B. Private Health Insurance
Funding for AT can sometimes be obtained through a person’s private health
insurance coverage. This coverage is normally considered a resource for physician
services, hospital stays, and medications but not often seen as a means for
paying for equipment. However, it is not uncommon to successfully pursue this
funding,
and it ought to be considered a viable option.
1. Eligibility
When trying to determine whether specific insurance coverage can be used to
pay for AT, a person ought to first know whether he/she is eligible for coverage
(i.e., a beneficiary). For example, a person may have an insurance policy that
does not include his/her siblings. It is common for spouses and dependent children
to be covered beneficiaries. The insurance contract should be read to determine
who is a covered beneficiary and how much insurance coverage is available to
a particular family member.
2. Coverage
The extent of coverage under a person’s private health insurance normally
will depend on the specific terms of the contract. The contract is typically
the vehicle through which the insurance company promises to pay
for specified healthcare.
It is important to know the terms of the insurance contract. A person may have insurance coverage through his/her employment or an individual insurance policy. Although the actual contract has the terms that are binding, the critical terms should be made available. If the coverage is through a person’s employment, a summary booklet ought to be provided to the employee; if an individual has his/her own coverage, the important language should be in the policy. In this article, this documentation will generically be referred to as the "insurance contract."
It is often critical to have medical personnel support the request for insurance
coverage. Before asking the insurance company to pay for AT, you should consider
what benefits and exclusions are outlined in the insurance contract as well
as how they are defined. The insurance contract will often have a list of covered
benefits for which it will pay and a list of exclusions for which it will not
pay. The following are examples of common benefits that might extend coverage
to AT:
o durable medical equipment
o orthotics
o prosthetics.
The following are examples of common exclusions that an insurance company might
cite as reasons to not pay for AT:
o experimental
o comfort or convenience item.
Written statements from treating professionals must show how the AT qualifies
as a covered benefit and does not fall under one of the specified exclusions.
3. Medical Necessity
Most insurance contracts require services to be medically necessary for payment
to be made. The contract may have a definition for "medically necessary,"
and it should be reviewed prior to submitting a request for payment.
Having medical documentation that shows how an item is medically necessary is
critical. A doctor’s statement is often key to showing an insurance company
that an item is medically necessary.
4. Appeals
If an insurance company denies a request for payment, an appeal normally can
be pursued. The procedure for the appeal ought to be outlined in the insurance
contract, and the beneficiary should examine the contract to
follow the steps to appeal the denial. Often an appeal can be successful by
simply submitting more information. During the appeal it is important to have
additional support that shows how the AT is a covered benefit, how it
does not fall within exclusion, and how it is medically necessary.
5. Contacts
The following contacts will assist an insurance beneficiary in obtaining funding
for AT through his/her private health insurance.
a. Questions and requests for assistance can be directed to one of the following:
The Georgia Advocacy Office
100 Crescent Centre Parkway, Suite 520
Tucker, GA 30084
(404) 885-1234 (voice or TTY)
(800) 537-2329 (voice or TTY)
(770) 414-2948 (fax)
info@thegao.org
http://www.thegao.org
Georgia Consumer Insurance Advocate
2 Martin Luther King Jr. Drive, Suite 1204
West Tower
Atlanta, GA 30334
(404) 463-1010
(404) 463-1067 (fax)
http://www.state.ga.us/insadvocate
Independent Review for Managed Care Beneficiaries
Valerie Hepburn
Department of Community Health
Division of Health Planning, Suite 34.262
2 Peachtree Street, NW
Atlanta, GA 30303
(404) 656-0655
http://www.communityhealth.state.ga.us
Patient Advocate Foundation
753 Thimble Shoals Blvd., Suite B
Newport News, VA 23661
(800) 532-5274
(757) 873-8999 (fax)
http://www.patientadvocate.org