INSURANCE,
MEDICAID, AND COMMUNITY CASE MANAGEMENT
An
18 year old with cerebral palsy received his care through
a Point of Service (POS) plan. His primary physician referred
him to a physiatrist for an evaluation related to the young
man's spasticity. This evaluation was covered by his insurance
plan, but many of the recommendations made based on the
evaluation were for items that were either not covered by
insurance or would be covered at a low rate.
The
parent of the 18 year old was given this information verbally,
but not in writing. The parent contacted an advocacy group
for help. The group assisted the parent with writing a letter
to the insurance company asking for a response in writing;
setting up a journal to document actions taken by the parent,
e.g., phone calls, letters, and referrals; and arranging
appointments with the state Medicaid program, the Rehabilitation
Program, and community provider for Respite and Case Management.
Four
months after the initial evaluation, the young man had received
a new wheelchair funded by insurance and was being evaluated
by the Rehabilitation Department for modifications at home.
With the help of the Community Case Management agency the
family was appealing another insurance decision and coordinating
between insurance and Medicaid.
