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This one is about: State of Ohio - Bureau of Children with Medical Handicaps Coverage
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State of Ohio - Bureau of Children with Medical Handicaps Coverage
Question: We have a parent in our Support Group that lives in Ohio. Her son is about 2 years old.
Their insurance company is refusing to cover surgery to correct his cleft palate because they say it was caused by his birth defect and they will not cover problems with the birth defect.
Have any of your group encountered this problem, and do you know of any other organization serving Ohio that they might turn to for help?
My name is Beth, I have a son, Paul who was born with a unilateral cleft lip and palate in the state of Ohio. He had 3 surgeries in Ohio and all of them were covered by our insurance. What was not covered by our insurance was covered through the Sate of Ohio's State of Ohio-Bureau of Children with Medical Handicaps Coverage.
My first line of attack would be to write letters to the insurance company and try to get them to overturn their decision. Many times, the "squeaky wheel gets the grease" when it comes to insurance companies covering things. I would also get as many doctors as possible to back the family and have them also write letters of appeal.
Also, it is always a good idea to get the pamphlet, "Parameters of Care" from the Cleft Palate Foundation. That pamphlet lays out all the disciplines necessary for the adequate repair of a cleft, as recognized by the American Cleft Palate/Craniofacial Association. The family can refer to this pamphlet and can copy the parts the insurance/HMO does not cover and send it to them with a letter. To get the pamphlet, call 1-800-24-CLEFT.
It also makes a difference if the insurance is an insurance company or an HMO. They are all different, but a letter-writing, phone-calling and just plain old harassing campaign can usually turn over a denial of coverage! They can get the State Insurance Commissioner involved as well, if need be. The big thing for them to realize is, DO NOT give up!!!
If none of this works, then the family will probably be eligible for the State of Ohio's Bureau of Children with Medical Handicaps (BCMH). When we took Paul to Children's Hospital, they had a liaison that informed us of BCMH and gave us the paperwork to fill out. Any child can apply to BCMH that has a "handicap" and the diagnosis of cleft palate is a covered diagnosis. There is a salary cap, but if the insurance will not cover the surgery/treatment, then chances are, BCMH will.
In our case, we had only one insurance and whatever was not covered by my insurance, was paid for by BCMH! It was great!
For more info on the BCMH program contact:
Ohio Department of Health -- Bureau for Children with Medical Handicaps
P.O. Box 1603
Columbus, OH 43216-1603
614-466-1700 or 1-800-755-GROW
Also an answer from Vickie:
If you are a low income family with no insurance, BCMH will pay 100% for everything related to the "handicapping condition", if you have a low income (and their definition of low income is very generous) and have insurance, and the insurance will pay for the treatment or surgery etc., then, the hospital will bill the insurance first, and the balance to
BCMH, the family pays nothing.
If the family is middle income, and they get denied, they can reapply to get into the copay program, this is where the family pays a certain amount of out of pocket expense, and then BCMH will pay everything over that amount, the co-pay is on a sliding scale, so one family may have to pay $200 per year, before the BCMH picks up the rest, and another family may have to pay $400, it is based on income.
To apply, 2-4 paycheck stubs for each person employed is required (photocopies of course), the last tax records that were filed (federal), I included things like our large monthly expenses (a photocopy of our mortgage coupon and car payment coupon, and so on, so they could factor that in as well) When I last applied, we were covered under an insurance plan that had a pre-existing conditions clause, I had to provide a copy of the documentation that showed this, this was not hard to do, I just called the human resources department and asked them for it, they gave me the appropriate reference to copy. I do recommend keeping a copy of everything that is sent in, just in case something gets lost or whatever.
This is a wonderful program, and is good for one full year, from the date of application (which becomes the effective date) to one day before that date, the next year. Each year, BCMH coverage must be reapplied for, but they mail it out in plenty of time. I found BCMH to be wonderful!
They also have a diagnosis program, if a child is suspected of having a handicapping condition, they will pay for testing and treatment having to do with that condition for a period of 3 months, there is not financial information that needs done for that, we did that for my niece when she was having GI problems, she was seen at the Children's GI clinic and we had to pay nothing, she had no insurance coverage at the time, but the problem was taken care of and she recovered beautifully, applying to the regular program was not necessary for her, but if she would have been found to have a condition that required longer term treatment, then it could have easily rolled over to the regular program. For this we went through the local health department, call them and tell them that you need to talk to someone about BCMH, (in Delaware, the nurse that specializes in this) will come out and fill out a paper, then have the parents sign that paper an you take it with you to the appointment.
Each child that has BCMH coverage has a managing physician, this doc is a BCMH provider and care is organized through that provider, Dr. *** is Doug's managing physician. My son also has a kidney anomaly and another doc at Children's treats him for this.
When you are accepted into the program, you get a letter, this must go with you to appointments where BCMH is going to be billed (meaning, the pediatrician does not need it, but the plastic surgeon does -- the pediatrician is probably not a provider and will not be billing BCMH for the visit, the surgeon will be a provider and will be billing BCMH) anyway, on the letter, is everything that is going to be covered under the BCMH coverage. For my son, there is a predetermined list of covered services, and these are what appear on the letter. To get the urologist added on, I had to have the managing doctor fill out a form and fax that to BCMH, the request was reviewed, and then added on, this does not have a pre-set list of covered services, so the urologist had to fill out another form and fax that to the managing physician that stated what were the anticipated claims that would need to be covered (this is easily added to later, and if you don't use it, no problem at all) then this is approved by the managing physician, and another form is added to the pile, and this is all faxed to BCMH for review, then you can either call BCMH and find out if it is approved (if you are needing the test or surgery very soon and can't wait) or you can wait until you get the revised approval letter.
This is all done by the doctor's offices, the patient or parent is not allowed to be involved in this area, I never had a problem with this, if I felt that my son needed something, we saw DR ******* and talked to him about it and he took care of it. The list of covered services is very generous indeed, it also includes things that might be related to the trauma of a chronic illness like a yearly evaluation by a psychologist, 4 nutritional consultations, and so on. I have to say that I have been extremely impressed with the coverage.
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