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How do we survive???

Discussion in 'Insurance Issues' started by KitKat, Jun 18, 2008.

  1. KitKat

    KitKat Approved members

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    I just received a letter from Anthem stating, after the approval of the CGMS, that we have met our $4000.00 DME cap. Well, then they tell me.....ALL SUPPLIES fall under DME!!! This is going to be unbearable for our family and it is shocking to me that insurance companies would do this to families.

    Are any of you facing something similar??
     
  2. Mama2H

    Mama2H Approved members

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    OMG that is horrible!!! Is there anything you can do? Insurance just plain sucks :mad:
     
  3. Thoover

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    You have to pay full price for supplies until you meet the 4,000? Or when you get the Sensor then the 4k kicks in??
     
  4. Mama2H

    Mama2H Approved members

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    Sounds like they have paid out 4000 and won't pay out anymore so they will have to pay out of pocket for supplies :(
     
  5. Nancy in VA

    Nancy in VA Approved members

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    Unfortunately many companies have DME caps. The CGMS most certainly falls in DME. But could you dispute the ongoing supplies as DME? Some companies are quick to call things DME that perhaps should be pharmaceutical supplies
     
  6. Thoover

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    Thanks I read it wrong. That is crazy.. They have MET the 4K DME. That is just awful.. Then I suppose that would be one huge expense. Just so Anthem has to do more paper trail I would ask them to get you a print out of all DME that you have purchased this year Or from Anniversary date of your policy when it kicks into a new year. Some are around November others start Jan 1.
    I do however keep all receipts of copays that we have paid out of pocket. Just a though.
     
  7. KitKat

    KitKat Approved members

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    We have met our $4000.00 max DME cap. We switched from Cozmo to the Real-Time pump. Hunter's doc felt he needed the CMGS because he suffers from hypo-unawareness. (He can be 35 and have NO idea) So...we switched and clearly maxed out the $4000.00 cap.

    So they won't pay anymore for pump supplies (infusion sets, tubing, insulin cartridges) and after appealing and WINNING....they won't pay for sensors! I have been crying all morning trying to figure this out. I quit my teaching job when Hunter was dx'd and just started going back part-time. My position has now been cut even more due to budgetary issues at the school. I feel like I have been hit in the stomach.

    I was told by our MM rep that my husbands work is who usually puts on the cap. Have you heard such a thing? I don't know how we are going to do it and I can't imagine telling my kids....NO MORE SPORTS and NO MORE GYMNASTICS (my daughter is a Level 7 gymanst @ age 9).

    DIABETES SUCKS BUTT!!!!
     
  8. Thoover

    Thoover Approved members

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    Now I wish I had extra supplies for what you use cause I would ship you a huge box of supplies.

    Hopefully someone else will read this thread and have some words of advise for you..

    (((HUGS))))
     
  9. hurrayupmom

    hurrayupmom Approved members

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    A couple of years ago, our supplier at the time called for 3 month order. I placed order like usual. Received order and was using supples, Received bill, our insureance denied order. I called insurance, they said suppler no longer in our network. Funny no one told us. Our bill was in the 2000.00. No coverage at all. We are still paying on this.:mad:
     
  10. iluvmhp

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    I would love some advise to. . . .We have a $2500 cap and all pump supplies are covered under DME also!!!!! We are pump shopping too, so once we get the pump, our DME is capped, so all supplies are on us. This really is absurd. As if we dont have enough to worry about!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
     
  11. BrendaK

    BrendaK Neonatal Diabetes Registry

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    Do you have any other insurance plans that you can enroll in during open enrollment? The best bet would be to switch plans ASAP!!! (Which is usually open enrollment)

    When DH started his new job, the HMO had a cap on DME, but the more expensive POS plan had no cap at all on DME. We ended up going with the POS hugly because of the DME issue. It's costing a lot more monthly for premiums, but a HUGE savings on the DME (and the fact that A+ takes the insurance!!)

    I'm so sorry you have to go through this. Unfortunately, this is really common w/insurance companies :mad:
     
  12. BrendaK

    BrendaK Neonatal Diabetes Registry

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    Oh -- Another thing to check. Does your state have any kind of Childrens' Special Health Care services? Some states have this program that will pay for all diabetes supplies no matter what your insurance or income level is. Michigan is one of those states. So please check into your state programs, too. When we lived in Michigan, we would not have survived without that program, even though we had insurance!!!
     
  13. KitKat

    KitKat Approved members

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    Brenda thank you for all your ideas...I am going to check on this TODAY!

    Indiana has Childrens Health Services but it has to do with income and we are a few thousands over!!

    I appreicate ALL your help!!
     
  14. iluvmhp

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    best of luck . . .please let us know if you find anything out . .. i will be researching too!
     
  15. dragonblimps_mom

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    If the cap was established by your husband's employer, go to them and request that they lift the cap in your case. Show them the letter of medical necessity from the endo. That cap is there to keep people from ordering top of the line hospital beds, electric chairs, all kinds of other DME equipment that is nice but not necessary in every case. This is entirely different. There are no cheaper substitutes. Push it, baby, push it!

    We cheering for you.

    Mary C., mom to Amelia
     
  16. tiffanie1717

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    This was what I was going to say. We live in PA and we are in the process of signing Kylie up for a Medical Access Card. Because JD is never going to go away and we are going to need supplies for the rest of her life, they will cover what our insurance will not. (once we get approved - and our income doesn't matter because of being insulin-dependent).

    Check it out!!
     
  17. KitKat

    KitKat Approved members

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    Update:

    Husband's work does NOT decided the cap. Anthem has a standard cap of $4000.00.

    Someone suggested disability insurance. He wouldn't qualify would he? I have called Children's Heath Services today...and waiting for a call back. But I am pretty sure it is based on income.
     
  18. SaltyAndSweet

    SaltyAndSweet Approved members

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    I am so sorry to hear about your stubborn insurance. I never understood the DME maximum cap when the insurance usually approves all DME items anyway! I hit my lifetime maximum with my secondary insurance about 10 years ago with the purchase of a respiratory therapy vest and I am afraid I may meet my primary insurance cap this year with my purchase of an insulin pump.

    I don't know if this can help, but I was told by a medical supply company to ask the insurance themselves to lift the cap. There has to be an appeal process or something to be able to change it. No doubt it would take a BIG fight, if it is even possible.

    There also may be some non-profit organizations that could help you out. One that comes to mind immediately is iPump.org, at least for pump supplies. You may also want to check with your state's insurance commission about your legal rights as well. There may be a government run insurance or assistance to help you. If I think of anything else I will post again.

    Also, if you can prove to the insurance that a piece of DME is "life sustaining" it should not go against your cap (or so I was told by my insurance, they may change their tune when I get close to my maximum).

    The only real fix to the problem is to change jobs/insurance policies. :(

    Wish I could be of more help!
     
  19. Brensdad

    Brensdad Approved members

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    I think some people have had some luck charging supplies to pharmacy instead of DME. By definition, anything that is "disposable" is not DME.
     
  20. badshoe

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    Confused?

    Click Uncle Sam!
    [​IMG]
     

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