Anyone get Blue Shield to pay for an AAC device?

[kenfused]

Our son turned 3 yesterday, and so he had his IEP yesterday as well.
We had funding thru the Regional Center in CA for his speech/OT/early
intervention therapy. Towards the end of our regional center funding
we had an Augmentative Communication eval, and the SLP recommended the
Vantage Lite AAC device.

We have submitted paperwork and a medical prescription to get this
covered thru Blue Shield of California and are crossing our fingers
that they will fund the device.

THe school district says it is the Regional Center's responsibility to
pay for the device if insurance does not pay, since they were the ones
that initiated the evaluation. However, the Regional Center states
that since he is 3 yrs old he does not qualify for services thru them,
and they will not pay.

Per the district, IF the device is needed (after we start pre-school),
they will obtain the device and then take Legal action against the
Regional Center (another government agency) to pay for it.
I hope it does not come to that,

Has anyone gotten Blue Shield of CA to pay for a device?

[Mcda...@aol.com]

            Hi, 

 

 In our case our primary ins. (which was not BCBS) denied our son's AAC device but his secondary ins. did.  We applied for the state ins. because of his disability.

 

I would think if the school agreed to the AAC today for his IEP then they should be funding it. 

 

 I don't live in CA and are not up on their laws on who should pay and not pay.  But I would think if your child needs the AAC to access the general currl. then I would think it falls on the SD to provide it regardless who said he should have one.

 

What do others think?  Anyone from CA?

 

Mary-Clare

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[Tina Moreno]

Hi. I'm not from CA (OH), but we had a device funded through Aetna.
We're in the mindst of an appeal with United Healthcare for a new
device.

It is always advisable, I think, for families to obtain the device
through medical insurance. Then it belongs to you and cannot be taken
from you for any reason. I pray that you are able to get the device
through Blue Shield or the Regional Center (if you then have ownership
of it).

If the SD determines that your sons needs a device, however, then they
must provide it. The problem is, however, that then the SD can
determine which device is most appropriate and, frankly, economical.
Your son may not end up with the device that is optimum for him. It
may not be the device you'd select for him. Further, you may
anticipate conflicts over whether the device must stay at school in
the evening, on the weekends and over the summer. Some school
districts do not allow students to take their devices home.

Keep fighting Blue Shield. If coverage is denied, file an appeal.
Look over your summary plan description. Is there an exclusion for
AAC devices? Is there coverage for durable medical equipment?

[Mcda...@aol.com]

        Hi Seeing your reply gave me a thought.  I think United Healthcare actually has a grant for up to 5,000 dollars.  I don't know if it is just for therapy but if it could be used for funding a device.  Check it out or does anyone here know more about it?  M-C

[Terri Hart-Ellis]

Blue Cross/Blue Shield, now called Anthem here (WI), covered our daughter's Dynavox, a keyguard, the padded carrying case and an extra external battery.  The AAC clinic told me during our eval  that neither private insurance nor medicaid ever pay for an extra battery, but I insisted that we try and gave them the wording for the report.

 

While we were waiting for approval, I got a letter directly from Anthem stating they would cover all recommendations - the clinic was not informed of this.  I called Anthem to verify.  Then the clinic informed me that private insurance will not actually move forward until medicaid declares what they'd cover and that if medicaid said they would not cover accessories, then private insurance never does.

 

However, within one week, the clinic heard back from medicaid stating that they would have covered the device, but nothing else. 

 

Anthem still covered all recommendations.  Medicaid covered the co-pay.

 

I cannot tell you why, I really don't know.  It is not what I expected based on talking to other families.  But this was recently, so I am hoping that it's a reflection of a new understanding of the medical necessity of the right device with the right accessories.

 

I hope that your claim with BC/BS works out the same way. I agree that having insurance cover the device is preferable to having to use what the school district is willing to provide - we had a bad experience with our district thinking that a huge laptop with removable touch screen and Boardmaker/SDP was appropriate for our then 4 year old.  

 

Best of luck,

Terri in WI
 

[kenfused]

Thanks everyone!
I'm going to look thru our policy details to see what it states on DME
and if there are any exclusions for AAC devices.
I'll keep you all posted on how it goes!
THANK YOU

[Tina Moreno]

Below is an email we received from our Dynavox representative for
alternative funding when we learned UHC denied our first claim. With
the help of an attorney, we're going to exhaust the appeal process
with UHC first.

One option is NOCK. Their website is www.nockonline.org. NOCK is a
non profit organization that operates primarily on donations. As
money is available, then requests are approved. This can be a lengthy
process depending upon funding that is currently available.

Another option to explore is the grant that United Health Care
offers. The website for the United Health Care Grant is www.uhccf.org
.

Perhaps you could check out another alternative funding source called
First Hand Foundation. The link for the First Hand Foundation is
http://www.cerner.com/firsthand/FirstHand_1a.aspx?id=28726.

[Mcda...@aol.com]

        Yes this is what I was talking about.  Thanks so much for posting it.  M-C

[Robin Hurd]

I put a call in to the funding department at PRC (the company that makes the vantage lite) to see what they knew about funding in CA.  Don't be afraid to call them yourself and make sure that they have everything they need on the funding request. They can look it up if you give them your child's name.   In the past, CA has been a tough place to get funding, since the government has been in such a financial pinch.  But I don't know how private insurance is, or what things are like lately.   If I hear anything back, I'll pass it along.  things vary so much from state to state(and even with how well the SLP wrote the eval.) that it's hard to know.  Has your evaluator gotten devices funded from private insurance?   In Pa 7 years ago, my kids devices were funded by blue shield.  We are getting ready to get new devices now, so I'll let everyone know how the funding goes once we get that far.   The last time around, I called blue shield every 2 weeks asking if they had everything they needed and when we would get an answer.  One of the people I talked to on one of these calls said that all the calls would help my case.   So, once you know everything has been turned in, dont' be afraid to call and ask how soon your child will get their voice!  sounding a bit desperate seems to be a good thing.  :)   Good luck to you and let us know what you find out!   Robin --- On Sun, 10/19/08, kenfused <kenl...@gmail.com> wrote:

From: kenfused <kenl...@gmail.com> Subject: Anyone get Blue Shield to pay for an AAC device?

[jae5bd]

Children who have medical needs are sometimes not insured
comprehensively to provide coverage for all of their medical
treatments.

The United Healthcare Children's Foundation (UHCCF) provides grants to
families to help pay for child health care services such as speech
therapy, physical therapy, occupational therapy sessions,
prescriptions, and medical equipment such as wheelchairs, orthotics,
and eyeglasses. Parents and legal guardians may apply for grants of up
to $5,000 each for child medical services and equipment by completing
an online application at the UHCCF Web site. If a grant is approved
for the child, the grant will help pay for approved medical services/
items after the child’s commercial health benefit plan submits payment
for services provided, if any. The grant funds are not paid to the
parent or child directly – invoices/bills are submitted to UHCCF for
approved medical services/items after the commercial health benefit
plan submits initial payment (if any) to the health care provider.

In January 2006, the United Healthcare Children's Foundation was
expanded to all 50 states; hence, funds are available nationwide. To
be eligible for a grant, children must be 16 years of age or younger.

www.uhccf.org

[Robin Hurd]

I just heard back from the company funding people.  I am assuming that you also have mediCAL as a back-up.  Sha said that they get funding from both blue shield and medi-CAL.  Sometimes blue shield will not do a prior auth (meaning that they won't tell you if they cover it until you actually purchase the device).      In the past, CA medical assistance money was frozen, but in the last month or so it has been opened up since the governor signed a new budget.   So she felt that your chances of being funded were pretty good.   Robin ---

[kenfused]

Well, I did not get the official "no" yet, but someone on my health
insurance website (our Blue Shield benefits go thru a company called
UMR) and they say AAC devices are specifically excluded in the general
provisions of our policy. So I guess we're in trouble.

We do not have medi-cal insurance.

I think now we'll have to jump thru hoops thru our school district,
and have to deal with their district/county specialist and wait for
them to recommend some other lower cost device

Argh

[Mcda...@aol.com]

            Hi, 

 

 Here are some other options for you.  What about your local Lions club or the Rotary club.  If you already have recommendations on what device and you can get some funding thru another source you could think about cost sharing the device.  Chin up and take a deep breath.  Think outside of the box besides just insurance.  I would also appeal any decision that is a No.  Ask who makes that decision and what are their credentials.  Hang in there I am sure others will have some ideas. 

 

M-C

---

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[kenfused]

THanks
Definitely going to appeal (if I can)
I am waiting to get a print copy of the policy (which I have never
seen).

I'm not sure you can appeal something if it is specifically singled
out as an exclusion, rather than somebody making a decision about the
denial.

[Robin Hurd]

remember that you, as the parent, hold the power with the district. You do NOT have to settle for a less expensive device, or even agree to having a re-eval. based on the fact that this device-recommended by a qualified evaluator-is more money than the school district may want to pay. If you agree with the evaluator that the recommended device is the one for your child, then don't give up on it too soon! Also, hold firm with your insurance company until you know.  Call them and bug them about the fact that your child needs this device. "after all, he can't even tell me when he's feeling sick or if something hurts without it."  Medical necesity to the insurance company is based on things like communciating pain or illness or relaying emergency info in an accident.  Imagine if something happened on the way home from school, for instance.   Without a device, he couldn't tell what happened, where he lived or anything to help them contact you if the driver were unconscious.  ---not to scare you, but things like this can help the people at the insurance company understand that we just arent asking for a device for the fun of it! sometimes, "squeaky wheels" get exceptions.  Don't give up! Robin

--- On Tue, 10/28/08, kenfused <kenl...@gmail.com> wrote:

From: kenfused <kenl...@gmail.com> Subject: Re: Anyone get Blue Shield to pay for an AAC device? To: "AAC Parents" <AACPa...@googlegroups.com>

[Colleen...@aol.com]

Hey -

I've been following this thread and haven't responded yet, but I should say that BCBS and other insurances have almost always denied us the first time around, even for emergency room services.  I have found that a kind voice on the phone to their member number sometimes results in "hints" that get the job done.  I was in another city in an emergency situation and the woman at BCBS told me that the doctor's office that I went to had coded my visit as an office visit, instead of emergency, which resulted in it being out of area service.  Sometimes, they give you all the info you need to get it done.  I am totally rooting for you and I hope this has been helpful.  The school district bought India's Vanguard.  I feel really lucky, because they recognized that it was best after the evaluation recommended it.  They didn't give us any problems after that for actually acquiring the device.  BUT, insurance denied the knee stabilizers on India's stander.  It was surreal, because, if the girl could stabilize her knees, we probably wouldn't need a stander.  Her pediatrician came to the rescue that time and threatened to report them with some kind of harassment.  I think he's going to get an extra soft pillow in heaven for his help.  :)  Best of luck to you.  Sometimes, this stuff is like pushing a truck up a very steep hill.  It sucks, but just keep moving.

 

Colleen

[amelia hong]

Hi,

I can tell how overwhelmed you are 'cuz we are in the same situation as you are. United HealthCare denied our request for the Vantage Lite for my daughter, claiming that it is a "benefit exclusion". I had a discussion with the UHC account rep for our company and was told that an appeal would likely be denied again because it was not a covered benefit to begin with.

But I asked that you not to give up yet. I went back to my policy, read over the language and I could not find the language that they used to deny my request. I spoke with an attorney and he told me that sometimes insurance companies just pulled languages from other company policies and applied to your case. Some will give up after receiving the denial letters and got alternative resources.

We are still awaiting for the reply from UHC at this point. It may end up that my policy really does not cover for the device, or we may be lucky to receive an overturn decision. But I know I had tried to search for the real answer.

In the meantime, like other listmates said, consult with the school district and see what they can do. We are fortuante that the school is supportive for the purchase and we will see how it goes.

Good luck to you and keep us posted.

Amelia

--- On Wed, 10/29/08, kenfused <kenl...@gmail.com> wrote:

> From: kenfused <kenl...@gmail.com>
> Subject: Re: Anyone get Blue Shield to pay for an AAC device?
> To: "AAC Parents" <AACPa...@googlegroups.com>

[Tina Moreno]

We are in the midst of our tier two appeal with United Healthcare with
the help of an attorney. We also have a specific exclusion in our
policy for AAC. Would you believe that AAC devices are referred to as
luxury and convenience items, along with TVs, VCRs and beauty parlor/
barber visits in our summary plan description?!?!?!

My husbands employer requires that you exhaust the appeal process with
the insurance company before involving them in the appeal. Our
attorney has had considerable success persuading employers to direct
insurance companies to fund a device when the matter is brought to
their attention. The fact is that employers have no clue what an AAC
device is, nor did they authorize the exclusion. They simply
purchased a plan, which was recommended by the insurance company.
Including coverage for an AAC device costs a moderate to large
employer literally pennies, yet it's excluded. We've copied my
husband's employer on all of our appeal documents. We are praying
that they will do the right thing for our son and authorize United
Healthcare to fund this device as durable medical equipment, which is
what it is because having a voice is NOT a luxury, as our plan
suggests!

Don't give up!

[Gayle Rich]

Yes, Sarah's device is almost 6 years old, but Independence BCBS in Philadelphia paid for it then. Prior to that device, none of the insurance companies were paying and we went through PA assistive device loaner program and then through a grant from them.

I also think it is important who is writing the letters/prescription for the devices. Sarah attended HMS School for Children with Cerebral Palsy in Philadelphia and their speech therapists had the letter of medical necessity down to a science. I should mention that we never had a denial for any other medical services or durable equipment either.

Do Not give up.

Gayle

[Robin Hurd]

Gayle,    how right you are!  the strength of the letter of medical necessity can vary greatly depending on who writes it!   Tina,   Thanks also for the tip about going to the employer who offers the coverage and having them contact the company to fund the item that is normally excluded.    Robin --- On Thu, 10/30/08, Gayle Rich <gayle...@carpedrm.com> wrote:

[Valerie Maples]

Running late, but I think another classification that has been successful is to call it a voice prosthesis.  Often they will not know they are the same thing, and they would never deny a person a leg or arm, so voice is also considered "essential" instead of educational.

Valerie

[Mcda...@aol.com]

            Valerie,  Great point.  M-C

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