA INSURANCE APPLICATIONS – ONLINE

The Department of Veterans Affairs (VA) has expanded its online benefits applications

http://www.benefits.va.gov/BENEFITS/Applying.asp

eBenefits is a joint VA/DOD website that provides Veterans and Service Members with safe, secure access to many self-service features, including applying online for VA benefits such as VA Compensation and Pension and Veterans Group Life Insurance. As of Veterans Day Nov. 11, 2017, this will be available to veterans even if the are not disabled or retired.

To obtain a Premium Account and be able to use all of the features available on eBenefits, choose the option that applies to you and register at www.ebenefits.va.gov:

Service Members, Veteran DoD Employees or Contractors – use your CAC to register
Retirees – use your myPay account to register
Veterans – visit your regional office to register in person

USING THE VA MEDICAL FACILITIES  – MEMBERS REPORTS

Recently a WW member (a retired military Vet) asked the membership about the wisdom of using VA Medical Facilities, even though currently covered by other medical insurance, such as TRICARE or USFHP programs.  Below are relevant parts from some of the responses from the WW membership:

(1) I’m also retired Air Force and under TRICARE, except I elected to take TRICARE Standard since it gives me more options about where I choose to get my medical care.  I’ve also tried the VA. I went to the VA Medical Center in Denver to see about getting them to pay for my TEP. I’m rated 100% disabled by the VA, and supposedly at the top of their priority for medical care. That was a couple of months ago, and I’m still waiting for an appointment. I don’t know about VA in your area, but here they are pretty much overwhelmed by vets and simply don’t have the resources to adequately take care of all of them.  You can really see where they need more funding to expand services. I’m still going to pursue getting the VA to pay for my TEP though. I haven’t had any luck getting reimbursed by TRICARE for the money I put out for my last two prosthesis, and am still out about $300.  If I can order any future prosthesis through the VA I figure it will save me a bundle and avoid the hassle of submitting TRICARE claims.  There are no restrictions for using both TRICARE and VA, which is nice since it provides more flexibility in which one you want to use. [Dennis Bonar]

(2)  I am retired Navy and 100% disabled by the VA and am also at age 65 and have been put on Tricare For Life and I had been on Medicare since age 59 but went on regular Medicare this year and Tricare For Life. I have used the VA clinic for my SLP and also supplies like my HME and indwelling prosthesis and I have always had a choice of which one I want to use. My primary care doctor first started taking care of me at Vance AFB about 10 years ago and then about 4 years ago he retired and the base assigned both my wife and me to him as a civilian Dr. to be our primary care doctor. We still get most of our medications from the base and what they don’t carry is covered by Tricare with a small co-pay.  I also paid Tricare premiums for my wife but found out that since I was 100% I didn’t have to pay a premium for Tricare. It took quite a while and some letter writing but they returned $400.00 that I had paid in and then I was put on Tricare For Life at age 65, and there is no co-pay for doctors or premiums for Tricare. Hope this helps and if you need me to explain more of this please let me know. I was also given the option of using a VA clinic that we have but they are not equipped to take care of cancer related problems so I opted to use the VA hospital which is in Oklahoma City and 100 miles away, but it is well worth it to me. I have never had any type conflict and have always had the choice of which one I wanted to use. The disadvantage would be the time waiting for a VA appointment but that has never been a factor for me to see an SLP and the ENT’s see me on annual basis.  [Logan Grayson]

(3)  I haven’t really used TRICARE as I have had private insurance through my employer (which happens to be a health insurance company).  The employer provided insurance was free but is now up to $3000 a year as my share for a family plan so I am considering switching over to TRICARE in the future. I have been using the VA on occasion for the past year or so to get my foot in the door there.  I use primary care only and continue to use my private specialists under my private insurance.   I have to agree with some that the VA has been stressed and is trying to do too much with too little.  Since the doors were opened to all veterans in 1996, rather than just disabled vets, the budget hasn’t keep up with the patient load.  To use the VA, you need to have a VA primary care provider who then refers you to the various specialty areas.  It is my belief that it is correct that use of the VA has no impact on his TRICARE standard. While I also doubt that it would impact PRIME, which is set up like a HMO, you should check with your local TRICARE office as the rules could be different. Since there is no cost to PRIME. I don’t see why they should object.  Vets should be aware that the VA will bill any private health insurance for services that are not for service connected disabilities.  The VA does not expect the Vet to pay the private insurance cost share. (Non disabled vets may face a VA copay for certain services. ) [Nick Fuhs]

(4)   I had a visit early on with the VA SLP and clinic manager ( same guy). He showed me their catalogue while I was there. Since then, I Email him when I need an item and he orders it for me. As I do not have a TEP,  I can’t speak for that process but for bibs, batteries, and a replacement SERVOX, I haven’t needed a visit .  They seem quite happy to fill my needs without clogging up their calendar.  My primary handles both of my prescriptions in a similar manner on my visits by rewriting them into the VA system after reviewing what my private docs have ordered.  As mentioned earlier, I continue to use my private specialists.  I recently had my ENT recommend a room humidifier due to winter dryness.  I had him write a script which I faxed to my VA primary. A few weeks later, a humidifier arrived at my door from the VA vendor via surface mail.  If you don’t have an initial primary visit within 30 days of registering (assuming that you are Category One), you could contact the patient advocate office.  Some VA centers, I am told, will extend that to specialty care as well, but there does seem to be a considerable difference of opinion on the matter. [Nick Fuhs]

(5)  I have been following the responses to your question re: VA healthcare.  I have found them to be interesting and informative.  My experience may shed a second opinion on the issue for you to look into.  In Delaware we have a VA clinic just 20 miles from where I live.  When they opened, I went to see what the requirements were for getting care from them.  It boiled down to this.

1.  I would forfeit my freedom to choose where I would get health care.  It would be only available through them.

2.  They would receive my Medicare part A & B payments as a result of their billing procedure.  Thus any attempt to seek healthcare from any other source would be at my expense.

 3.  Any care required which they could not provide would be provided at the VA Hospital in Wilmington, DE.  No option.

4.  Lary supplies would be provided on a case by case basis, as long as funds are available.  (this caveat had a ring all too familiar after spending 26 years dealing with fund availability)

In my travels, I have inquired from many concerning VA healthcare just as you have done here on the list.  I have found raves that would exceed the best in the civilian world.  I have also received some horror stories.  My concern is what option does one have if he is caught up in the horror end of the story?  That being said, I have chosen to not seek healthcare from the VA even though it costs me.  I use Medicare supplemented with Tricare For Life.  Don’t confuse any other Tricare plans with Tricare For Life.  If you are not familiar with it you might choose to check it out.  It is free and takes no effort on my part other than to show up at the healthcare provider for service. [Max Hoyt]

(6)   I use the Biloxi, MS VA for ENT/SLP appointments, Laryngectomee supplies, some prescriptions that are mailed to the house, eyeglasses, dental and some medical conditions.  I also have the VA listed as the hospital of choice on my Medic Alert Information and personal data card. (100% SC) (100% CRSC). I also receive travel pay for each visit but I put all of it in a jar on my fireplace mantle to someday, help a laryngectomee less fortunate than me.

I use the Keesler AFB Medical Center, Biloxi, MS for some primary care, prescriptions, etc.  I prefer some of their medications over those of the VA medications. (Retired CWO4, USN) (Tricare).  Both facilities are within 40 miles of the house. I use a civilian Dermatologist and a civilian Rheumatologist because they are nearly next door to where I live. (Medicare and Tricare for Life).  Your medical options are numerous.

My Biopsy was at Keesler AFB and surgery was at MD Anderson, Houston, TX 6-24-03.  I still go to MD Anderson every 4 to 6 months for a follow-up and the cost is absorbed by Medicare/Tricare.  Also, Houston has one of the most modern VA Hospitals in the Nation.  I rarely spend any out of pocket money and do not pay any insurance premiums because my supplemental insurance company told me that renewal was not necessary after “Tricare for Life”.

By the way, I was disabled prior to having my laryngectomee but did not utilize the VA until joining Web Whispers which MD Anderson recommended.  I became to realize that the VA would provide all my Laryngectomee supplies and that cut down 95% of my reimbursement paperwork with Medicare and Tricare.  That was a great relief.

When I applied and you approved my membership, you contacted Roger Jordan because we both live in Diamondhead, MS.  Roger, my wife and I met one morning to attend our first weekly Nu-Voice Club of the MS Gulf Coast. That first meeting was enjoyable, informative and I miss meetings only when on vacation, sick, traveling or have a conflicting medical appointment.  I have also been awarded 100% SC for my Laryngectomy and because of Vietnam duty, Combat Related Special
Compensation.

I appreciate receiving help from everyone that offered advise, prodding and all kinds of assistance.  I was going to send this directly to you but so many others have helped that I want to share some of my good news and thoughts with them also. [Paul Moody]

(7) I am having a TEP done at Tripler Army / VA care facility in Hawaii , they are very competent and caring and said this is the way it is done and
I don’t doubt that . They said they have done many like this.
Richard

(8) One thing you can count is the V.A. treating you right because all the Vets I know love the treatments they receive from them and the speech pathologist are very good. Our groups pathologist was trained at the V.A in Minn. and she knows her stuff.
Lou Chi 09

(9) I have to add the Wade Park VA in Cleveland because of the most excellent treatment I have received there. All you Vets out there should feel very confident about the medical care you will get. And if perchance you end up at a facility that is less than A-One, check with us on the WW list and we can help you out. And I shall end with a mantra I have voiced before: all you taxpayers are getting your moneys worth from the Veterans Hospitals.|
John Shepley

(10) I would like to mention the VA in Atlanta, GA. I have
been getting my care there for 10yrs now. The services there are
great, without them there is no doubt, I would not be alive today.
Kudos to the VA Medical system.
Robert Pitts

(11) I have had reason to go to the VA in Dayton, OH, Boston, MA,
Charleston, SC and of course my primary SLP & ENT are in Columbia, SC. The service and care I have received has been first rate in every case. The reports I get from other Vets, larys and non larys, is the same.
Sapp Funderburk

Medicare

MEDICARE, WHAT IS IT?

Medicare is our country’s health insurance program for people age 65 or older. Certain people younger than age 65 can qualify for Medicare, including those who have disabilities and those who have permanent kidney failure or amyotrophic lateral sclerosis (Lou Gehrig’s disease). The program helps with the cost of health care, but it does not cover all medical expenses or the cost of most long-term care.

Medicare is financed by a portion of the payroll taxes paid by workers and their employers. It also is financed in part by monthly premiums deducted from Social Security checks.

The Centers for Medicare & Medicaid Services is the agency in charge of the Medicare program.  However you apply for Medicare from Social Security.  They can give you general information about the Medicare program.

There are several web sites that are very informative and deal with your health care benefits under Medicare.  They include excellent links with information used in this introduction to Medicare.
http://www.medicare.gov
http://www.cms.hhs.gov/home/medicare.asp

Overview:

Medicare has four parts

• Hospital insurance (Part A) that helps pay for inpatient care in a hospital or skilled nursing facility (following a hospital stay), some home health care and hospice care.
• Medical insurance (Part B) that helps pay for doctors’ services and many other medical services and supplies that are not covered by hospital insurance.
• Medicare Advantage (Part C) formerly known as Medicare + Choice plans are available in many areas. People with Medicare Parts A and B can choose to receive all of their health care services through one of these provider organizations under Part C.
• Prescription drug coverage (Part D) that helps pay for medications doctors prescribe for treatment.

Beneficiary Cost Sharing and Out of Pocket Spending:

Medicare has relatively high cost-sharing requirements and covers less than half (45%) of beneficiaries’ total costs. Medicare premiums and cost-sharing requirements are indexed to rise annually; the monthly Part B premium has nearly doubled between 2000 and 2006.

In 2006, the Parts A, B, and D (standard) deductibles are $952, $124, and $250, respectively.

Unlike most employer-sponsored plans, Medicare has no cap on out-of-pocket spending.

The Role of Private Plans in Medicare:

Private plans are playing a larger role in Medicare through a revitalization of the Medicare managed care program, now known as Medicare Advantage, as well as through the new Part D drug benefit.

Medicare Advantage. Medicare HMOs have been an option under Medicare since the 1970s, although the majority of beneficiaries have remained in the traditional fee-for-service program.. In 2006, virtually all beneficiaries have a choice of one or more Medicare Advantage plans, with enrollment now at 16% of the total Medicare population.

Medicare pays HMOs and other plans to provide all Medicare-covered benefits).

Medicare Prescription Drug Plans. Beneficiaries can obtain the new Medicare drug benefit through private stand-alone prescription drug plans (PDPs) and Medicare Advantage prescription drug plans (MA-PDs). Medicare pays plans to provide the standard drug benefit, or one that is actuarially equivalent.

Additional Sources of Coverage:

In addition to Medicare, most beneficiaries have some form of supplemental coverage.

Employer-sponsored plans:

Employers are a key source of supplemental coverage, assisting about 11 million retirees on Medicare. However, retiree health benefits are on the decline; only 33% of large firms offered retiree benefits in 2005, down from 66% in 1988). An additional 2.6 million Medicare beneficiaries are active workers (or spouses) for whom employer plans are the primary source of coverage.

Medigap and other coverage:

Many beneficiaries purchase private supplemental policies, known as Medigap. 3 million beneficiaries receive supplemental assistance through the Veterans Administration or some other government program, according to HHS.

Problems with prothesis reimbursement

In trying to update this problem, I put together some of the explanations and published this in our list 6/2/15… but this actually started in October 2010….

Medicare Changes….What does it all mean?
Meaghan Benjamin, Atos
(Taken from VoicePoints Whispers on the Web – Dec 2010)

This is an overview of what the most recent Medicare changes regarding L8509 include. It is being presented in a Q & A format based on the most common questions I have received from the field. I want to stress the importance of consulting the financial/billing people for your institution to determine all the nuances of billing. This overview is meant to answer general questions and help each clinician best determine how they need to proceed in order to meet the new guidelines. This change went into effect on Oct.1st 2010:

Why can’t any DME companies such as ATOS or Apria bill for the indwelling style prosthesis any longer?

Atos Medical is considered a Durable Medical Equipment company. Medicare has taken indwelling style prostheses away from the DME MAC which is the division of Medicare that DME companies are able to submit claims to for reimbursement. Indwelling style prostheses have been moved into A/B MAC which is the division that hospitals/facilities submit claims to for reimbursement. In order for a reimbursement to be processed, the facility must purchase and bill for the prosthesis.

What is DME? Durable Medical Equipment.

In order for something to be considered DME, it generally falls under the following guidelines: (1) Can be used again (2) Can be used in the home (3) Is not useful in the absence of illness or injury (4) Is either rented or purchased (5) Is single patient use

As a facility, we are not a licensed DME provider and are unable to bill for durable medical equipment. Does this mean we can’t bill for the indwelling style prosthesis?

No, you should be able to bill for the indwelling style prosthesis (L8509) as it is no longer considered a DME item and as such can only be billed by non DME facilities such as the hospital or doctor’s office. As a result, your facility can now bill for indwelling style prostheses and get reimbursed even if they are not a licensed DME provider.

If we are not a licensed DME provider, can we bill Medicare for other items such as HMES or Freehands valve?

No, you can not as HMES fall under DME and in order to bill Medicare for DME, you must have licensed DME provider status.

What about non-indwelling style prostheses (L8507). How are those billed?

Non Indwelling style prostheses (L8507) are still considered to be DME as they are patient changeable. As a result, in order to bill for reimbursement, these would fall under the same category as HMEs or Freehands valves and can only be billed to Medicare by a licensed DME provider. As a result, the DME companies can continue to submit claims on behalf of the patients for these items.

How does Medicare reimbursement work for DME items?

To give an example, Indwelling style prostheses all use the same HCPC code regardless of brand. Medicare has a fee schedule that is set based on Region and is referred to as the allowable rate. Medicare reimburses 80% of their allowable rate. If the allowable rate in your region is 115.00, Medicare will reimburse 92.00 for an indwelling prosthesis. The patient and/or secondary insurance is typically responsible for the rest. The way most facilities submit billing is to include the CPT (procedural code) as well as the HCPC code for the device used during the procedure.

How does it work with private Insurance?

Currently, DME providers can still submit claims on behalf of patients for all items including L8509 indwelling style voice prostheses.

If my facility is not a licensed DME provider, can I still bill the private insurances for all items related to laryngectomy care?

This is an excellent question for your billing people. Technically the answer is yes. Remember, the definition of DME is the same for both Medicare and Private so you can only bill each patient one time for each item used with that patient. All billable items must be new and single patient use. To determine your reimbursement, you should work directly with your financial/billing people to determine the contract you have with individual private insurance companies which will determine how your facility bills and is reimbursed from private insurance companies.

Our facility doesn’t stock indwelling style prostheses. Can a patient call one of the Vendors and purchase an indwelling style prosthesis directly?

Yes, as long as they have the appropriate prescription on file. If the patient is Medicare, the patient needs to agree that no claims will be filed for reimbursement (ABN form) and as a result, accept responsibility for payment. If the patient has private insurance, the vendor can file their claim as has been customary.

According to CMS, what HCPC codes regarding Postlaryngectomy care can be billed by a hospital/facility that are a non-licensed DME provider?

L8509 (indwelling style prostheses)

According to CMS, What HCPC codes regarding post laryngectomy care can ONLY be billed by a licensed DME provider?

A7501 Free Hands Starter Kit
A7502 Free Hands Membranes
A7503 Titanium Cap
A7507 HME Cassettes
A7508 Baseplates
A7520 Larytube
A7523 Shower Aid
A7524 Larybutton/Barton Button
A4456 Remove
A4364 Silicone Glue
A7526 Laryclip/tube holder
A4456 Provox cleaning towel
A9270 Free Hands cleaning and storage box
E1700 Therabite System
E1701 Therabite Bite pads
E1702 Therabite ROM scales
L8500 Electrolarynx
L8505 Trutone Hands Free
A5120 (AU) Skin Tac
L8507 Non Indwelling Style Prosthesis
L8510 Personal Amplifier (i.e boomvox, chattervox, sonivox etc)
L8511 plug
L8512 Gel caps (quantities of 10)
L8513 Brush
L8514 Dilator
L8515 Gel Cap Insertion System
L8499 Kapigel Spacer

Basically this means that all products and accessories associated with laryngectomy supplies (with the exception of L8509) can only be billed to medicare for reimbursement if your facility is a licensed DME provider.

In the WW Forum, we have a notice posted about InHealth and Edgepark:
Lary Products & Suppliers – Edgepark Carries Blom-Singer® Products.
From: Kevin Madden 11/5/12

InHealth has partnered with Edgepark to provide you with the best possible
care Good news! Now you can purchase your Blom-Singer® products through
Edgepark. Edgepark carries Blom-Singer® products, including
§ Voice prostheses and accessories
§ HMEs
§ Housings and supplies
§ Laryngectomy tubes
Edgepark offers the most extensive insurance coverage of any full-line,
mail-order medical supplier. Edgepark can work with you to find out if your insurance covers your supply needs. Call or visit Edgepark online
Web: www.edgepark.com
Phone: 1-800-321-0591
(There is an attachment, but we cannot send attachments to this list.)

In our Forum were letters from both ATOS and InHealth explaining what was happening at the time it happened.

In our list archives, a great letter from Carla DeLassus Gress, ScD, CCC-SLP explained to one of our members what her choices were and she lays it our very plainly. You should be able to bring this up in our archives… Password is sent to you EVERY weekend in Jeff’s report..

HIGHLIGHTS:
There are a few options: Switch to a patient-changeable device, if that is appropriate for you. Even if you can’t change the prosthesis yourself and need the clinician to do it, you can use a pt-changeable device as though it was an “indwelling-style” and have the clinician change it as they have been doing.

Another option is to find a clinician that stocks the clincian-changeable prosthesis that you like. If you are in a large metro area, you might have more success locating a facility which will provide the device to you and bill Medicare.

The last (as in last resort) option would be to pay out of pocket if the pt has the financial resources to do so. Personally I think this is a disgrace, since most of our Medicare pts have paid their dues and should be able to get reimbursed for a medical device that helps to restore speech for a medical problem, and not have to jump through 356 hoops to get it!

My personal note:

I am using the B-S change it yourself prosthesis. I order them 2 at a time, pay. They file with Medicare and the money is returned to me by Medicare and AARP -Plan F and I think covers all or most of it. I do not take them to an SLP to change. Mine is the old fashioned way but it works! I think the low pressure self-changing one still sell for about $70 each.

Pat Sanders
lary 1995

Advice from our Members

June 2011

This person, who asked for her Mom, is dealing with MediCare (HMO)with Secure Horizons as a primary. But She also has MediCal (Medicaid) as a second/backup (whatever that means). She is getting ready to have chemo and the drug is only 80% covered by Secure Horizons (MediCare).

The chemo provider should be told of her MediCal coverage on the
initial visit and should bill them as secondary after the HMO claim is
processed.

Secure Horizons Medicare Advantage health insurance plans are sold by
United Healthcare Insurance company . They offer, among other plans,
a Medicare advantage HMO. Medicare Advantage plans are private health
insurance plans that replace original Medicare for patients who choose
these plans. Mom has to be sure she follows the HMO rules on
referrals and stays in the HMO network of providers to get the most
benefit from her plan. She should have a benefit booklet which
explains all of this and a primary care doctor to oversee her care.
Secure Horizons offers more than one HMO plan so you need to
understand which one she is in . See her booklet and this website
https://www.medigap.com/secure-horizons-medicare-plans/

Her Secure Horizons insurance is her primary insurance. The primary
insurance will pay first and the rules of the primary insurance have
to be followed to get them to pay and usually to get any coverage from
the secondary insurance.
Secondary insurance pays after the primary and may pick up any
balances or cost shares remaining. It is important that each medical
provider ( doctor, hospital, clinic, etc) know that she has a
secondary and bills to the secondary after the primary has paid. You
want to avoid having to bill the secondary yourself as the
documentation needed can be difficult to manage. Secondary private
insurance would process a received medical claim to determine what
they would have paid had their insurance been primary, compare that
amount to the balance remaining on the provider’s bill and pay the
lesser of the two amounts . Medi-Cal should work much the same way.

MEDI-Cal is California’s Medicaid program and will function as her
secondary insurance. As a publicly funded program, the claim
processing rules may be a little different so you need to check with
them to understand the specifics. It is likely that the chemo billers
are very familiar with all of this. See for information on MEDI-Cal.

http://www.dhcs.ca.gov/services/medi-cal/Pages/default.aspx

Make sure that each medical office that she deals with understands
her insurance and has current copies of her insurance cards. Many
issues can be avoided if the medical bills are submitted correctly the
first time.
Nick Fuhs Class of 94
Former health insurance analyst

APPEALS

My suggestion is to appeal within the 30-day period. Make an appeal even if you don’t think you have solid grounds. If the MedAdvantage plan denies your appeal, you get a second chance to appeal before a “independent” Medicare-appointed arbitrator. Perhaps all you need to say is that the procedure was pre-approved and clearly the MedAdvantage plan had made a clerical error in giving the denial.

I am constantly getting claims denied. So far, I’ve been able to reverse the denial on appeal in 100% of the cases. Most of the time, the denial is overturned on the first appeal; but once Ihad to make a second appeal the Medicare-appointed arbitrator.

Be sure to send you appeal by certified mail, and get the signed receipt of the appeal. Without proof that you actually sent the appeal ina timely manner, you have no hope.
R Walloch

From the Kaiser Family Foundation, February 2007

Information specific to Coverage of Supplies:

There have been many questions about Medicare coverage of Durable Medical Equipment (DME).  It is important to understand that our coverage and co-pays are affected by the provider we deal with.  Understanding this will help us understand the differences in coverage.  It is not that Medicare is different from state to state, the status of our provider with Medicare is what may be different.   Reimbursement from Medicare is standard based on the following criteria: 

Please pay particular attention to the following if you are covered by Medicare. 

What is the difference between “participating” and “non-participating” suppliers of durable medical equipment (DME)?

There are three types of Durable Medical Equipment (DME) suppliers. The one you choose affects how much your costs will be.

• Suppliers who are enrolled and “participating” in Medicare must bill Medicare and accept assignment (the Medicare-approved amount) as payment in full. You can only be billed 20 percent of that amount (plus any unmet portion of your Part B deductible).
• Suppliers who are enrolled but “not participating” in Medicare are not required to accept assignment. They are allowed to charge you their standard rate and can ask for payment up front. Medicare will then reimburse you for 80 percent of its approved amount, and you pay the balance.
• Suppliers who are not enrolled in Medicare are not required to bill Medicare. You may have to submit the claim to Medicare yourself. These suppliers are allowed to charge you their standard rate and can ask for payment up front. Medicare may then reimburse you for 80 percent of its approved amount, and you pay the balance.

Note: You must go to an enrolled supplier to get coverage for medications, diabetes supplies and capped rental items.

Why is it better to find a durable medical equipment supplier who takes Medicare assignment?

Unlike doctors, if a DME supplier accepts Medicare but does not take Medicare’s assignment, it can charge you any amount over Medicare’s allowed amount. That means you will be responsible for the 20 percent coinsurance plus whatever else the supplier wants to charge.

Visit www.medicare.gov or call 1-800-MEDICARE for a list of DME suppliers who accept assignment.

Medigap

WHAT IS MEDIGAP?

Not too many people are familiar with Medigap insurance, although it would be helpful to them if they were. It can potentially be very helpful to individuals seeking coverage for health care needs.

Medigap is an insurance which covers the gaps in health care coverage not covered by Medicare. Although Medigap is a private coverage insurance program or offering, it is highly regulated by both federal and state government.  For this reason, it is affordable for many members of the population.

Since the cost of health care is so high these days, even if you’re only responsible for the deductibles, a major illness could have you facing big bills. When doctors or surgeons or other providers charge more than Medicare finds “reasonable,” you will have to pay the difference.

Medicare tells doctors (“assigns”) how much it will pay for any given service. Some doctors charge more than Medicare assigns. When a doctor does not “accept assignment” in this way, you the patient must pay the difference. Plans F, I and J pay 100% of this additional charge.( See chart below).  Prior to a visit, ask if your provider accepts “assignment”.  This may help you avoid unexpected health care costs.

Standardized Medigap Plans and Benefits

There are 12 Medigaps plans designed to help fill the gaps in Medicare coverage. The plans are standardized to offer the same benefits regardless of which company offers them. The only difference between companies is cost.

The most popular Medigap plans are C and F. Note: The numbers listed below are for 2007.

Your State Department of Insurance can give you a list of companies which sell Medigap plans in your state. You can also call your State Health Insurance Assistance Program or the National Medicare Hotline (1-800-MEDICARE) for free Medicare help. In addition, the Medicare.gov web site lets you compare Medigap plans in your area.  (on a personal note, I have had difficulty getting through to the Medicare Hotline.  I suggest your local State Insurance Office as the first call)). 

When should you buy Medigap insurance?

It is best to apply for Medigap insurance sometime in the first six months of receiving coverage by Medicare. During this first six months, insurers are required to sell you the policy you want, even if you are considered high risk, or have a preexisting condition. Medigap are guaranteed to be renewable, and cannot be canceled as long as you keep paying the premiums.

There are ten different standardized Medigap plans authorized by the federal government. However, individual states can decide which and how many are offered for sale to its residents. The basic coverage of Plan A is offered in every state, and every insurance company which sells Medigap must offer Plan A coverage.

Plan A covers payments you would be responsible for if you were hospitalized for over 60 days, and Medicare no longer covered you. Medigap also pays non-hospital care which Medicare Part B would not cover. Moreover,  Plan A would cover the first three pints of blood you would need, in or out of the hospital. Therefore, plan A is a basic coverage.

Plan J tends to be the most popular plan.  Plan J  pays the deductibles for all hospitalization expenses, the deductibles for non-hospital care, coinsurance charges for days 21 through 100 in a nursing home, all doctor’s fees over the approved amounts, at-home recovery care, prescription drugs, preventative medical care, and even foreign emergency medical care.,Plan J is the most costly of all of the plans, but it is also the most comprehensive of all of the plans.

Choosing among all the policies offered can be confusing, so study the various plans carefully. The Medigap insurer, MUST provide you with a comparison chart that explains clearly what each plan covers or does not cover. You can also call Social Security and ask them to send you their free booklet Guide to Health Insurance for People with Medicare. This is a very helpful booklet on the various alternatives available.  Consider calling your state’s Department of Aging to find out about various package plans offered in your state.  The United Seniors Health Cooperative at 1331 H. Street, NW, Suite 500, Washington, DC 20005, offers a free analysis of the various Medigap plans. It is wise to get in touch with them before making your decision.

Before you decide, do as much comparison shopping as possible, before you decide. The American Association of Retired Persons, or AARP, offers a plan, as do large groups such as Blue Cross/Blue Shield. Generally plans offered by large groups like these, are cheaper.

In the end, study the plans and choose wisely, making sure that your Medicare and Medigap policies together cover as many health crises as possible.. No matter which insurance company offers a particular plan, all plans with the same letter cover the same benefits.

Medigap Plans: Listing by Plan

Refer to the Medicare chart of coverage plan definitions.  

There are 12 standard Medicare supplemental (Medigap) insurance plans which help pay for some of your costs in the Original Medicare Plan and for some health care costs the Original Medicare Plan will not  cover.. (If you are in a Medicare Advantage Plan, such as a Medicare Health Maintenance Organization (HMO), you don’t need a Medigap policy.)

Each standard plan, labeled A through L, offers a different set of benefits, fills different “gaps” in Medicare coverage, and varies in price. Medigap plans K and L are new plans which became available in 2006. The basic benefits for Medigap plans K and L are different from the basic benefits offered in plans A through J. These plans are designed to have lower monthly premiums, but have higher out-of-pocket costs.

For instance, all Plan C policies have the same benefits no matter which company sells the plan. However, the premiums can vary.  Premiums are the agreed upon costs paid for medical coverage for a defined benefit period.  In other words, if you join a Medigap plan, you pay premiums every year at the time of your new enrollment period. 

If you are in a Medicare Advantage Plan, such as a Medicare Health Maintenance Organization (HMO), you don’t need a Medigap policy. If you live in Massachusetts, Minnesota or Wisconsin, you have different standard Medigap plans to buy. Check with your state insurance department.

Basic Benefits

All Medigap plans must cover certain basic benefits. These basic benefits are as follows:

Medicare Part A coverage:

• Coinsurance for hospital days 61-90 ($248 in 2007) and 91-150 ($496 in 2007)
• Cost of 365 more hospital days in your lifetime, once you’ve used all Medicare hospital benefits

Medicare Part B coverage:

• Generally, all coinsurance and co-payment amounts after your meet the $131 (in 2007) yearly deductible for Medicare Part B
• The first three pints of blood

Medigap Plan A

• Basic Benefits

Medigap Plan B

• Basic Benefits
• Medicare Part A Hospital Deductible: $992 in 2007 for each benefit period for hospital services

Medigap Plan C

• Basic Benefits
• Medicare Part A Hospital Deductible
• Skilled Nursing Home Costs:
  • Your cost ($124 in 2007) for days 21-100 in a skilled nursing home
• Medicare Part B Deductible:
  • Yearly deductible for doctor services ($131 in 2007)
• Foreign Travel Emergency
  • 80% of the cost of emergency care outside the U.S.
  • Up to $50,000 during your lifetime
  • You pay a yearly deductible of $250

Medigap Plan D

• Basic Benefits
• Medicare Part A Hospital Deductible
• Skilled Nursing Home Costs
• Foreign Travel Emergency
• At-Home Recovery
  • Help for activities of daily living, such as bathing and dressing, if you are already receiving skilled home care covered by Medicare.
  • Help for up to eight weeks after you no longer need skilled care
  • Will pay up to $40 per visit, seven visits per week, or a total of $1,600 per year

Medigap Plan E

• Basic Benefits
• Medicare Part A Hospital Deductible
• Skilled Nursing Home Costs
• Foreign Travel Emergency
• Preventive Care: Up to $120 per year for preventive services not covered by Medicare

Medigap Plan F*

• Basic Benefits
• Medicare Part A Hospital Deductible
• Skilled Nursing Home Costs
• Medicare Part B Deductible
• Medicare Part B Excess Charges:
  • Pays 100% of the difference between your doctor’s charge and the Medicare approved amount, if your doctor does not accept assignment
• Foreign Travel Emergency

Medigap Plan G

• Basic Benefits
• Medicare Part A Hospital Deductible
• Skilled Nursing Home Costs
• Medicare Part B Excess Charges:
  • Pays 80% of the difference between your doctor’s charge and the Medicare approved amount, if your doctor does not accept assignment
• Foreign Travel Emergency
• At-Home Recovery

Medigap Plan H

• Basic Benefits
• Medicare Part A Hospital Deductible
• Skilled Nursing Home Costs
• Foreign Travel Emergency

Medigap Plan I

• Basic Benefits
• Medicare Part A Hospital Deductible
• Skilled Nursing Home Costs
• Medicare Part B Excess Charges:
  • Pays 100% of the difference between your doctor’s charge and the Medicare approved amount, if your doctor does not accept assignment
• Foreign Travel Emergency
• At-Home Recovery

Medigap Plan J*

• Basic Benefits
• Medicare Part A Hospital Deductible
• Skilled Nursing Home Costs
• Medicare Part B Deductible
• Medicare Part B Excess Charges:
  • Pays 100% of the difference between your doctor’s charge and the Medicare approved amount, if your doctor does not accept assignment
• Foreign Travel Emergency
• At-Home Recovery
• Preventive Care

Medigap Plan K**

• Basic Benefits
  • 100% of Part A coinsurance plus coverage for 365 days after Medicare benefits end
  • 50% hospice cost-sharing
  • 50% of Medicare-eligible expenses for the first three pints of blood
  • 50% Part B coinsurance after you meet the yearly deductible for Medicare Part B, but 100% coinsurance for Part B preventive services
• 50% of Skilled Nursing Home Coinsurance
• 50% of Medicare Part A Hospital Deductible
• Annual out of pocket limit of $4,140 in 2007.

Medigap Plan L**

• Basic Benefits
  • 100% of Part A coinsurance plus coverage for 365 days after Medicare benefits end
  • 75% hospice cost-sharing
  • 75% of Medicare-eligible expenses for the first three pints of blood
• 75% Part B coinsurance after you meet the yearly deductible for Medicare Part B, but 100% coinsurance for Part B preventive services
• 75% of Skilled Nursing Home Coinsurance
• 75% of Medicare Part A Hospital Deductible
• Annual out of pocket limit of $2,070 in 2007.

*Plans F and J also have a “high deductible option.” If you choose the “high deductible option” on Medigap Plans F and J, you will first have to pay a $1,860 deductible in 2007 before the plan pays anything. This amount can go up every year. High deductible policies have lower premiums, but if you get sick, your costs will be higher.

IMPORTANT** The basic benefits for plans K and L include similar services as plans A-J, but the cost-sharing for the basic benefits is at different levels. The annual out-of-pocket limit increases each year for inflation.

Plans A-L are standardized by the federal government. Not all plans may be available in your area. Consider the benefits offered by each plan and look for one that best meets your individual needs.

Medicaid

What is Medicaid?

Per Wikipedia.com, Medicaid is defined as the following:

Medicaid in the United States is a social health care program for families and individuals with limited resources. The Health Insurance Association of America describes Medicaid as a “government insurance program for persons of all ages whose income and resources are insufficient to pay for health care”.[1] Medicaid is the largest source of funding for medical and health-related services for people with low income in the United States. It is a means-tested program that is jointly funded by the state and federal governments and managed by the states,[2] with each state currently having broad leeway to determine who is eligible for its implementation of the program. States are not required to participate in the program, although all have since 1982. Medicaid recipients must be U.S. citizens or legal permanent residents, and may include low-income adults, their children, and people with certain disabilities. Poverty alone does not necessarily qualify someone for Medicaid.
The Patient Protection and Affordable Care Act significantly expanded both eligibility for and federal funding of Medicaid. Under the law as written, all U.S. citizens and legal residents with income up to 133% of the poverty line, including adults without dependent children, would qualify for coverage in any state that participated in the Medicaid program. However, the United States Supreme Court ruled in National Federation of Independent Business v. Sebelius that states do not have to agree to this expansion in order to continue to receive previously established levels of Medicaid funding, and many states have chosen to continue with pre-ACA funding levels and eligibility standards.

What is the difference between Medicare and Medicaid?

Medicaid and Medicare are government-sponsored healthcare programs in the U.S. The programs differ in terms of how they are governed and funded, as well as in terms of who they cover. Medicare is an insurance program that primarily covers seniors ages 65 and older and disabled individuals who qualify for Social Security, while Medicaid is an assistance program that covers low- to no-income families and individuals. Some may be eligible for both Medicaid and Medicare, depending on their circumstances. Under the Affordable Care Act (a.k.a., “Obamacare”), 26 states and the District of Columbia have recently expanded Medicaid, thus enabling many more to enroll in the program.

This information is from Diffen.com and the following link will help explain the difference further:
http://www.diffen.com/difference/Medicaid_vs_Medicare

More than 7 million low-income beneficiaries are dually eligible for Medicare and Medicaid. Most qualify for full Medicaid benefits, including long-term care and dental, and get help with Medicare’s premiums and cost-sharing requirements. Some do not qualify for full Medicaid benefits, but get help with Medicare premiums and some cost-sharing requirements under the Medicare Savings Programs, administered under Medicaid.

Other Choices

In our Medicare section of Common Concerns, scroll down to:
PROBLEMS WITH PROTHESIS REIMBURSEMENT

“WHAT IF….?” Insurance Answers

Dorothy Lennox, Luminaud, Inc.

info@luminaud.com

[Part 1 of 3 from HeadLines, 2004]

What can I do if the supplier I want to get a product from will not bill my insurance company? Even though the insurance company sent them an authorization??

Background: Insurance company authorizations, unfortunately, usually have fine print that indicates they are not promises to pay. If the supplier provides the product and submits a claim, then the insurance company will consider paying IF all the factors are right. But it is very hard for a supplier, especially one who sells all around the country by mail order, to determine the coverage and current eligibility for all of its customers with insurance, especially considering that there are thousands of insurance companies, each with its own rules. Many of the suppliers serving laryngectomees have had great losses in unpaid bills and in phone, letter and fax time and in employee wages trying to collect from insurance companies. Some have regretfully decided that continuing to bill insurance companies would force them to either raise prices for everyone or go out of business.

So what can you do? Here are 3 possibilities:

1) You can pay for the product yourself and then try to get reimbursement from your insurance company. When you place your order, ask your supplier to include more than one copy of the “paid” invoice and also to include descriptive information on the product. Get a claim form from your insurance company, fill it out, and send it to the address the insurance company specifies, along with a copy of your invoice, a copy of information describing the product, and a physician’s explanation of your need for the product. If the product is covered by the insurance company, then you should get some amount of reimbursement. If the product is something you will be ordering regularly, get several copies of the claim form and make copies of the descriptive material, along with the physician’s statement so you can easily send them along each time you send a claim.

2) You can find out if your supplier and insurance company will work with proforma (as a matter of form) invoices – this is an invoice with all the particulars filled in except the serial number (if there is one) and the shipping date. The supplier sends the invoice to the insurance company, and if the company pays the bill, THEN the supplier sends the merchandise. Often the insurance company will accept the invoice by FAX. Sometimes this works out very well and very quickly. Sometimes it drags on and you have to contact both sides to make sure they’re doing their part but when it does work it can be very helpful, especially in the purchase of a more expensive item that you cannot afford to pay for up front.

If the proforma invoice option is acceptable to both the insurance company and the supplier, you or the insurance company would need to provide the supplier with the insurance company name, address, phone number, fax number, name of a specific contact person – and also with all of your own information – name, address, phone number, insurance policy and ID#, Social Security number, date of birth – any such information the insurance company would require to be put on the paperwork. Because of the extra time, phone calls and paperwork involved, your supplier may be willing to use this method for the sale of several hundred dollars in merchandise but perhaps not for $15 worth of stoma covers. The more information you have ready and the easier you make it for the supplier, the more likely they will be to be willing to do proforma invoices for you. (Note: Insurance companies often have dozens or hundreds of representative with dozens of fax machines. Make sure you get rep names and phone and fax numbers that will get you and your supplier to the right people or department each time – not just the general insurance company number.)

3) You can find a local medical equipment provider who works with your insurance company and see if they can and will act as a middleman, buying the product(s) you need from the supplier and billing them to the insurance company for you. Your insurance company should be able to give you a list of the local medical providers that they deal with. (The provider list may already be in the information your insurance company gives you when it renews your policy, along with the list of doctors that work with your insurance company.) Then ask your supplier if s/he is willing to sell the equipment you want to a local provider.

Of course, the local provider may say they don’t carry the product you want and don’t know anything about the product you want – but if you are prepared and show them the product description and give them the contact information for the supplier – and give the supplier the name and telephone number of the local provider – then you may be able to get the two companies together and make the needed arrangements. Do everything you can to make it as easy as possible for them by having descriptions, contact information, insurance information and doctor’s prescription or orders ready. The less phoning/faxing or paperwork that has to be done on either side, the more willing they may be to handle the transaction for you.

Insurance Answers [Part 2 of 3]

WHAT CAN I DO IF I got a product from a supplier and paid in full, but the supplier will not fill out a claim and send it to my insurance company to get reimbursement for me???

Background: This may seem like coldhearted behavior by a supplier, but please be aware that many of the suppliers in the laryngectomee field are small companies, selling nationwide, and that the profit margins in this special market are usually much lower than the general profit for medical markets. Since there are literally thousands of insurance companies around the country, many with their own unique forms, requirements and procedure, it is not surprising that suppliers often feel that it would be impossible, both financially and timewise, for them to obtain/figure out/fill out these forms. So what can you do?

You can make sure that you are prepared to fill out and submit your own claim forms to your insurance company with as little hassle and expense to yourself as possible. Get a supply of claim forms from your insurance company – enough to allow for throwing away mistakes and enough to have several for future needs. Study the forms and instructions so that you understand what information they require. Plan ahead. If you need a doctor’s statement, ask for it at a regular visit or check-up so you don’t have to make a special trip back.. If you are expecting to get repeat orders of a product, ask the doctor to write something indicating that you will need refills and stating how many and how often. Then get copies made so that you can send in a copy with each claim. When you order from your supplier, request enough copies of your paid invoice to use for insurance, taxes, your own records and anything else you might need copies for. (Depending on the supplier’s computer invoicing program, it is often fairly easy for a supplier to send you more copies of the invoice at the time your order is processed, but much more difficult and time consuming for them to have to generate copies at a future date, so you might have to wait longer or might be charged for the extra service. Therefore, it’s much better to ask for what you need at the time you order.) If the supplier cannot or will not give you as many copies as you want, then get copies of the originally invoice made locally. (Note: Aside from insurance – if you order supplies regularly from the same supplier and want records of all your purchase for a year for taxes, proof of expenses for subsidized housing requirements, etc. be sure to KEEP the copies of your invoices as they come in and file them carefully. If you ask your supplier for “copies of all the invoices I’ve had for the last year” because you had a fire or disaster of some sort, most companies will be happy to help you, but if you routinely throw them away or lose them and then repeated ask for copies at a later date, you cannot expect your supplier to very cheerful and prompt about the extra work or to do it at no charge.)

Also, when you order, ask your supplier for descriptive information on the product you’re submitting a claim for and include the description along with your invoice and the doctor’s statement. Again, if it is to be a repeated order, get several copies made so that you will have one to send with each claim.

WHAT CAN I DO IF my insurance company says that I must purchase from a “Preferred Provider” instead of from the company that sells a product I need? How do I find a Preferred Provider? What if they don’t carry the product.

Background: Some insurance companies have legal and financial agreements with specific providers. If you go to a provider who is not in the insurance company’s network or on their Preferred Provider list, then you may not get full insurance coverage – or may not get any coverage at all. So what can you do?

There is often a way around the Preferred Provider problem. Your insurance company will have a list of the companies they work with as providers. Check with some of those nearest to you, show them information on the product you want and provide them with contact information on the manufacturer and a couple of major suppliers. The provider may be able to buy the product and then bill your insurance company. Some manufacturers or suppliers may offer a small discount to the local Preferred Provider to help things along – and the Preferred Provider is often allowed by the insurance company to add a mark-up of a reasonable percentage – so it sometimes works out quite well all around. (The insurance company often ends up paying more this way, but they are apparently often willing to do that to have the whole process taken care of through the proper channels and procedures.)

(Note: Sometimes insurance companies or health plans have agreements with Preferred Providers that require the Preferred Provide to furnish any covered product for which the insured person had a prescription or doctor’s order. Even if it means a loss for the provider, the provider must handle the sale in order to maintain its “preferred” status. An occasional loss of that sort may be worth it to the provider in order to keep its preferred status for the many routine items like diabetic supplies, incontinence supplies, etc. that are quite profitable.)

Insurance Answers [Part 3 of 3]

WHAT CAN I DO IF my insurance company says the product I want is not covered and turns down my claim?

The best thing to do is to try to anticipate and prevent the rejection in the first place by providing very obvious and detailed information with your claim showing that the products are logically covered just as any prosthetic device would be.

Insurance policies may be vague about more unusual items like artificial larynges and not mention them by name, but your policy should tell you if it covers prosthetic devices such as artificial limbs. Electronic artificial larynges and TEP prostheses are true prosthetic devices – replacements for a part of the body that has been lost or that is no longer functioning. If your insurance would cover an artificial leg for you so that you would not have to go around in a wheelchair for the rest of your life if you lost your own leg, then it should not deny coverage for an artificial larynx or TEP voice prostheses for you so you can speak again and are not left with writing or gesturing to communicate for the rest of your life.

Tracheostoma covers, from the little foam patches to the HMEs (Heat/Moisture Exchangers), are really artificial noses.

Voice amplifiers enhance the function of the voice production mechanism. They may be harder to get coverage for, but Medicare is covering them now and insurance companies often follow their lead – though Medicare, apparently not understanding voice amplifiers fully, indicated that they are only for people with their larynges in tact, so coverage for them is much more iffy for laryngectomees – but worth a try!

A good number of insurance company denials for laryngectomee products are no doubt because the claim does not include sufficient information about the product and the need. Examiners see dozens of claims a day for diabetes, heart problems, etc. But any given examiner may see a claim for laryngectomee products only very occasionally, so the need and the product have to be explained very well. You want the examiner to read it and think, “Yes, that’s obviously a prosthetic or medically necessary device and it makes sense that our insurance company would cover that.” Otherwise, he/she may turn it down to save the time and hassle of looking into it further. Examiners probably get some sort of efficiency rating on how many claims are handled a day and if they have to spend a lot of time looking up information to figure out the products, they may not bother – may just deny it and figure it is another claim that has been processed that they won’t have to think about anymore.

So the important thing in getting coverage is making sure that the insurance company examiners understand that the products you are order are prosthetic devices and/ or fill a valid medical function. When you or the doctor or someone helping you is writing or speaking about it, artificial larynx should not be referred to as a “speaker” or a “talk box” or an “amplifier.” Always refer to is as a “prosthesis” or “prosthetic device” or an “electronic artificial larynx.” he same applies to TEP prostheses. It is common and quicker to just write or say TEP, but it should always be “TEP Prosthesis”. Stoma coverings should be referred to as stoma filters or and explained as devices that act as artificial noses in warming, moisturizing and filtering incoming air. On stoma covers/filters/HMEs, hopefully the doctor can give a standing order for the product(s) to be supplied every so often and then you can just send in a copy of that doctor’s order each time you send a claim. Voice amplifiers should always be called “voice amplifiers” and not just amplifiers – and the medical need to assist the voice production mechanism should always be emphasized rather than the social or emotional wish to be able to carry on a conversation easily.

Doctors are busy and don’t like to write much, but if you, the doctor, the speech pathologist, the respiratory therapist – someone – can supply some reasonable DETAIL about the product and the need, you have a lot better chance of coverage, both initially and then if you do have to appeal. Again, descriptive sheets from suppliers can be a big help.

OK – So what can you do if you the insurance company turns you down?

APPEAL!!! Any denials on products for laryngectomees should definitely be appealed unless the insurance company can show you in writing that such things are specifically excluded from coverage. The insurance company’s own paperwork should tell how to appeal. Look everything over. Figure out what can be improved. Get a better write up from your doctor and/or additional information from your speech pathologist or respiratory therapist. Get more extensive descriptive material from your supplier. Put it all together and APPEAL – make the insurance company ‘s people take the time to really think about it. Someone’s study showed that if you go to the 2nd or 3rd round of appeal you’re much more likely to be successful, so don’t give up after just one try. Help teach the people who make the decisions about the products you need. The more the examiners from insurance companies, Medicare, Medicaid learn about laryngectomee products, the easier it will be for all laryngectomees to get coverage more routinely without as much hassle.

Dorothy Lennox,

info@luminaud.com

Luminaud, Inc.