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soonerwife

Very helpful member
Joined
Mar 16, 2016
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1,571
Reason
Lost a loved one
Diagnosis
10/2015
Country
US
State
OK
City
Cleveland
We have United Healthcare Insurance.

January 2nd, I am planning to order whatever medical equipment my PALS needs.

What will insurance not cover?

I am looking at power wheelchair, eye gaze communication, cough assist, shower chairs, grab bars and whatever else he may need.

We are also looking in to redoing our entry to the walk in shower and removing part of a wall next to the toilet. The shower has a 6" threshold and the opening is only about 26".

Lot's of changes coming... What I don't want to do is order something and then find that I should have ordered something different and then it's too late.

Thanks in advance for all your help!
 
When you say UHC, do you mean a private (non-Medicare plan), a Medicare Advantage plan or a Medicare supplement that he has in addition to Medicare?
 
UHC is private insurance through my employer.
 
You should have the help of someone familiar with insurance forms, the right buzz words to use to get items covered, etc. For example, you may not be covered for a "shower chair". It has to be a commode chair that can double as a shower chair and not referred to as a shower chair in the paperwork. The MDA/ALS or ALSA can help you through all of this through their clinics. Just call the nearest office of either one and ask to get a clinic appointment. At the clinic your husband will be seen by a team that will evaluate all his needs, recommend equipment, and the clinic doctor will write the prescriptions. They will do all the paperwork for you. This is really important when getting a power chair. You need a therapist and a wheelchair seating specialist to get a properly fitted chair that is adaptable for your future needs. A salesman at your local medical equipment store isn't qualified for that.
 
We go to the MDA Clinic quarterly. They have a mobility specialist there. So we need to see him and a physical or occupational therapist to be fitted for his chair?
 
For powerchairs, communication devices, you will prescription from your doctor. And an evaluation, and will need to sized properly. Check with your insurance to make sure what durable medical equipment is covered and what the requirements are.
Patrick
 
You certainly don't have to but I strongly recommend it for any expensive equipment-- and all disability equipment seems to be expensive! You really do need knowledgeable people to get you the right chair. Even they can make mistakes, but buying your first chair on your own is asking for trouble -- insurance denials due to incomplete verification of need being the biggest issue. The power chairs outfitted for ALS patients are complex equipment and having complete and correctly worded justification forms for each addition to a standard power chair is important. Calling the MDA office might be able to to get you into an earlier clinic if you need to get any of the equipment more quickly. You will probably have to get the cough assist ordered through a pulmonologist but having the clinic doctor order everything else will be faster and more likely to be done correctly than your family doctor and his staff can do it.
 
The grab bars are nonreimbursable, so you can get those now, if he needs them. Most of the suction cup types are useless but Moen's are pretty good.

Certainly spec the renovation before ordering the shower + commode chair.

Eye gaze likely won't be covered until/unless he can't use alternative switches/mice, and CoughAssist, which has specific indications, requires a script with that documentation.

Yes, use your clinic but be aware that different clinics are aligned more closely with certain DMEs/wheelchair brands, so do your own research here and/or elsewhere.
 
Your coverage will depend on the specific contract your employer has. Is it a PPO or HMO? You should have a policy or access to your coverage online. When I was employed, my PPO (BCBS) would only pay for 80% of durable medical equipment. When I went on SSDI and got a BCBS supplement, Medicare paid 80% and BCBS paid 20% for most DME. If I had stayed on the college insurance, it would be secondary to Medicare and would NOT cover the additional 20%. You need to check your coverage first.

When does Medicare kick in for him? I waited for all my DME because the wait was six months and it saved me thousands out of pocket by waiting.

Was he ever in the military? If so, everything changes for the better.

No matter what your coverage, you'll have to pay out of pocket for a lot.
 
Thanks Laurie! Good info on the grab bars. Hopefully the shower guy will be by in a day or two so we will have a better idea of what to do about the shower chair.

KimT, we have a PPO. I know that starting Jan 1, my insurance goes to 85% coverage from 90% and my deductible goes up. Our max out of pocket is $2500 + deductible. I am sure the power wheel chair will take care of most of that if not all.

He has Medicare Hospitalization but not regular medical insurance. We waived that since my employer said our coverage is better and we don't need medicare.

He was never in the military.

I am going to attempt to attach some pics of my bathroom.

We need to remove the 6" threshold and enlarge the door. The part I am struggling with is the fixtures on next to the door so they will need to be changed. I can't decide if I want to move them closer to the corner still pointing towards the back wall but use an ADA bar where the handheld can move up or down and hopefully also pivot. Or, if I want to move it to the other wall and hope too much water doesn't splash out.

Pics were turned when I uploaded them. Sorry, I don't know how to change them.
 

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As others have already replied, it just depends.

I also have private a UHC policy through an employer. UHC has contested some things, but overall I have been very pleased with what they have covered.

What they cover will depend on the contract your employer has with UHC. It also depends on how well your doctor(s) and DME provider(s) are able to justify the need, work with UHC, and just be persistent.

I found that the DME was the key in getting my Power Wheelchair. They did what was necessary to get the things I really wanted paid for, failing only on the cupholder and seat elevate function. I paid for those myself.

To give you an idea of what is possible, UHC paid for my Permobil C500s VS wheelchair, which is the model with the standing feature. It has all the power movements (legs, tilt, recline, stand). It has lots of extra parts to support my body (leg supports, lateral thoracic supports, headrest, and arm supports (on the sides of the arm rests). They paid for the lighting kit, spare snow tires, and the high speed motors. Overall, the chair was about $55,000. I read online that a comparably equipped Permobil F5 VS (which replaces the C500 in their line) is now about $75,000.

I do not believe Medicare would have paid for this wheelchair, let alone all the extras that I got with it.

On a hopeful note, My UHC policy will apparently buy a wheelchair every 3 years (typical is every 5 years). I can't believe I have had my wheelchair for 2 years already. Before long I plan to start the process all over again, as I have a lot of miles on my wheelchair.

My UHC policy is outrageously expensive. It is our single largest expense. But, I think it has been worthwhile.

Steve
 
That's awesome Steve!

I do believe I read that they would pay for one every three years. I am glad you have been pleased.

The only thing they have denied so far is the feeding kits for the feeding tube which is actually just a syringe.

My understanding when I spoke with them today was that they won't pay for disposable items and that is what they consider the syringes.

We have had pretty good luck so far. Hopefully it will continue. All the changes can add up pretty quick.
 
"What is covered?" can only be answered by reading the actual plan documents, which the employer is required to make available.

In general, the rule is that any equipment that is medically necessary will be covered by a health plan unless there is a clear exclusion. Ambiguities are generally interpreted in the enrollee's favor. Common exclusions are for hygiene equipment, "convenience" items, and "over the counter" equipment.

The plan documents will also specify the cost sharing arrangement (i.e., the co-payment or coinsurance amount). 80/20 is a common cost sharing arrangement, but it can be different.

In all cases, the first and most important step is documenting medical necessity. This should be done by an ALS-literate occupational therapist who is NOT employed by the health plan and who knows how to explain the progressive/future needs of the patient and how to anticipate and avoid improper application of the "hygiene," "convenience," and "over the counter" exclusions by the health plan.

Time is of the essence. Don't delay, because months-long delays in the provision of DME are common for PALS.

Note: sometimes it's faster, easier, and cheaper to buy DME new or used over the Internet. If you search Google Shopping you can learn the true market price of DME items, which can be far, far less than the phony list prices your insurer may use to calculate your co-pay.
 
Dave, you are right about the real market price of used DME equipment vs. the list price.

My primary wheelchair had an insane list price (which I am confident the insurance company did not actually pay). The price I paid for my backup wheelchair, which was less than 2 years old and had only 26 miles on it, was essentially the same as the deductible for my primary wheelchair.

Steve
 
A couple of reminders from this thread:

Every payor has hundreds or thousands of plan variants. One UHC or Regence or Aetna plan certificate and benefits summary tells you about one plan.

"Medical necessity" is a semantic term and is not the absolute standard for coverage. You will see very little in a plan certificate about medical necessity. What you will see is what the sought-after equipment is doing/what it's treating and what expected outcomes are. When you look up your plan's provisions on line, look at "technology assessments" and "medical policies" for what they are looking for in terms of documentation.
 
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