How to get an HMO to pay for elec. w/c

[Judith]

Has anyone had the experience of getting their Medicare Advantage Plan (HMO) medical insurance to pay for an electric wheelchair?
I had to switch insurance this year to a HMO. I will probably need a w/c in the near future. I asked my primary doc about an electric one. She said a PT would come to my house and evaluate me and since my arms are still working, the insurance would probably deny an electric one. I asked for a referral to a PT who specializes in PLS/ALS. She could only set me up with an "in network" PT and said that that PT would have to refer me to one that specializes in the disease, if he couldn't treat. Well, I went to the PT yesterday and spent about 45 min. pulling teeth, to get him to refer me to an
"out of network" PT in Loma Linda who understands the disease.
If the referral is authorized by my insurance co. to go to the "out of network" PT in Loma Linda, and that PT suggests an electric w/c for me, will my HMO pay for it even though the PT is "out of network"?
HMO's are such a joke. I hate to be spinning my wheels for nothing.
Would like to know if anyone has had an experience with HMO's.

Judith

 

[Connie]

Hi Judith

I have been told by my physician for a large HMO that they will provide one wheelchair for an ALS/PLS patient. She recommended that when my husband needs a wheelchair, buy it ourselves and then let the HMO (K.....) pay for the more expensive, electric one.

I was very thankful for her good, honest advice.

Take care!

Connie

 

[Judith]

Connie,

Did your doctor state your husband could get an electric w/c if his arms were still working?
My primary doctor led me to believe they would only pay for a manual one, if my arms were still able to push, and if they come out once and deny you, then it's very hard to get them to approve the next time they come out.
The thing is, we need to have someone evaluate us who thourougly understands the disease. And as you've probably found out primary's and PT's don't know anything unless the PT specializes in the disease.
If your insurance will pay for an Electric w/c while your husband's arms are still working, please let me know!

judith

 

[Connie]

Hi Judith,

Our HMO will only provide an electric wheelchair if Gordie can no longer use his arms.

Connie

 

[Judith]

I have good news since I posted my question asking if anyone had the experience of getting their Medicare Advantage Plan (HMO) medical insurance to pay for an electric wheelchair?
I went to my HMO's "in network" neuro and he said he would refer me for an electric w/c. The person from my Medicare HMO came out. He had never heard of PLS or ALS. He said they would approve a basic electric w/c. I told him the basic w/c would not be acceptable for a progressive disease.
I proceeded to tell him that in the future, my arms, hands and legs would not work at all, and even though my arms work now, the strain of using a manual w/c would increase the weakness in the muscles at a faster pace. I told him that I can only use the muscles for stretching and range of motion exercises.
He got in touch with his supervisor and they in turn got in touch with a rehab. specialist in L.A. and they all came to my home to evaluate me.
I had printed out a document from ALSA that listed all the functions on a w/c that ALS patients will need whether now, or in the future. I gave them each copies of it and went through each function one by one. I told them why I need them, or will need them in the future.
They authorized the Quantum 600 w/c for me. I got the w/c with all the functions that I need now and will need in the future. The w/c has a joy stick for me to use and also one in the back of the chair, for the attendant to use when I no longer can use my hands. The seat electronically elevates, as do the footpegs, and it will tilt backwards. It will fully recline, so when the time comes that I cannot get into bed by myself, my husband can elevate the chair and recline it and just roll me onto the bed. I asked for a Roho cushion and I got it.
This has been a real blessing from the Lord. I really didn't expect a Medicare HMO Plan to provide this expensive w/c.
The supervisor of my medical plan told me I was their first patient with this disease. He was appreciative to be informed and asked if he could keep the copy of the document that I printed out.
When I first began on this quest, My friend Sharonca, helped me a great deal and insisted that I be assertive and stick to my guns on what I needed. I did that, and I am so grateful for her advice.

Connie,
Did your neuro, who specializes in PLS/ALS, refer Gordie for an electric w/c? If so, then he/she knows that even though your husband's arms still work, wheeling himself would be too much strain on those muscles. You should do your homework, come prepared and have an answer as to why Gordie needs a functional w/c that will meet his needs as the disease progresses. Believe me, most everyone in the health industry that I have been in contact with, knows little to nothing about PLS/ALS.
As we have all heard, You have to be your own advocate.
Keep trying and don't give up!

judith

 

[Connie]

Hi Judith,

I am so happy that you were so well prepared and did your homework and got a w/c that will meet your needs now and in the future. I will follow your lead and make sure I do the same when the time comes. Fortunately, Gordie doesn't need any w/c yet and he has just recently started walking with a cane due to decreased balance and rigidity in his legs.

I really had a wonderful experience meeting our new PCP with our HMO after our former PCP left the HMO. I randomly chosea female doctor, partially because I felt I may better be able to relate to a woman and I was having a really difficult time emotionally, being on the verge of tears so much of the time because of the reality of my life with Gordie with a terrifying (at the time) disease that really changed our life and our future plans.

So, I waited until the last minute when I needed to see her for an initial visit so she could re-order my routine medications like blood pressure meds. I had been sick with a flu and home sick from work when I went to see her.

Sitting in the examination room, I dreaded seeing yet another doctor. Who needs a PCP after all the neurologists we had seen over the past almost two years? Not me. I didn't have time to waste and life was tough.

Instead, in came an incredibly wonderful woman who understood me when she asked how I was doing and I broke down in tears. I told her about Gordie's illness and she immediately understood and explained that her father had died a year ago from ALS and multiple family members had also died from the wicked disease. I have never felt so relieved. I really wasn't just a nutcase. She validated my feelings and my reality and offered hope.

I really do believe that God watches out for us and there are angels among us and one of them is Dr. Walter. She and her family are very active in ALSA and raise significant money for ALS awareness and research. She truly is an angel and even offered her Mother as a support( after getting her mother's approval) in the event that I might want to talk with her or email her. I always know I have someone to turn to.

I thank God for each and every one of you for your insights and the support I feel from each of you.

Thank you from the bottom of my heart,

Connie

 

[Judith]

Praise the Lord, Connie,
I am so happy for you that you found a good PCP who truly understands ALS.
My PCP and Neuro are women. While my PCP doesn't know much about PLS/ALS, she is very personable and takes time with me. My neuro is great. I can't speak due to the disease, so I email her whenever I have a question, or something on my mind and she replies right back. She is wonderful and so compasionate.
God is good. Keep the faith. Jesus knows right when to step in!

Judith