Old 09-09-2015, 05:56 PM #1 (permalink)
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Default Those with Private Ins and Medicare

For those of you who have private insurance as primary and Medicare as secondary, make sure to read your benefits book closely. I have BCBS through my wife's work and just found out today that they will not cover a speech generating device. Buried on page 123 of a 427 page document, it states that although they cover some DME, they will not cover speech generating devices. Oh well.....

Also, in my state of WV, I cannot get a Medicare Supplement (Medigap) as they are only available to those 65 or over. Not available for those on disability.

Vince
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Old 09-10-2015, 03:35 PM #2 (permalink)
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Default Re: Those with Private Ins and Medicare

Wow Vince, that is just messed up. Sorry to hear you're subject to such nonsense.
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Old 09-10-2015, 08:25 PM #3 (permalink)
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Default Re: Those with Private Ins and Medicare

Have you talked to ALS Assn. to see if they will get it for you?
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Old 09-10-2015, 08:56 PM #4 (permalink)
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Default Re: Those with Private Ins and Medicare

Not so fast, Vince. Which Blues do you have? What is the date of your plan certificate?

Some of the Blues, including Anthem, the big kahuna, cover them and that gives you an evidence base. Search sgd BCBS, d/l the policies for coverage, talk to your case mgr, appeal up if/when you need an SGD (is this a now or future need?). Blues travel in packs for stuff like this so I would not presume anything but that your Blue is out of date. Also, you may be able to get MC to pay as secondary as a last resort if you submit it and the BCBS actually denies it, but it may not come to that.
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Old 09-10-2015, 10:35 PM #5 (permalink)
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Default Re: Those with Private Ins and Medicare

Laurie,
We have Anthem. The denial specifically stated that our contract did not allow sgd's. I pulled out our Plan Document and sure enough it excludes sgd's.
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Old 09-11-2015, 12:41 AM #6 (permalink)
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Default Re: Those with Private Ins and Medicare

Ah, so at contract level you can appeal pointing to the national policy. In other words, your contract isn't following national policy so it's an inferior contract, which is not illegal and yes, a named exclusion but ALS is an exceptional disease. It's worth a shot. What other DME is excluded by name?

If the employer on the contract is large, meaning any leverage, get them involved. Of course, if it's a self-funded plan, it's their contract, so you pretty much have to and so would make your case to the HR person who oversees the contract. If it's an individual policy, I'd go the case management/force a rejection of the order/appeal process depending on what you're comfortable with.

Either way, start with a letter from the doc stating how you meet all the national Anthem policy criteria that are listed and go from there.

I would also check into the Medicare as secondary payor angle. Is this traditional Medicare we are talking, or a private plan?

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Old 09-11-2015, 10:21 AM #7 (permalink)
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Default Re: Those with Private Ins and Medicare

Why can't these damn insurance agencies realise that this is people's lives they are messing with, not just a number on a computer screen!
Vince, I really hope you manage to get it sorted and get a speech Device.
God bless, Janelle x
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Old 09-11-2015, 10:25 AM #8 (permalink)
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Default Re: Those with Private Ins and Medicare

Thanks. I'm o.k. for now with my iPad and Verbally Plus. It would be nice to have the "real" one as I could connect it to my computer, telephone and even TV. I can't talk on the phone anymore and it is just too cumbersome to try to put the phone on speaker and then type from my iPad.

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Old 09-11-2015, 03:12 PM #9 (permalink)
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Default Re: Those with Private Ins and Medicare

Vince, I use the iPad too. I have verbally Plus, but I like AAC Flip Writer better. Have you tried it? There is a free one you can get to try first. Lock your screen so it won't turn on you. I love it!
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Old 09-11-2015, 09:23 PM #10 (permalink)
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Default Re: Those with Private Ins and Medicare

ks goes through about a lot of that here. state's do haves a lot to do with this. all we do is hope that love ones can donate. like max puts out there.
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Old 09-12-2015, 11:47 PM #11 (permalink)
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Default Re: Those with Private Ins and Medicare

Vince,
If you can still type on the iPad, what about Skype on the iPad if you want to see each other, and use the chat function at the same time, or any chat program if you don't want the video?

That way, you wouldn't need to worry about a phone at all.

Also, as far as the TV, if your TV or attached device uses Airplay, you can use your iPad to control what you see on your TV screen -- apart from Netflix, Amazon Video and all that, most of the networks have apps now. Depending on the networks you watch and your needs, you could add a SlingTV sub for networks like ESPN, while cutting the cable cord.

And, of course, you can also port the iPad screen to your computer or vice versa.
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