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coffeemom

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Reply with quote  #1 
My s dx with RAN age 12 from a doctor I highly respect. Insurance covered the assessment out of state OR. But would not cover services and infact don't want to cover services at Seattle children's b/c we are not in that county. How do you get quality help in this situation?

Another question, since that dx in May he has been eating better gained 2 lbs, he is convinced the problem is solved. Does this disorder "hide" once it's been found out? Then Just as we had another assessment seems like symptoms start flaring up again.

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OneToughMomma

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Reply with quote  #2 
Dear coffeemom,

I can't answer your question about insurance as I don't live in the US.

You've certainly been through this mill with your kids, and I bet you already know the answer to you second question.  Your s can't tell you how ill he is.  His behaviours will tell you. Does he eat freely, enjoy food, respond normally to exercise or lack thereof?  Is his weight truly appropriate to height?

I'm so sorry you're having to go through all of this, but you are doing great and your kids are lucky to have you.

xoOTM

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D in and out of EDNOS since age 8. dx RAN 2013. WR Aug '14. Graduated FBT June 2015 at 18 yrs old. [thumb]
Torie

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Reply with quote  #3 
Have you tried speaking to the providers you would like to use about this? They are often very helpful in fighting with the insurances. xx

-Torie

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Kali

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Reply with quote  #4 
Coffeemom,

So sorry you are having difficulty with the "system"

Do you have a case manager for your son?
If not can you request to be assigned to one and work with them to request what is known as a "single case agreement" to cover the services your son needs? 

It looks as though if you have been denied, you can appeal the decision. 

You may already have already gone through these steps but just in case you haven't, here is some info I found online.

What levels of care are typically covered by Medicare and Medicaid?
Most Medicare and Medicaid plans offer only inpatient and outpatient coverage for eating disorders treatment. It is important to contact your insurance company to see if there are limits to this coverage and to verify what treatment your specific plan offers for eating disorders.

What steps can I take to get Medicare or Medicaid to cover treatment for an Eating Disorder if I encounter roadblocks or am seeking residential treatment?

Step One: Contact your insurance company and ask to be assigned a Case Manager. Since each insurance provider may have differing protocols, this step may involve different approaches for different insurance companies. The key is to remain persistent in getting the same person to work directly with you throughout your efforts to obtain treatment. The role of a case manager is to advocate for you, to be your voice and to work with your insurance provider to get approval for treatment coverage.

Step Two: Once you have a case manager, tell them, “I need to find a treatment center where I can receive (insert level of care) treatment for my son's eating disorder. Can you please help me arrange a Single Case Agreement?” A Single Case Agreement is a onetime contract between the insurance company and the treatment provider. If you have a treatment center in mind that you would like to receive care from, mention that information to your Case Manager now. It is also important to remember, just because your insurance provider is willing to do a Single Case Agreement does not mean the treatment center you prefer will be willing to accept. In step two it is vital to remain persistent, but also open to hearing what options are available.

Step Three: Follow-up with information requested from your Case Manager and remain persistent. It is important to respond to requests swiftly so you can access treatment as soon as possible. Requests may include, but are not limited to completing medical screenings, completing assessments and providing treatment recommendations from any pre-existing treatment providers. If a Single Case Agreement is initially denied, you may appeal the denial working with your Case Manager.

Best wishes,

Kali



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sk8r31

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Reply with quote  #5 
Hi coffeemom,

As if it isn't tough enough to fight this blasted illness, dealing with US insurance companies can be the icing on the cake!

Kali has given you some stellar info and advice.  I also live in WA state, and we did ask for a single case agreement, & to have a case manager.  It truly did help; not always having to explain your situation over and over to various and sundry folks.

Plus, and this is a BIG one, insurance companies want to save money.  If you lay out what treatment you need for your kid, and why the best evidence-based treatment will result in a shorter treatment time or could avoid multiple admissions etc.  they are more likely to respond favorably.

We went to the UCSD 5-Day Multi-Family program, and initially the insurance was only going to cover 60% of treatment, but in the end, they covered 100%.

It is worth being a squeaky wheel, even though you are exhausted from dealing with ED.

Sending you warm support,
sk8r31

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It is good to not only hope to be successful, but to expect it and accept it--Maya Angelou
coffeemom

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Reply with quote  #6 
Thank you for the encouragement you all. I will pursue a case manager and see where it leads. Glad to hear single case agreements are possible.
I appreciate all the support and helpful advice.

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