Sunday, July 17, 2011

Making Sense of Healthcare Coverage

Let me start off by saying I am very grateful for the government healthcare assistance Robert receives. Really I am. Sometimes, though, I am left scratching my head about coverage decisions!

1. Vision care. When Robert first moved to a care facility in Sacramento, he needed a primary doctor and I also thought it would be a great idea to get his eyes checked and for him to see a dentist. I was fairly confident he hadn’t seen either in quite some time so wanted to take care of this for him. The primary doctor was priority number one so arranged that using the doctor affiliated with his first care facility (he now has a new doctor that is affiliated with New Home and will have yet another one once he moves in with me). Eyes and teeth were next but before the eye appointment, I bought Robert reading glasses because he was squinting while working on his word search puzzles. Can’t have that! Sat him down on the seat of his walker at CVS, gave him several pairs to try on to find the right magnification as well as a style he actually liked. Hours later, he was able to read his puzzle book without squinting! The vision appointment was made but then something happened and I needed to change it to the following month.

Well, vision coverage wasn’t covered the next month (it must have been a new budget year). Ugh. So much for that idea! At least Robert had the reading glasses and was able to do his puzzles. Once Robert moved to New Home, vision coverage was restored and his eyes were checked (and the doctor confirmed the reading glasses we bought were sufficient). When Robert moves in with me, vision check ups are back to not being covered. Even though, it would seem, the state is saving money by having Robert live with a family member.

Can someone explain the logic of this to me, please?

2. Dental Care. A similar story. At New Home, Robert had a surgical dental appointment where he was put under anesthesia in case extensive tooth extractions or other dental work was necessary. This procedure is done every five years. When living at New Home, Robert gets four cleanings a year paid for by Medi-Cal. When he moves into my home, his dental coverage is: zero! We go from excessive dental coverage to non-existent and yet the state saves a gazillion dollars by having a family member care for Robert?

Where’s the logic? Anyone?

3. Incontinence Supplies. Robert uses pull up briefs during the day (which keep him dry for the most part but also allow him the independence to use the restroom when he can). At nighttime, the only way to keep him dry is to use the adjustable strap briefs (like a regular diaper) and use a pull up brief over that. Medi-Cal/Medicare only pays for one type of brief. Robert can have the adjustable strap briefs or the pull up briefs. Not both. Even if the pull ups help his independence and the adjustable strap keeps him dry at night (which reduces the risk of a rash leading to doctor visits, medication – you get the point). I’m very grateful they at least pay for one kind, though, but can’t understand why they draw the line at one particular kind. For quite some time, I didn’t realize this could be paid for at all if it was medically necessary so was going broke buying those things! Now I personally purchase two bags of the adjustable briefs a month and he’s clean and dry. Definitely worth it.

I wonder, though, why aren’t both covered if both are medically necessary?

Let me reiterate: I am grateful for the state and federal government paying for Robert’s medical care. I understand the government doesn’t have to do this. I just want to make sense of the coverage! I just want to understand the logic of it. I am curious how these rules came to be. Was the approval process so watered down in committee that the rules became nonsensical?

These are just a few examples of healthcare coverage that makes no logical sense. Everyone seems to have a story about ridiculous healthcare coverage decisions (whether through private insurance or the government). I’d love to hear your stories (personal note to Atticus -- take as much room and time as you need!).


KeepUpWeb said...

You chose the perfect title for your article. Health care management makes absolutely no sense. Your case is the perfect example of why government should not be managing our healthcare.

Trish Hughes Kreis said...

Sherryl, Thanks for stopping by my blog! Can you tell I use Blogger instead of WP? :-)

You would think after these examples and the experiences I've had with Robert, I'd be against a national healthcare plan but I actually support it. We just need more common sense!

What I have found interesting this weekend (because my mother-in-law was at the Travis AFB ER and then admitted to their hospital), is the astounding care she is receiving! She was given subpar care in Sacramento using her private insurance & Medicare but went to Travis and the care there is phenomenal. How can the government get it right there but not with Medi-Cal/Medicare? There are so many problems with all insurance (private or federal or state). It's all a mess, definitely with no easy answers.

mem said...

Here's one for you - I was born hard of hearing and my hearing aids are not covered under insurance. They are considered 'durable medical equipment' and therefore not medically necessary. Crazies. Keep up the great work on behalf of your brother!!

Kathy Lowrey said...

I feel your pain in this area. The V.A. only allows 4 packages of disposable undergarments a month. We need at least 7 so we have to buy the rest ourselves.
And just to get the Pull up style was a chore in itself, Dr request, explanation why he needed the pull up style... red tape red tape. Took a few months tho get the right ones but we did.

I even carried them into the pharmacy and said see this (tape style), this is NOT what we need. See this (pull up) THIS IS what we need. He had to call the main pharmacy while I was there to verify we would get the right thing. UGH!

At least Hubby gets something and that's more than some get at all so I appreciate it, just get annoyed at how hard we have to work to get the right things.

Trish Hughes Kreis said...

Kathy, So frustrating! As if you have the time to go into the pharmacy to straighten them out. Argh! I understand where you're coming from -- you don't want to seem ungrateful. I get that! It is really frustrating and seems so unnecessary to have to work so darn hard to get the benefits we're told our loved one gets. Hugs to you and Hubby!

Trish Hughes Kreis said...

Momma Mara, Oh my goodness -- talk about frustrating! Hearing aids are not medically necessary even though you have trouble hearing? Then would they EVER be classified as medically necessary? I don't know if you have private insurance or if it's through the state but I wonder if there's a process for you to appeal that decision (you probably already did that but throwing it out there). Thank you for reading and commenting. I hope you come back! Take care.