Doctor to Doctor Review: Employer Provided Group Health Insurance

It’s been one thing after another since the placement of our special needs siblings for adoption in 2003. We added our children to our Employer Provided Group Health Insurance as soon as possible. In order to be sure all of their needs are met children adopted from foster care have Medicaid or State medical benefits until the age of 18 as part of the Adoption Assistance provided for special needs children. Our private employer group health insurance is seen as Primary with the Medicaid/State medical as secondary.

Recently the federal government has passed laws requiring insurance companies treat mental health coverage, benefits and services the same as the medical portion of the policy. The Mental Health Parity law is supposed to make it possible for mental health issues to be treated the same as any other medical problem an employee or their dependents might suffer.

It has been one heck of a roller-coaster ride dealing with Primary and Secondary insurance coverage. Especially, under the circumstance of a mental health issue. Our daughter finally Hit her limit and went over the edge after the holidays. We used our private employer provided insurance to have her placed into a two-week sub-acute psychiatric hospitalization. Our private insurance approved kicking and screaming the whole way. The details of that will be part of future Blogs.

Since, I understand some of the politics and insurance reasons that go on behind our back I haven’t been as surprised or upset by the decisions and documents our insurance company has made. I’m sure most non-insurance people would be more confused and upset then I am, but the fact is I am upset.

Within a few days following our daughters admission to the psychiatric unit our insurance company started holding Doctor to Doctor conferences and decided that our daughter no longer “qualified” for hospitalization under the terms of our insurance policy. Our insurance will only continue to pay if she is homicidal or suicidal. Our daughter is neither of these at this point in time.

A Doctor employed by the insurance company makes the final decision not the doctors who provide our child with mental health care. Without the Adoption Assistance Medicaid/State Medical insurance our daughter would have been discharged over a week ago. If the only insurance we had was the group health we would have needed to ask for an appeal. When the insurance company makes a dramatic decision like this one, a letter of “Initial Denial of Authorization” is issued and we have certain rights when this happens.

The next Blog will discuss what to do when you or an insured family member receives an Initial Denial of Authorization letter from an insurance company.

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Glossary of Insurance Terms:

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