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Ohio Medicaid a blessing and a curse.

Discussion in 'Parents of Children with Type 1' started by Judy&Alli, Sep 13, 2011.

  1. Judy&Alli

    Judy&Alli Approved members

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    Hello everyone,
    My dd has medicaid. I was informed today that she cannot recieve a new pump for 8 years. She will be pumping for 4 years this March. So I asked what happens after March if it breaks. Absolutely no upgrade or new pump until she hits the 8 year mark. So I am guessing she will have to go back to MDI if the pump breaks. I am so torked off, I think they need to come live a day in the life of a cwd. Has anyone had a pump actually last 8 years?

    On the otherhand I do feel blessed to have this coverage so far, I just feel they are out of line thinking a pump will last 8 years.

    Is there anyone out there that has Ohio medicaid?
     
  2. Flutterby

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    Thats just out right crazy! I know NH its every 4 years.. 8 years is ridiculous.
     
  3. mom24grlz

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    um wow. We have Ohio medicaid, I just automatically thought that after 5 years Ashleigh could get a new pump. Is the medicaid your main insurance or secondary? We have 3 insurances on Ashleigh, with medicaid being the secondary insurance.
     
  4. Judy&Alli

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    I thought so too. I thought I would start early so we have no lapse in unwarrantied pumps. I had no idea this was coming!!! And yes this is the only coverage right now.
     
  5. bnmom

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    We have Anthem primary and Ohio Medicaid as secondary. Anthem wasn't going to cover the pump at all, but Medicaid did. Our CDE said 5 years before we could get another, but I've never asked Medicaid directly.

    That 8 yr thing would totally suck, but then again I can't complain because Medicaid has saved my a$$. They've picked up a TON of costs Anthem won't touch. I thank God for that Medicaid backup every single day.

    I wonder if it's like some other things where the endo can get them to override? I'd ask your endo's billing office, they probably know alot more about what can be worked out.
     
  6. Lisa P.

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    Not in Ohio, but wanted to point out the Omnipod program they have running right now. The deal is supposed to be that you get the control thingamagig and a month's worth of pods if you have a current pump that's not Omnipod, and after rebates the cost to you is $150. I've considered it myself as a backup. Not a long term solution and it would mean a different system, but at least then you'd have two "pumps" if one broke. When I talked to our insurance, they said they'd cover pods as well as pump supplies for our Ping, they don't care what pump we use if they don't have to pay for it, they'll cover supplies from either company (not sure they entirely understood the pods were a lot more expensive, but hey!:eek:)

    Hope that helps.
     
  7. lynn

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    I am in Michigan and have a friend with a daughter who only has medicaid. When she first got a pump for her daughter she was told that it would be replaced in four years when the warranty was up. Four years came and she tried to order a new pump and was told that they had worked out a deal with Minimed to warranty the pump for five years so she would have to wait another year.

    Could it be that Ohio has worked out a similar deal? I hope so.
     
  8. sammysmom

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    I just did the omnipod thing and you do not get the one month worth of pods with the deal. Just the PDM. The pods go through your insurance. We swapped pods for infusion sets and just paid for the PDM. I thought you got one months worth of pods with the deal but apparently not. Still, it is a great deal. You get the $50 credited back to your credit card after 3 orders of pods.
     
  9. Sarah Maddie's Mom

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    If your current pump is still in warranty I would examine it closely, very, very closely and see if there are any hairline cracks and if so, call now and have the pump replaced. ;)
     
  10. jilmarie

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    This. My pump is out of warranty as of this summer, and my insurance doesn't cover pump supplies. I had a tiny tiny hairline crack by the reservoir and called to have it replaced a month before my warranty ended. It's a legitimate reason for a replacement, and you get a "new" pump before the warranty ends. My pumps almost always have tiny cracks near the reservoir window.
     
  11. Judy&Alli

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    Do you have straight Medicaid? Or do you have Care Source or something like that? For some reason they never changed us to an HMO type thing. I was also under the impression that if you have another insurance that medicaid would drop you. I never heard of it being a secondary. I am very interested in this option.

    If you ever get a minute could you call your pump company and see if they know of an 8 year pump policy. No rush, I am just curious. And if you can't that is ok too.
     
  12. 2type1s

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    I have had Morgans ORIGINAL animas pump for 8 years. We use it every time one of the other ones break! It seems like they started making them cheaper around 6 years ago. We got through at least one a years between the girls. But the old one worked fine for 5 years, now it's our back-up! I need to call o Morgans now...has a crack at the reservoir! Again
    I don't understand how an insurance company can make a decision like that! Infuriating!
     
  13. Judy&Alli

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    I am not sure. I would be ok with 5 years, 8 years not so much.
     
  14. Judy&Alli

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    We have had many, many pumps replaced. I just don't see how it will last 4 more years. It is infuriating!
     
  15. bnmom

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    We have Molina - it was a choice of that or Care Source...I'd heard Molina was better but I honestly never compared the two (this was around dx so my thoughts were elsewhere!) I'm surprised you don't have either as they told me I had to pick one or they'd pick for me. But I know they give you a chance to switch plans at least once a year.

    They don't care if you have other insurance - their only requirement is that costs are run through the other insurance first (medicaid demands to be secondary and whatever other policy you have is primary). But so far, they pick up 100% of whatever is left over after Anthem (short of some over the counter stuff).

    Our CDE is the one that mentioned 5 years and I know she's on vacation for a couple weeks but I've put it on my list of things for the next time I talk to their office in case she knows of a workaround (we're through Childrens Hospital so they're really experienced with finding specific insurance workarounds!) I'll post here or pm you when I talk to them. Please do let me know if you find out anymore as well. :cwds:
     
  16. mom24grlz

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    Same situation here. Anthem is our primary and Medicaid is our secondary. We also have BCMH as a third party insurance.
     
  17. mom24grlz

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    My answers to your question are in Red. Since we also use medicaid as a secondary insurance.
     
  18. Brensdad

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    I read through Ohio's administrative code, and I am almost certain that someone has made an error on a billing code or modifier. It's possible someone mis-read the code and thinks that the pump is a rented item vs. a purchased one (this is a very common error when dealing with payment for DME from Medicare/Medicaid.) I would also ask them to look at how it was billed, because Medicare's federal rules for Medicaid (Medicaid is federal money and comes with lots of rules and stipulations that virtually mirror Medicare) always require replacement of an item if repair costs exceed replacement OR the item is no longer covered under warranty.

    What I find interesting is that Ohio Medicaid requires a 3-month "trial" of the pump prior to purchase, and then later on the code states that "previously used" pumps are "never" authorized for purchase. I'd bet this little jumble of legal lingo could be causing the problem as well.

    http://codes.ohio.gov/oac/5101:3-10-29

    Best of luck.
     
  19. Judy&Alli

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    Thanks Nick,
    I read the whole thing. What is really interesting is that they were going to take Alli's pump away if her A1C wasn't under 8% in the first 3 months. Such ridiculous rules. I am sure they put these rules in place for people who abuse the system. It is so frustrating.

    I am going to call the endo as others suggested and see if they know how to fix this. She needs the MM pump because her insulin requirements have grown dramatically. Animas only has 200 unit cartridge. So maybe that is medical necessity, who knows??? I am flabberghasted that they think a pump will last 8 years.

    I will also try to call medicaid. I don't know if I will actually get someone on the phone though. But thanks for the suggestions. :)
     
  20. Melissata

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    That is just hard to believe. I think that I would be calling to talk to someone different and ask to be sent the policy that states this. I have never had to deal with Medicaid before, since it is secondary for my daughter but that just seems so ridiculous. I hope that you find a way around this.

    I am curious as to the Dexcom though. Are they paying for it? I was under the impression that neither Medicaid nor Medicare covers either CGM or Omnipod.
     

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