Re: Just recieved an email from my insurance....

[Guest guest]

Your best bet is the ERISA arbitration. The person who is making the

decision is not the same person who's money is being spent, so it is

defiintely about what's best for the child, not what's best for the

employer.

You may have to do one more internal appeal to qualify (you have to

have exhausted all of your internal appeals before you can request

ERISA arbitration).

Also, I would recommend writing a letter to the CFO of PFChangs

telling them that this is a financially disadvantageous decision for

them as it will surely cost them MORE to continue to deny your request

and pay for outside counsel for an ERISA arbitration than it will to

give in now.

You can also try the " contacting your local consumer support groups "

approach, companies especially like PFChangs HATE bad publicity.

Sheri

> OK, let me start by saying that I'm the insurance advocate for the

Let Them

> Hear Foundation, and appealing insurance denials is my entire life.

Deep

> breath. The enemy isn't Aetna, the enemy is your employer

>

> Self insured companies mean that INSTEAD of paying premiums, the

company is

> trying to save money by creating it's own insurance pool. Typically

this is

> done by larger companies (i.e. more than 500 employees). Self funded

> insurance means your employer is the insurer, Aetna is only the 3rd

party

> administrator, processing claims on behalf of your employer, paying

money

> out of the pool of funds that the employer created. Following the

rules set

> by . . . you guessed it . . . your employer. Because self-insured

plans are

> governed by federal law, not state law, and federal law pre-empts

> conflicting state law, there is absolutely zero that anyone in your

state

> goverment can do to help you.

>

> Here is where you need to get creative.

>

> 1) Appeal the insurance denial by using one of the very fine

templates on

> the listen-up.org web site. Several people have had success in

overturning

> hearing aid denials

>

> 2) If the denial is overturned, request an ERISA arbitration where a

third

> party (not connected with either Aetna or your employer) gets to decide

> whether or not hearing aids are medically necessary for your child's

> particular condition

>

> 3) Work the situation from the inside. Contact the person in your HR

> department in charge of benefits and ask them if they know that they

> specifically excluded this. If you feel you have a strong employement

> position, go to your boss and let him know you're unhappy with the

situation

> and ask if he will intervene or perhaps work out a one time bonus to

you to

> pay for the hearing aids (companies love this solution because it's

> relatively cheap, makes the employee happy, and doesn't set a

precedent for

> other hearing aid payments).

>

> If you need help with either the appeal or the ERISA arbitration let me

> know, you can contact me at my work e-mail at sbyrne@l...,

> although I should tell you that I'm taking emergency appeals until

January

> 3rd since I am totally swamped right now.

>

> Good luck,

>

> Sheri

>

>

>

> >Message: 16

> > Date: Tue, 20 Dec 2005 01:16:29 -0000

> > From: " saraandchadd " <saraandchadd@y...>

> >Subject: Just recieved an email from my insurance....

> >

> >For the first time it was put in black and white for me. " Hearing

> >aids arent' covered by a lot of insurance companies because they are

> >considered developmental and not medically necessary " . I feel like

> >throwing up. I am so red with anger right now I can't even explain

> >yet. NOT MEDICALLY NECESSARY!!!! I think I might drive tonight

> >without my glasses on 'cause to me they can be put in the same

> >category!!!! I am so beyond ticked off it isn't even funny. I know

> >that this has been brought before many states and my state has seen

> >the ignorance in this comment. HOWEVER, Aetna has found a loop hole.

> >They are a self-financed company. The law doens't apply to them. They

> >can basically deny whatever they feel like denying that day!!!!!!! I'm

> >contacting my insurance commisoner tomorrow. I'm not letting this end

> >here.

>

>

>

>

> All messages posted to this list are private and confidential. Each

post is the intellectual property of the author and therefore subject

to copyright restrictions.

>

>

>

>

[Guest guest]

Your best bet is the ERISA arbitration. The person who is making the

decision is not the same person who's money is being spent, so it is

defiintely about what's best for the child, not what's best for the

employer.

You may have to do one more internal appeal to qualify (you have to

have exhausted all of your internal appeals before you can request

ERISA arbitration).

Also, I would recommend writing a letter to the CFO of PFChangs

telling them that this is a financially disadvantageous decision for

them as it will surely cost them MORE to continue to deny your request

and pay for outside counsel for an ERISA arbitration than it will to

give in now.

You can also try the " contacting your local consumer support groups "

approach, companies especially like PFChangs HATE bad publicity.

Sheri

> OK, let me start by saying that I'm the insurance advocate for the

Let Them

> Hear Foundation, and appealing insurance denials is my entire life.

Deep

> breath. The enemy isn't Aetna, the enemy is your employer

>

> Self insured companies mean that INSTEAD of paying premiums, the

company is

> trying to save money by creating it's own insurance pool. Typically

this is

> done by larger companies (i.e. more than 500 employees). Self funded

> insurance means your employer is the insurer, Aetna is only the 3rd

party

> administrator, processing claims on behalf of your employer, paying

money

> out of the pool of funds that the employer created. Following the

rules set

> by . . . you guessed it . . . your employer. Because self-insured

plans are

> governed by federal law, not state law, and federal law pre-empts

> conflicting state law, there is absolutely zero that anyone in your

state

> goverment can do to help you.

>

> Here is where you need to get creative.

>

> 1) Appeal the insurance denial by using one of the very fine

templates on

> the listen-up.org web site. Several people have had success in

overturning

> hearing aid denials

>

> 2) If the denial is overturned, request an ERISA arbitration where a

third

> party (not connected with either Aetna or your employer) gets to decide

> whether or not hearing aids are medically necessary for your child's

> particular condition

>

> 3) Work the situation from the inside. Contact the person in your HR

> department in charge of benefits and ask them if they know that they

> specifically excluded this. If you feel you have a strong employement

> position, go to your boss and let him know you're unhappy with the

situation

> and ask if he will intervene or perhaps work out a one time bonus to

you to

> pay for the hearing aids (companies love this solution because it's

> relatively cheap, makes the employee happy, and doesn't set a

precedent for

> other hearing aid payments).

>

> If you need help with either the appeal or the ERISA arbitration let me

> know, you can contact me at my work e-mail at sbyrne@l...,

> although I should tell you that I'm taking emergency appeals until

January

> 3rd since I am totally swamped right now.

>

> Good luck,

>

> Sheri

>

>

>

> >Message: 16

> > Date: Tue, 20 Dec 2005 01:16:29 -0000

> > From: " saraandchadd " <saraandchadd@y...>

> >Subject: Just recieved an email from my insurance....

> >

> >For the first time it was put in black and white for me. " Hearing

> >aids arent' covered by a lot of insurance companies because they are

> >considered developmental and not medically necessary " . I feel like

> >throwing up. I am so red with anger right now I can't even explain

> >yet. NOT MEDICALLY NECESSARY!!!! I think I might drive tonight

> >without my glasses on 'cause to me they can be put in the same

> >category!!!! I am so beyond ticked off it isn't even funny. I know

> >that this has been brought before many states and my state has seen

> >the ignorance in this comment. HOWEVER, Aetna has found a loop hole.

> >They are a self-financed company. The law doens't apply to them. They

> >can basically deny whatever they feel like denying that day!!!!!!! I'm

> >contacting my insurance commisoner tomorrow. I'm not letting this end

> >here.

>

>

>

>

> All messages posted to this list are private and confidential. Each

post is the intellectual property of the author and therefore subject

to copyright restrictions.

>

>

>

>

[Guest guest]

Your best bet is the ERISA arbitration. The person who is making the

decision is not the same person who's money is being spent, so it is

defiintely about what's best for the child, not what's best for the

employer.

You may have to do one more internal appeal to qualify (you have to

have exhausted all of your internal appeals before you can request

ERISA arbitration).

Also, I would recommend writing a letter to the CFO of PFChangs

telling them that this is a financially disadvantageous decision for

them as it will surely cost them MORE to continue to deny your request

and pay for outside counsel for an ERISA arbitration than it will to

give in now.

You can also try the " contacting your local consumer support groups "

approach, companies especially like PFChangs HATE bad publicity.

Sheri

> OK, let me start by saying that I'm the insurance advocate for the

Let Them

> Hear Foundation, and appealing insurance denials is my entire life.

Deep

> breath. The enemy isn't Aetna, the enemy is your employer

>

> Self insured companies mean that INSTEAD of paying premiums, the

company is

> trying to save money by creating it's own insurance pool. Typically

this is

> done by larger companies (i.e. more than 500 employees). Self funded

> insurance means your employer is the insurer, Aetna is only the 3rd

party

> administrator, processing claims on behalf of your employer, paying

money

> out of the pool of funds that the employer created. Following the

rules set

> by . . . you guessed it . . . your employer. Because self-insured

plans are

> governed by federal law, not state law, and federal law pre-empts

> conflicting state law, there is absolutely zero that anyone in your

state

> goverment can do to help you.

>

> Here is where you need to get creative.

>

> 1) Appeal the insurance denial by using one of the very fine

templates on

> the listen-up.org web site. Several people have had success in

overturning

> hearing aid denials

>

> 2) If the denial is overturned, request an ERISA arbitration where a

third

> party (not connected with either Aetna or your employer) gets to decide

> whether or not hearing aids are medically necessary for your child's

> particular condition

>

> 3) Work the situation from the inside. Contact the person in your HR

> department in charge of benefits and ask them if they know that they

> specifically excluded this. If you feel you have a strong employement

> position, go to your boss and let him know you're unhappy with the

situation

> and ask if he will intervene or perhaps work out a one time bonus to

you to

> pay for the hearing aids (companies love this solution because it's

> relatively cheap, makes the employee happy, and doesn't set a

precedent for

> other hearing aid payments).

>

> If you need help with either the appeal or the ERISA arbitration let me

> know, you can contact me at my work e-mail at sbyrne@l...,

> although I should tell you that I'm taking emergency appeals until

January

> 3rd since I am totally swamped right now.

>

> Good luck,

>

> Sheri

>

>

>

> >Message: 16

> > Date: Tue, 20 Dec 2005 01:16:29 -0000

> > From: " saraandchadd " <saraandchadd@y...>

> >Subject: Just recieved an email from my insurance....

> >

> >For the first time it was put in black and white for me. " Hearing

> >aids arent' covered by a lot of insurance companies because they are

> >considered developmental and not medically necessary " . I feel like

> >throwing up. I am so red with anger right now I can't even explain

> >yet. NOT MEDICALLY NECESSARY!!!! I think I might drive tonight

> >without my glasses on 'cause to me they can be put in the same

> >category!!!! I am so beyond ticked off it isn't even funny. I know

> >that this has been brought before many states and my state has seen

> >the ignorance in this comment. HOWEVER, Aetna has found a loop hole.

> >They are a self-financed company. The law doens't apply to them. They

> >can basically deny whatever they feel like denying that day!!!!!!! I'm

> >contacting my insurance commisoner tomorrow. I'm not letting this end

> >here.

>

>

>

>

> All messages posted to this list are private and confidential. Each

post is the intellectual property of the author and therefore subject

to copyright restrictions.

>

>

>

>

[Guest guest]

I do not understand how ERISA arbitration would work

against a large self-insured company. I too work for

a large self-insured company and they cover new

hearing aids every five years but limit the amount to

$1000 per aid. Now I realize that that is more than

some folks have, but with two hearing impaired

children, it doesn't come close to covering the cost

of their hearing aids.

The reason they give me is that this is coverage they

have determined they will provide as part of their

medical insurance policy (similar to other companies,

fiduciary responsibility to set coverage limits, etc.)

I'm not sure where ERISA could help? How does that

work? Thanks,

Judy

--- sbyrne1281 wrote:

>

> Your best bet is the ERISA arbitration. The person

> who is making the

> decision is not the same person who's money is being

> spent, so it is

> defiintely about what's best for the child, not

> what's best for the

> employer.

>

> You may have to do one more internal appeal to

> qualify (you have to

> have exhausted all of your internal appeals before

> you can request

> ERISA arbitration).

>

> Also, I would recommend writing a letter to the CFO

> of PFChangs

> telling them that this is a financially

> disadvantageous decision for

> them as it will surely cost them MORE to continue to

> deny your request

> and pay for outside counsel for an ERISA arbitration

> than it will to

> give in now.

>

> You can also try the " contacting your local consumer

> support groups "

> approach, companies especially like PFChangs HATE

> bad publicity.

>

> Sheri

>

>

> > OK, let me start by saying that I'm the

> insurance advocate for the

> Let Them

> > Hear Foundation, and appealing insurance denials

> is my entire life.

> Deep

> > breath. The enemy isn't Aetna, the enemy is your

> employer

> >

> > Self insured companies mean that INSTEAD of paying

> premiums, the

> company is

> > trying to save money by creating it's own

> insurance pool. Typically

> this is

> > done by larger companies (i.e. more than 500

> employees). Self funded

> > insurance means your employer is the insurer,

> Aetna is only the 3rd

> party

> > administrator, processing claims on behalf of your

> employer, paying

> money

> > out of the pool of funds that the employer

> created. Following the

> rules set

> > by . . . you guessed it . . . your employer.

> Because self-insured

> plans are

> > governed by federal law, not state law, and

> federal law pre-empts

> > conflicting state law, there is absolutely zero

> that anyone in your

> state

> > goverment can do to help you.

> >

> > Here is where you need to get creative.

> >

> > 1) Appeal the insurance denial by using one of the

> very fine

> templates on

> > the listen-up.org web site. Several people have

> had success in

> overturning

> > hearing aid denials

> >

> > 2) If the denial is overturned, request an ERISA

> arbitration where a

> third

> > party (not connected with either Aetna or your

> employer) gets to decide

> > whether or not hearing aids are medically

> necessary for your child's

> > particular condition

> >

> > 3) Work the situation from the inside. Contact

> the person in your HR

> > department in charge of benefits and ask them if

> they know that they

> > specifically excluded this. If you feel you have

> a strong employement

> > position, go to your boss and let him know you're

> unhappy with the

> situation

> > and ask if he will intervene or perhaps work out a

> one time bonus to

> you to

> > pay for the hearing aids (companies love this

> solution because it's

> > relatively cheap, makes the employee happy, and

> doesn't set a

> precedent for

> > other hearing aid payments).

> >

> > If you need help with either the appeal or the

> ERISA arbitration let me

> > know, you can contact me at my work e-mail at

> sbyrne@l...,

> > although I should tell you that I'm taking

> emergency appeals until

> January

> > 3rd since I am totally swamped right now.

> >

> > Good luck,

> >

> > Sheri

> >

> >

> >

> > >Message: 16

> > > Date: Tue, 20 Dec 2005 01:16:29 -0000

> > > From: " saraandchadd " <saraandchadd@y...>

> > >Subject: Just recieved an email from my

> insurance....

> > >

>

=== message truncated ===

__________________________________________________

[Guest guest]

What is ERISA? I was told that I have 2 levels of appeals and then a medical

review board that is completely independent of either PFChangs or Aetna. Is

that the same thing.

Also, what I am being told is that my auidiologist do not have a contract with

Aetna to be a provider of hearing aids - have no idea how they can have one as

audiologists but not as hearing aid providers -- so instead of my coverage being

80or 100% it should be 60% -- but they aren't even covering that. new

developments.

Judy Wagner wrote:

I do not understand how ERISA arbitration would work

against a large self-insured company. I too work for

a large self-insured company and they cover new

hearing aids every five years but limit the amount to

$1000 per aid. Now I realize that that is more than

some folks have, but with two hearing impaired

children, it doesn't come close to covering the cost

of their hearing aids.

The reason they give me is that this is coverage they

have determined they will provide as part of their

medical insurance policy (similar to other companies,

fiduciary responsibility to set coverage limits, etc.)

I'm not sure where ERISA could help? How does that

work? Thanks,

Judy

--- sbyrne1281 wrote:

>

> Your best bet is the ERISA arbitration. The person

> who is making the

> decision is not the same person who's money is being

> spent, so it is

> defiintely about what's best for the child, not

> what's best for the

> employer.

>

> You may have to do one more internal appeal to

> qualify (you have to

> have exhausted all of your internal appeals before

> you can request

> ERISA arbitration).

>

> Also, I would recommend writing a letter to the CFO

> of PFChangs

> telling them that this is a financially

> disadvantageous decision for

> them as it will surely cost them MORE to continue to

> deny your request

> and pay for outside counsel for an ERISA arbitration

> than it will to

> give in now.

>

> You can also try the " contacting your local consumer

> support groups "

> approach, companies especially like PFChangs HATE

> bad publicity.

>

> Sheri

>

>

> > OK, let me start by saying that I'm the

> insurance advocate for the

> Let Them

> > Hear Foundation, and appealing insurance denials

> is my entire life.

> Deep

> > breath. The enemy isn't Aetna, the enemy is your

> employer

> >

> > Self insured companies mean that INSTEAD of paying

> premiums, the

> company is

> > trying to save money by creating it's own

> insurance pool. Typically

> this is

> > done by larger companies (i.e. more than 500

> employees). Self funded

> > insurance means your employer is the insurer,

> Aetna is only the 3rd

> party

> > administrator, processing claims on behalf of your

> employer, paying

> money

> > out of the pool of funds that the employer

> created. Following the

> rules set

> > by . . . you guessed it . . . your employer.

> Because self-insured

> plans are

> > governed by federal law, not state law, and

> federal law pre-empts

> > conflicting state law, there is absolutely zero

> that anyone in your

> state

> > goverment can do to help you.

> >

> > Here is where you need to get creative.

> >

> > 1) Appeal the insurance denial by using one of the

> very fine

> templates on

> > the listen-up.org web site. Several people have

> had success in

> overturning

> > hearing aid denials

> >

> > 2) If the denial is overturned, request an ERISA

> arbitration where a

> third

> > party (not connected with either Aetna or your

> employer) gets to decide

> > whether or not hearing aids are medically

> necessary for your child's

> > particular condition

> >

> > 3) Work the situation from the inside. Contact

> the person in your HR

> > department in charge of benefits and ask them if

> they know that they

> > specifically excluded this. If you feel you have

> a strong employement

> > position, go to your boss and let him know you're

> unhappy with the

> situation

> > and ask if he will intervene or perhaps work out a

> one time bonus to

> you to

> > pay for the hearing aids (companies love this

> solution because it's

> > relatively cheap, makes the employee happy, and

> doesn't set a

> precedent for

> > other hearing aid payments).

> >

> > If you need help with either the appeal or the

> ERISA arbitration let me

> > know, you can contact me at my work e-mail at

> sbyrne@l...,

> > although I should tell you that I'm taking

> emergency appeals until

> January

> > 3rd since I am totally swamped right now.

> >

> > Good luck,

> >

> > Sheri

> >

> >

> >

> > >Message: 16

> > > Date: Tue, 20 Dec 2005 01:16:29 -0000

> > > From: " saraandchadd " <saraandchadd@y...>

> > >Subject: Just recieved an email from my

> insurance....

> > >

>

=== message truncated ===

__________________________________________________

[Guest guest]

ERISA is the federal law that governs self-insured plans. It maybe

that the medical review board they are describing is an ERISA

arbitration. If it isn't, you have that option left to you also in

addition to the appeals that you've described

Sheri

> > > OK, let me start by saying that I'm the

> > insurance advocate for the

> > Let Them

> > > Hear Foundation, and appealing insurance denials

> > is my entire life.

> > Deep

> > > breath. The enemy isn't Aetna, the enemy is your

> > employer

> > >

> > > Self insured companies mean that INSTEAD of paying

> > premiums, the

> > company is

> > > trying to save money by creating it's own

> > insurance pool. Typically

> > this is

> > > done by larger companies (i.e. more than 500

> > employees). Self funded

> > > insurance means your employer is the insurer,

> > Aetna is only the 3rd

> > party

> > > administrator, processing claims on behalf of your

> > employer, paying

> > money

> > > out of the pool of funds that the employer

> > created. Following the

> > rules set

> > > by . . . you guessed it . . . your employer.

> > Because self-insured

> > plans are

> > > governed by federal law, not state law, and

> > federal law pre-empts

> > > conflicting state law, there is absolutely zero

> > that anyone in your

> > state

> > > goverment can do to help you.

> > >

> > > Here is where you need to get creative.

> > >

> > > 1) Appeal the insurance denial by using one of the

> > very fine

> > templates on

> > > the listen-up.org web site. Several people have

> > had success in

> > overturning

> > > hearing aid denials

> > >

> > > 2) If the denial is overturned, request an ERISA

> > arbitration where a

> > third

> > > party (not connected with either Aetna or your

> > employer) gets to decide

> > > whether or not hearing aids are medically

> > necessary for your child's

> > > particular condition

> > >

> > > 3) Work the situation from the inside. Contact

> > the person in your HR

> > > department in charge of benefits and ask them if

> > they know that they

> > > specifically excluded this. If you feel you have

> > a strong employement

> > > position, go to your boss and let him know you're

> > unhappy with the

> > situation

> > > and ask if he will intervene or perhaps work out a

> > one time bonus to

> > you to

> > > pay for the hearing aids (companies love this

> > solution because it's

> > > relatively cheap, makes the employee happy, and

> > doesn't set a

> > precedent for

> > > other hearing aid payments).

> > >

> > > If you need help with either the appeal or the

> > ERISA arbitration let me

> > > know, you can contact me at my work e-mail at

> > sbyrne@l...,

> > > although I should tell you that I'm taking

> > emergency appeals until

> > January

> > > 3rd since I am totally swamped right now.

> > >

> > > Good luck,

> > >

> > > Sheri

> > >

> > >

> > >

> > > >Message: 16

> > > > Date: Tue, 20 Dec 2005 01:16:29 -0000

> > > > From: " saraandchadd " <saraandchadd@y...>

> > > >Subject: Just recieved an email from my

> > insurance....

> > > >

> >

> === message truncated ===

>

>

> __________________________________________________

>

[Guest guest]

['s insur. contact sent an email stating] " Hearing aids arent'

covered by a lot of insurance companies because they are considered

developmental and not medically necessary "

,

i would get your ENT to write a letter stating that for your daughter

digital hearing aids are " medically necessary. " Use the language the

insurance company uses in the denial letters, and forward your ENT for

inclusion in her/his letter. i know it sounds simple and obvious.

However, after battling an insurance company myself for over a year, i

tried this approach and it worked.

[Guest guest]

['s insur. contact sent an email stating] " Hearing aids arent'

covered by a lot of insurance companies because they are considered

developmental and not medically necessary "

,

i would get your ENT to write a letter stating that for your daughter

digital hearing aids are " medically necessary. " Use the language the

insurance company uses in the denial letters, and forward your ENT for

inclusion in her/his letter. i know it sounds simple and obvious.

However, after battling an insurance company myself for over a year, i

tried this approach and it worked.

[Guest guest]

['s insur. contact sent an email stating] " Hearing aids arent'

covered by a lot of insurance companies because they are considered

developmental and not medically necessary "

,

i would get your ENT to write a letter stating that for your daughter

digital hearing aids are " medically necessary. " Use the language the

insurance company uses in the denial letters, and forward your ENT for

inclusion in her/his letter. i know it sounds simple and obvious.

However, after battling an insurance company myself for over a year, i

tried this approach and it worked.

[Guest guest]

Sheri,

Is there anything we can do on the federal level to change the way hearing

aid coverage is provided overall?

Putz

Illinois Families for Hands & Voices

_www.handsandvoices.org_ (http://www.handsandvoices.org/)

_www.ilhandsandvoices.org_ (http://www.ilhandsandvoices.org/)

Email: support@...

[Guest guest]

Sheri,

Is there anything we can do on the federal level to change the way hearing

aid coverage is provided overall?

Putz

Illinois Families for Hands & Voices

_www.handsandvoices.org_ (http://www.handsandvoices.org/)

_www.ilhandsandvoices.org_ (http://www.ilhandsandvoices.org/)

Email: support@...

[Guest guest]

I'm so sorry I've been out of the loop a bit - between classes always

seems to be the busiest for me. I guess if you're a professor giving a

final you don't want to bring your computer in to be fixed unless it's

absolutely necessary.

We successfully petitioned our insurance company (which at the time

didn't pay for hearing aids). The letter that our pediatrician wrote is

here:

http://www.listen-up.org/haid/haidfund2.htm

since ours is a managed care plan, we asked our pediatrician (who

technically approves all services) to send in this letter. I actually

wrote it with input from our audiologist and our pediatrician. We

initially got a form letter back saying it wasn't a covered benefit (duh

- we knew that!) so I called and asked that a case manager review our

request. That phone call probably lasted an hour - of course the person

answering the phone didn't want to move it further along. But finally

she agreed - the case manager approved our request pretty much on the

spot. They included earmolds as well as hearing aids.

The happy ending for us is that our insurance now does pay for kids'

hearing aids - our pediatrician and we think we got the ball rolling!

I would chime in and agree with what said that for families who are

choosing to pursue an oral communications route, hearing aids or an

implant may be the " treatment of choice " but not everyone chooses that

so please, let's be cautious with what's said.

And thanks, Sheri, for your excellent note!

Barbara

bhcalimom wrote:

> ['s insur. contact sent an email stating] " Hearing aids arent'

> covered by a lot of insurance companies because they are considered

> developmental and not medically necessary "

>

> ,

>

> i would get your ENT to write a letter stating that for your daughter

> digital hearing aids are " medically necessary. " Use the language the

> insurance company uses in the denial letters, and forward your ENT for

> inclusion in her/his letter. i know it sounds simple and obvious.

> However, after battling an insurance company myself for over a year, i

> tried this approach and it worked.

>

>

>

>

> ------------------------------------------------------------------------

>

[Guest guest]

I really don't believe this is an issue of what is medically necessary. I think

what it boils down to when you take all of the confusing scientific and

insurance lingo out of it is that ----- if someone choses to make medical

interventions for their HOH/deaf child then in the case of mild/moderate

children, hearing aids are the only medical intervention that is available right

now. By insurances denying coverage for hearing aids it is denying us the

ability to make make medical interventions in our childs care. Now this might

be where the term " medically necessary " would come in because hearing aids may

not be seen as a " medical " issue since they are apart from the body. But it is

the only " medical " way to treat a " medical " problem. As we all know hearing

loss is caused by " medical issues " either conductive issues or the nerve (of

course there are others) so why is a " medical problem " being denied treatment?

Barbara Mellert wrote: I'm so sorry I've been

out of the loop a bit - between classes always

seems to be the busiest for me. I guess if you're a professor giving a

final you don't want to bring your computer in to be fixed unless it's

absolutely necessary.

We successfully petitioned our insurance company (which at the time

didn't pay for hearing aids). The letter that our pediatrician wrote is

here:

http://www.listen-up.org/haid/haidfund2.htm

since ours is a managed care plan, we asked our pediatrician (who

technically approves all services) to send in this letter. I actually

wrote it with input from our audiologist and our pediatrician. We

initially got a form letter back saying it wasn't a covered benefit (duh

- we knew that!) so I called and asked that a case manager review our

request. That phone call probably lasted an hour - of course the person

answering the phone didn't want to move it further along. But finally

she agreed - the case manager approved our request pretty much on the

spot. They included earmolds as well as hearing aids.

The happy ending for us is that our insurance now does pay for kids'

hearing aids - our pediatrician and we think we got the ball rolling!

I would chime in and agree with what said that for families who are

choosing to pursue an oral communications route, hearing aids or an

implant may be the " treatment of choice " but not everyone chooses that

so please, let's be cautious with what's said.

And thanks, Sheri, for your excellent note!

Barbara

bhcalimom wrote:

> ['s insur. contact sent an email stating] " Hearing aids arent'

> covered by a lot of insurance companies because they are considered

> developmental and not medically necessary "

>

> ,

>

> i would get your ENT to write a letter stating that for your daughter

> digital hearing aids are " medically necessary. " Use the language the

> insurance company uses in the denial letters, and forward your ENT for

> inclusion in her/his letter. i know it sounds simple and obvious.

> However, after battling an insurance company myself for over a year, i

> tried this approach and it worked.

>

>

>

>

> ------------------------------------------------------------------------

>

All messages posted to this list are private and confidential. Each post is the

intellectual property of the author and therefore subject to copyright

restrictions.

[Guest guest]

I understand what you're saying but unfortunately you have to play their

game - you have to put it in terms of what insurance companies

understand and what will trigger them to pay. I know when the

pre-approval was requested for my older son, Tom's, CI, they at first

were going to deny coverage because the baseline for CI eligibility is

75 db. Tom has one frequency level where his db is 70 (at the very

lowest frequency). So our audiologist intervened for us.

Barbara

Sara Chaddock wrote:

> I really don't believe this is an issue of what is medically

> necessary. I think what it boils down to when you take all of the

> confusing scientific and insurance lingo out of it is that ----- if

> someone choses to make medical interventions for their HOH/deaf child

> then in the case of mild/moderate children, hearing aids are the only

> medical intervention that is available right now. By insurances

> denying coverage for hearing aids it is denying us the ability to make

> make medical interventions in our childs care. Now this might be

> where the term " medically necessary " would come in because hearing

> aids may not be seen as a " medical " issue since they are apart from

> the body. But it is the only " medical " way to treat a " medical "

> problem. As we all know hearing loss is caused by " medical issues "

> either conductive issues or the nerve (of course there are others) so

> why is a " medical pro! blem " being denied treatment?

>

> Barbara Mellert wrote: I'm so sorry

> I've been out of the loop a bit - between classes always

> seems to be the busiest for me. I guess if you're a professor giving a

> final you don't want to bring your computer in to be fixed unless it's

> absolutely necessary.

>

> We successfully petitioned our insurance company (which at the time

> didn't pay for hearing aids). The letter that our pediatrician wrote is

> here:

>

> http://www.listen-up.org/haid/haidfund2.htm

>

> since ours is a managed care plan, we asked our pediatrician (who

> technically approves all services) to send in this letter. I actually

> wrote it with input from our audiologist and our pediatrician. We

> initially got a form letter back saying it wasn't a covered benefit (duh

> - we knew that!) so I called and asked that a case manager review our

> request. That phone call probably lasted an hour - of course the person

> answering the phone didn't want to move it further along. But finally

> she agreed - the case manager approved our request pretty much on the

> spot. They included earmolds as well as hearing aids.

>

> The happy ending for us is that our insurance now does pay for kids'

> hearing aids - our pediatrician and we think we got the ball rolling!

>

> I would chime in and agree with what said that for families who are

> choosing to pursue an oral communications route, hearing aids or an

> implant may be the " treatment of choice " but not everyone chooses that

> so please, let's be cautious with what's said.

>

> And thanks, Sheri, for your excellent note!

>

> Barbara

>

>

> bhcalimom wrote:

>

> > ['s insur. contact sent an email stating] " Hearing aids arent'

> > covered by a lot of insurance companies because they are considered

> > developmental and not medically necessary "

> >

> > ,

> >

> > i would get your ENT to write a letter stating that for your daughter

> > digital hearing aids are " medically necessary. " Use the language the

> > insurance company uses in the denial letters, and forward your ENT for

> > inclusion in her/his letter. i know it sounds simple and obvious.

> > However, after battling an insurance company myself for over a year, i

> > tried this approach and it worked.

> >

> >

> >

> >

> > ------------------------------------------------------------------------

> >

>

>

> All messages posted to this list are private and confidential. Each

> post is the intellectual property of the author and therefore subject

> to copyright restrictions.

>

>

>

>

[Guest guest]

I understand what you're saying but unfortunately you have to play their

game - you have to put it in terms of what insurance companies

understand and what will trigger them to pay. I know when the

pre-approval was requested for my older son, Tom's, CI, they at first

were going to deny coverage because the baseline for CI eligibility is

75 db. Tom has one frequency level where his db is 70 (at the very

lowest frequency). So our audiologist intervened for us.

Barbara

Sara Chaddock wrote:

> I really don't believe this is an issue of what is medically

> necessary. I think what it boils down to when you take all of the

> confusing scientific and insurance lingo out of it is that ----- if

> someone choses to make medical interventions for their HOH/deaf child

> then in the case of mild/moderate children, hearing aids are the only

> medical intervention that is available right now. By insurances

> denying coverage for hearing aids it is denying us the ability to make

> make medical interventions in our childs care. Now this might be

> where the term " medically necessary " would come in because hearing

> aids may not be seen as a " medical " issue since they are apart from

> the body. But it is the only " medical " way to treat a " medical "

> problem. As we all know hearing loss is caused by " medical issues "

> either conductive issues or the nerve (of course there are others) so

> why is a " medical pro! blem " being denied treatment?

>

> Barbara Mellert wrote: I'm so sorry

> I've been out of the loop a bit - between classes always

> seems to be the busiest for me. I guess if you're a professor giving a

> final you don't want to bring your computer in to be fixed unless it's

> absolutely necessary.

>

> We successfully petitioned our insurance company (which at the time

> didn't pay for hearing aids). The letter that our pediatrician wrote is

> here:

>

> http://www.listen-up.org/haid/haidfund2.htm

>

> since ours is a managed care plan, we asked our pediatrician (who

> technically approves all services) to send in this letter. I actually

> wrote it with input from our audiologist and our pediatrician. We

> initially got a form letter back saying it wasn't a covered benefit (duh

> - we knew that!) so I called and asked that a case manager review our

> request. That phone call probably lasted an hour - of course the person

> answering the phone didn't want to move it further along. But finally

> she agreed - the case manager approved our request pretty much on the

> spot. They included earmolds as well as hearing aids.

>

> The happy ending for us is that our insurance now does pay for kids'

> hearing aids - our pediatrician and we think we got the ball rolling!

>

> I would chime in and agree with what said that for families who are

> choosing to pursue an oral communications route, hearing aids or an

> implant may be the " treatment of choice " but not everyone chooses that

> so please, let's be cautious with what's said.

>

> And thanks, Sheri, for your excellent note!

>

> Barbara

>

>

> bhcalimom wrote:

>

> > ['s insur. contact sent an email stating] " Hearing aids arent'

> > covered by a lot of insurance companies because they are considered

> > developmental and not medically necessary "

> >

> > ,

> >

> > i would get your ENT to write a letter stating that for your daughter

> > digital hearing aids are " medically necessary. " Use the language the

> > insurance company uses in the denial letters, and forward your ENT for

> > inclusion in her/his letter. i know it sounds simple and obvious.

> > However, after battling an insurance company myself for over a year, i

> > tried this approach and it worked.

> >

> >

> >

> >

> > ------------------------------------------------------------------------

> >

>

>

> All messages posted to this list are private and confidential. Each

> post is the intellectual property of the author and therefore subject

> to copyright restrictions.

>

>

>

>

[Guest guest]

I understand what you're saying but unfortunately you have to play their

game - you have to put it in terms of what insurance companies

understand and what will trigger them to pay. I know when the

pre-approval was requested for my older son, Tom's, CI, they at first

were going to deny coverage because the baseline for CI eligibility is

75 db. Tom has one frequency level where his db is 70 (at the very

lowest frequency). So our audiologist intervened for us.

Barbara

Sara Chaddock wrote:

> I really don't believe this is an issue of what is medically

> necessary. I think what it boils down to when you take all of the

> confusing scientific and insurance lingo out of it is that ----- if

> someone choses to make medical interventions for their HOH/deaf child

> then in the case of mild/moderate children, hearing aids are the only

> medical intervention that is available right now. By insurances

> denying coverage for hearing aids it is denying us the ability to make

> make medical interventions in our childs care. Now this might be

> where the term " medically necessary " would come in because hearing

> aids may not be seen as a " medical " issue since they are apart from

> the body. But it is the only " medical " way to treat a " medical "

> problem. As we all know hearing loss is caused by " medical issues "

> either conductive issues or the nerve (of course there are others) so

> why is a " medical pro! blem " being denied treatment?

>

> Barbara Mellert wrote: I'm so sorry

> I've been out of the loop a bit - between classes always

> seems to be the busiest for me. I guess if you're a professor giving a

> final you don't want to bring your computer in to be fixed unless it's

> absolutely necessary.

>

> We successfully petitioned our insurance company (which at the time

> didn't pay for hearing aids). The letter that our pediatrician wrote is

> here:

>

> http://www.listen-up.org/haid/haidfund2.htm

>

> since ours is a managed care plan, we asked our pediatrician (who

> technically approves all services) to send in this letter. I actually

> wrote it with input from our audiologist and our pediatrician. We

> initially got a form letter back saying it wasn't a covered benefit (duh

> - we knew that!) so I called and asked that a case manager review our

> request. That phone call probably lasted an hour - of course the person

> answering the phone didn't want to move it further along. But finally

> she agreed - the case manager approved our request pretty much on the

> spot. They included earmolds as well as hearing aids.

>

> The happy ending for us is that our insurance now does pay for kids'

> hearing aids - our pediatrician and we think we got the ball rolling!

>

> I would chime in and agree with what said that for families who are

> choosing to pursue an oral communications route, hearing aids or an

> implant may be the " treatment of choice " but not everyone chooses that

> so please, let's be cautious with what's said.

>

> And thanks, Sheri, for your excellent note!

>

> Barbara

>

>

> bhcalimom wrote:

>

> > ['s insur. contact sent an email stating] " Hearing aids arent'

> > covered by a lot of insurance companies because they are considered

> > developmental and not medically necessary "

> >

> > ,

> >

> > i would get your ENT to write a letter stating that for your daughter

> > digital hearing aids are " medically necessary. " Use the language the

> > insurance company uses in the denial letters, and forward your ENT for

> > inclusion in her/his letter. i know it sounds simple and obvious.

> > However, after battling an insurance company myself for over a year, i

> > tried this approach and it worked.

> >

> >

> >

> >

> > ------------------------------------------------------------------------

> >

>

>

> All messages posted to this list are private and confidential. Each

> post is the intellectual property of the author and therefore subject

> to copyright restrictions.

>

>

>

>

[Guest guest]

So if we wanted to fight to change the law that allows self funded plans to deny

aids even when the state has a law demanding coverage from regular insurances

then ERISA is who we have to fight? Putting all my ducks in a row here....

sbyrne1281 wrote:

ERISA is the federal law that governs self-insured plans. It maybe

that the medical review board they are describing is an ERISA

arbitration. If it isn't, you have that option left to you also in

addition to the appeals that you've described

Sheri

__________________________________________________

[Guest guest]

I feel like the insurance CEO are the the gods of our society and we are all

little puppets on puppet strings. This is a horrible feeling to realize that

you have very little control of the situation and that infact it all lies in one

hands man.

Barbara Mellert wrote: I understand what

you're saying but unfortunately you have to play their

game -

__________________________________________________

[Guest guest]

I think about that all the time - ditto for the appointment secretaries

who have your life in their hands! I'm *very* nice to those folks!

<grin> It is very frustrating - we all know!

Barbara

Sara Chaddock wrote:

> I feel like the insurance CEO are the the gods of our society and we

> are all little puppets on puppet strings. This is a horrible feeling

> to realize that you have very little control of the situation and that

> infact it all lies in one hands man.

>

> Barbara Mellert wrote: I understand

> what you're saying but unfortunately you have to play their

> game -

>

[Guest guest]

There is a bill in Congress that would provide a tax CREDIT for hearing aids.

Not a deduction or an itemization but a tax credit. So the money you spend on

HA gets taken off of your tax bill. Don't know the number ... in GA

-----

[Guest guest]

There is a bill in Congress that would provide a tax CREDIT for hearing aids.

Not a deduction or an itemization but a tax credit. So the money you spend on

HA gets taken off of your tax bill. Don't know the number ... in GA

-----

[Guest guest]

There is a bill in Congress that would provide a tax CREDIT for hearing aids.

Not a deduction or an itemization but a tax credit. So the money you spend on

HA gets taken off of your tax bill. Don't know the number ... in GA

-----

[Guest guest]

Ohhh....more info please.

pcknott@... wrote:

There is a bill in Congress that would provide a tax CREDIT for hearing aids.

Not a deduction or an itemization but a tax credit. So the money you spend on

HA gets taken off of your tax bill. Don't know the number ... in GA

-----

All messages posted to this list are private and confidential. Each post is the

intellectual property of the author and therefore subject to copyright

restrictions.

[Guest guest]

IMO (I'm not Sheri!LOL!) is yes, just fight. There is nothing in life that

can't be done when there are many voices behind the issue - especially one like

this.

Enemy #1 - Federal law and regulations which these self insured plans are

under (Department of labor I believe)

Enemy #2 - Medicaid - they need more education and facts about analog vs.

digital and the benefits of hearing aids overall.

ALSO - I would like to look more into the balance issue that can sometimes be

affected by a hearing loss. I think if that can be linked as a side affect of

hearing loss it would help in the " medically necessary " catagory. Of course -

only for those who wish to be aided.

Parentsofdeafhoh@... wrote:

Sheri,

Is there anything we can do on the federal level to change the way hearing

aid coverage is provided overall?

Putz

Illinois Families for Hands & Voices

_www.handsandvoices.org_ (http://www.handsandvoices.org/)

_www.ilhandsandvoices.org_ (http://www.ilhandsandvoices.org/)

Email: support@...

[Guest guest]

IMO (I'm not Sheri!LOL!) is yes, just fight. There is nothing in life that

can't be done when there are many voices behind the issue - especially one like

this.

Enemy #1 - Federal law and regulations which these self insured plans are

under (Department of labor I believe)

Enemy #2 - Medicaid - they need more education and facts about analog vs.

digital and the benefits of hearing aids overall.

ALSO - I would like to look more into the balance issue that can sometimes be

affected by a hearing loss. I think if that can be linked as a side affect of

hearing loss it would help in the " medically necessary " catagory. Of course -

only for those who wish to be aided.

Parentsofdeafhoh@... wrote:

Sheri,

Is there anything we can do on the federal level to change the way hearing

aid coverage is provided overall?

Putz

Illinois Families for Hands & Voices

_www.handsandvoices.org_ (http://www.handsandvoices.org/)

_www.ilhandsandvoices.org_ (http://www.ilhandsandvoices.org/)

Email: support@...