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‹#›&=
#13;
1
Insurance Funding for SGDs<=
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•Presented
by:
•
•Lewis
Golinker, Esq.
•Director,
Assistive Technology Law Center
•401
East State Street, Suite 300
•Ithaca,
New York 14850
•607-277-7286
(v)
•607-277-5239
(fax)
•Lgolinker@aol.com (e-mail)
•
•Bridges
to Better Advocacy
•Austin,
Texas
•April
7, 2006
2
3
2 Systems of Benefits
•Insurance Policies
•Health Benefits Plans
–4 types:
•Self-funded plans
•Partially-funded plans
•Insured plans
•Exempt plans
4
Policies & Plans
–=
Insurance Policies: pur=
chased
from an insurance comp=
any as
a package. A premium is paid and claims are paid from the accumulated premiums by the insurer. Risks of utilization are borne by insurer.
–Health Benefits Plans: employer creates a plan; writes its own scope of benefits; and pays claims out of its own assets. Risk of utilization is borne by employer. The plan may hire an insurer to administer the plan.
5
Types of Health Benefits
Plans
•self-funded: an employer or association =
creates a plan
and funds it totally, from company or association assets.
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•partially-funded: the plan purchases an =
insurance pol=
icy
to cover certain risks (excess cost or “stop-loss”policies).
•insured plan: the employer or association =
creates a pla=
n,
but the plan then purchases insurance to cover its outlays.
•exempt plan: the term applied to a plan <=
span
style=3D'font-family:Arial;mso-ascii-font-family:Arial;mso-bidi-font-famil=
y:
"Times New Roman";mso-hansi-font-family:Arial;font-size:88%'>issued by a
government.
6
Policies & Plans Are Subject to Different Legal=
Rules
=
Type of
Benefit
----------------
Legal Syste=
m Applicable&=
#13;
Insurance Policy
=
;
Insured Pla=
n
Exempt (Government) Plan=
3;
Self-Funded Benefits Plan
Partially Funded Benefits Plan
State Common Law Rules o=
f Insurance <=
/span>Interpretat=
ion
Yes
Yes
Yes
No
No
State Insurance Non-=
Discriminat=
ion Statutes=
3;
Yes
Yes
Yes
No
No
ADA
Yes; 12201(c)(1)=
Yes; 12201(c)(2)=
Yes; 12201(c)(2)=
No; 12201(c)(3)
No; 12201(c)(3)
ERISA Preemption&=
#13;
Not Applicable
Exempt
=
Exempt
=
Yes
Yes
=
7
3 Sources of Controlling Law
•Insurance
Policies, Insured & Exempt Plans are governed by:
•
–State
Contract Law & Common Law
–State
Unfair Trade Practices Law
–Americans
with Disabilities Act
8
2 Types of Denials
•Insurers’ and Health Benefits Plans’ <=
span
style=3D'position:absolute;top:38.0%;left:12.17%;width:80.14%;height:7.75%=
'>SGD denials will be based on:&#=
13;
•
–“Adverse ‘Fit’ Determinations”
–Express Exclusions
9
Strategy: Expect A “Yes”
• Long History of SGD Coverage
• Strong Legal Protections
• Lots of Supporting Information
•Low Incidence Need; No Woodwork =
Effect
• Cost:Defense Ratio is Very Low
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<=
span
style=3D'font-family:Arial'>•Diversity in Theory; Common in Practice
10
Legal Basis to Expect A “Yes”
•Legal Rules that G=
overn
Policies:
–Duty
to Investigate Claims
–Ambiguity
–Any
Reasonable Interpretation to Support Coverage Controls
–Exceptions
Read Narrowly
–Non-Discrimination
Absent Actuarial Data
11
Why Was SGD Denied?
Adverse ‘Fit’ Determinations
Adverse ‘Fit’ Determinations
Not DME
Not Medical In Nature
Not Covered
Useful in
Absence of Illness or Injury
Not Treatment
Not Medically Necessary
Not Treatment
for Underlying Condition
Convenience Item
No Medical Purpose
Educational or Vocational Purpose
12
Why Was The SGD Denied?
Express Exclusions
Express Exclusions
•=
Express Exclusions:
–Policy
or Plan states SGDs are excluded
–SGDs
fit within scope of larger benefit exclusion (e.g., developmental care (care to treat a developmental =
disability affecting speech development))
13
Responding to Adverse Fit Determinations
•What
Benefits Are Covered?
•Reviewer
Credibility: Can reviewer credibi=
lity be questioned?
•Duty
to Investigate: What did reviewer look at prior to deciding?
<=
/span>
–Internal Search: Has Insurer or Plan addressed similar issues previously?
–=
External Search: Have professional literature; professional societies, and other =
funding sources addressed similar issues?
14
What Benefits Are Covered?<=
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•=
Look for DME
•=
Look for Prosthetic Devices
=
•=
Look for Definitions:
–=
No definition at all
–=
Copies Medicare
–=
Copies Parts of Medicare
–=
Idiosyncratic
–=
Lists specific items
15
DME Definitions: Medicare
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•=
DME is equipment that:
–=
1. Can
withstand repeated use;
–=
2. =
Primarily
and customarily is used to serve a medical purpose;=
3;
–3.=
Generally
is not useful to an =
=
individual
in the absence of illness or injury; and
<=
/span>
–=
4. Is
suitable for use in the home.
•=
42 C.F.R. 414.202
16
DME Definitions
•DME
which is used for medical necessity [sic] such as:
–=
Appliances which replace lost body part;
<=
/span>
–=
Orthotic devices such as arm, leg, neck, and back braces;
–=
Hospital type beds;
–Equipment needed to increase mobility, =
such as a wheelchair;
–Respirators and other equipment for the use of oxygen;
–=
Monitoring devices.
17
DME Definitions: BCBS of California<=
/b>
•Equipment
which is:
–1. Determined to be medically necessary t=
o treat an illness or injury or condition;
<=
/span>
–2. Of no further use when the medical necessity ends;
–3. For exclusive use of the patient;
=
–4. Not primarily for comfort or
convenience
–5. Not for environmental control or
exercise
–6. Manufactured specifically for medical
use
•Includes
wheelchairs, hospital beds, and other items the Plan determines are DME.
=
•
<=
/div>
18
Reviewer Credibility
•Who
Reviewed? Is the reviewer identified?
•Does
reviewer have any knowledge or experience relevant to SGDs?
–=
Conduct Google.Com search
–=
Check state
medical society web page&=
#13;
–=
Check AMA web page:
–http://webapps.ama-assn.org/doctorfinder/html=
/patient.html
•What
was scope of investigation of claim?
–Ask for production of all documents examined or reviewed
19
Internal Search
•Look at how Insurer or Plan answered same =
questions in other cases
=
–Search for Prior “Yes” Decisions
•www.aacfundinghelp.com
–Existence of Prior “Yes” creates=
duty
to investigate and explain:
•Was scope of benefits and vocabulary the same?
•Even if different, why do differences justify “yes” then, and “no” today?
20
Internal Search
•Clinical
Criteria: Many insurers have adop=
ted SGD clinical criteria:
–More
than 2 dozen BCBS programs
–Aetna:
•www.aetna.com/cpb/d=
ata/CPBA0437.html=
–CIGNA:
•www.cigna.com/healt=
h/provider/medical/procedural/coverage_positions/medical/mm_0049_coveragepositioncr=
iteria_speech_generating_devices.pdf
–Harvard-Pilgrim
Health Plan:
•/HPHCONNECT/USERGUI=
DES/DURABLE_MEDICAL_EQUIPMENT.PDF
–
<=
/span>
21
External Search
•What do other information sources have =
to say about key questions:
=
–Professional
societies
–Other
funding sources
•=
Did insurer or plan look?
•=
How can its interpretations be <=
span
style=3D'position:absolute;top:73.25%;left:12.17%;width:91.94%;height:6.75=
%'>“reasonable” or not arbitrary when they conflict with this information?
•
22
Not DME
•Compare, if no definition:
–Medicare
–Medicaid
–Other Insurers
•If definition, will be definition specific
23
Not Treatment
•Compare:
–AMA
–American
Academy of Neurology
–American
Academy of Physical Medicine & Rehabilitation
–Formal
Request
•All posted at:
www.aug=
cominc.com/funding.html
–Tricare
– Congress expressly authorized coverage
–VA
24
Not Treat Underlying Condition
•Not likely to be part of standard
<=
/div>
–Insurer or plan can’t invent sta=
ndards
to apply or import
them from elsewhere if not stated in policy or plan
•Not consistent with coverage of wheelchairs, <=
/span>other mobility aids, oxygen, oth=
er
common D=
ME
items – none address underlying condition
•Medicare SGD decisions
25
Not Serve A Medical Purpose=
•Compare:
–FDA, 48 Fed. Reg. 53049 (No. 23, 1983) codifying, 21 C.F.R. 890.3710.
–Medicare
•DME Definition
•SLP Functional Treatment Goals
–Medicaid
26
Not Medical In Nature
<=
span
style=3D'font-family:Arial'>•Not How DME is worded in definition
•Phrase was used in old Medicare NCD, but that was withdrawn April 2000, and =
replaced Jan. 1, 200127
Useful Absent Illness or Injury
•No one who can speak will be evaluated =
or consider SGD:
speech rate is > 10 x SGD rate
• Devices are “dedicated” – no use except as SGDs
28
Convenience Item
•Compare:
–Medicare
(only program ever to call SGDs convenience items in policy; dropped “convenience item” label in April
2000, effective,
Jan. 1, 2001)
–Tricare
– has regulations defining convenience items; never considered SGDs under this rule
–Anecdotes:
both Medicare and Tricare have examples of convenience items (SGDs are nothing like them); court and other statements about importance of <=
/span>communication
29
Educational or Vocational
Purpose
•<=
/span>Compare:
Medicare; Medicaid; FDA
•Use
“but for” (solely because of) test: not because of work or school
needs SGD
•Stated
as alternative to “primarily and customarily serve a <=
u>medical
purpose”
–Factually
wrong: Education less than 20% of day; work less than one t=
hird
– hardly “primarily”
30
Adverse Fit Determinations<=
/div>
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•=
Summary:
–=
Attack on these excuses mirrors Medicaid and Medicare
–=
We have more than sufficient information from unassailable sources to show that =
reasonable interpretations support coverage and that denials have no comparable basis beyond individual reviewer opinion
31
Express Exclusions
•Basi=
s:
insurers and plans have freedom to
cover whatever they want
•3 Step Challenge:
–Ensure express exclusion for SGDs exists
–Isolate exclusion as only reason for denial
–Look to apply external (to policy or plan) legal framework to neutralize or void <=
/span>exclusion
32
Is There An SGD Exclusion?<=
/div>
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•Policy or Plan must state exclusion for SGDs or SGDs must fit within a broader =
exclusion
•=
If no exclusion, non-coverage or excluded claim is merely reviewer opinion, and this is an adverse fit determination
•Exclusions are non-discretionary; they =
apply the policy or plan; they don’t require interpretations
33
Express Exclusions
•DME Exclusions:
Appliances, devices and equipment not covered by the plan include, but are not limited to: speech devices; ….
34
Express Exclusions
•Gen=
eral
Exclusions: The Plan does not pay for benefits under the Plan for any expense related to:
–Which results from: (1) pervasi=
ve developmental disability; (2) m=
ental retardation; (3) conduct disord=
ers;
or (4)
developmental disorders;
–
35
Express Exclusions
•General
Exclusions: The Plan does not pay for benefits under the Plan for any
expense related to:
–For
Developmental Care, which means services or supplies, … which:
–A)
are provided to a member who has not previously reached the level of development (i.e., developmental delay) expected fo=
r the
member’s age
in the following areas of major life activity:
(1) intellectual;
(2) physical; (3) receptive and expressive language; …
–B)
are not primarily rehabilitative in nature (restoring fully developed skill=
s that
were lost or impaired due to injury or sickness; or
<=
/div>
–C)
are primarily educational
36
Express Exclusions
•=
Computer “story boards” or “light talkers” for communication impaired individuals
–Federal
Employee Health Benefits Program, 1997
•Computer
equipment/devices such as “story boards” or other communication aids to assist =
=
communication impaired
individuals
–Federal
Employee Health Benefits Program, BCBS Policy, 2005
•
<=
/div>
37
Isolate the Exclusion As Sole Basis =
for
Denial
•Sho=
w that
SGD otherwise will be co=
vered
•If =
coverable and exclusion is void, result can be approval of device, rather than remand for further proceedings
–=
E.g.,
Iwata v. Intel Corp., 349 F.S=
upp.2d
135, 142 (D.Ma=
ss.
2004)
38
External Legal Framework: <=
/span>State Law
•State
Health Insurance Unfair Discrimination Statutes prohibit:
–Making or permitting any unfair <=
span
style=3D'position:absolute;top:44.5%;left:16.66%;width:82.77%;height:5.75%=
'>discrimination
between individuals of the same class and of
essentially the same hazard in the amo=
unt
of premium, policy fees or rates cha=
rged
for any accident or health insurance
policy or in the benefits payable thereunde=
r,
or in any of the terms or conditions of =
such
policy ···
39
External Legal Framework: ADA
•Titles I through IV of this Act shall not be
construed to prohibit or restrict—•(1) an insurer, … health maintenance organizati=
on,
or any agent, or entity that administers benefit
plans, or similar organizations from underwriting risks, =
classifying
risks, or administering such risks that are based
on or not inconsistent with State law; or
(2) a person or organization covered by this Act from establishing, sponsoring, observing or administering the terms of a bo= na fide benefit plan that are based on underwriting risks, classifying risks, or administering such risks that are based on or not inconsistent with State law;
(2) a person or organization covered by this Act from establishing, sponsoring, observing or administering the terms of a bo= na fide benefit plan that are based on underwriting risks, classifying risks, or administering such risks that are based on or not inconsistent with State law;
•
•=
ADA,
Section 501(c)(1) & (2), 42 USCA § 12201(c)(1) & (2).•
40
Challenging Express Exclusions
•=
ADA and state law claims will overlap – may allow =
choice
of forum
•<=
/span>Demand production of all data, reports, studies and
other information on whi=
ch SGD
exclusion is based.
•=
Specifically demand all actuarial or cost basis fo=
r SGD exclusion
•=
No actuarial basis exists to exclude SGDs
–=
2003 estimate of cost per member per month: 1/10
cent
–=
Policy or plan will not have to be re-priced (incr=
ease premium) if SGDs were not excluded.
•=
If not cost based, what is the basis for SGD
exclusion? What purpose does exclusion service? Why did SGDs ever come to notice?
41
Additional Resources
•WWW.AAC-RERC.COM
–RMRP
for SGDs: outline of SLP assessment
–Protocol
for data gathering in SLP assessment
–Model
reports
•WWW.AUGCOMINC.COM
–Medical
Professional Society Letters
–Formal
Request (profes=
sional
literature review)
•WWW.AACFUNDINGHELP.COM
–>
May 1, 2006
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‹#›&=
#13;
Insurance is a very important SGD=
funding
source. This graph represents the=
number
of distinct insurers that have been reported to have approved SGDs. [not the number of claims that have be=
en
approved.]
This graph tells 2 types of information:
(1) that insurance is one of the oldest SGD funding sources. It began just as SGDs were introduced =
for
consumer use; and (2) it shows th=
at
insurance has increased greatly. =
In the
early 1990s, the number of insurers reported to have approved SGDs rose
between 100-200. By 2006, the num=
ber
reported is 1170, which represents a substantial under-count of the total.=
Insurance policies are what we al=
l think
of, but health benefits plans are a large part of the field, and raise
significant legal issues.
Unfortunately, this session is not long enough to tackle both of th=
ese
forms of private health benefits. Will address
only traditional insurance policies.
Note: same legal principles will apply to insured and exempt plans,=
but
not self or partially funded plans.
Will refer to everything we are talking about today as “policies.”<=
/div>
The type of health benefit – poli=
cy or
plan – does not affect the scope of coverage.
Either can be comprehensive or not, and either can cover SGDs or no=
t. Thus, the SLP can conduct an assessmen=
t and
write a report without knowing what type of health benefit is involved. Bu=
t if
the SGD is denied, the type of benefit is essential to help with a funding
appeal.
Insured and Exempt Plans are subj=
ect to
the same legal rules as policies. Self-
and partially-funded plans are subject to distinct legal framework.
The question clients will present=
is how
we show these denials violates at least one of the 3 sources of governing
law. [Apollo 13 analogy: we have =
to
make this fit into this, using only this….”]
Diversity / Commonality: If
Medicare is a single national program, with a single set of rules; insuran=
ce
is the polar opposite. There are =
many
thousands of sources of insurance and the key elements of coverage can be
distinct for every one. But in
practice, that is not true. Common
vocabulary, and despite governing law grounded in state law, and common
law, the applicable legal rules are almost universal.
No Woodwork Effect: means decision to cover SGDs won’t result in lo=
ts
of other stuff being presented for “me too” coverage.
Cost:Defense Ratio: is my term for what I hope is a calculation don=
e by
a defendant to decide whether it is worth defending a claim. If the cost of an item is very low, and
overall, the cost of accepting this cost is low, as compared to the cost of
defending the claim, why bother?
Experienced this with Medi-Cal when we filed a lawsuit against Medi=
caid
SGD payment rate cuts. Medi-Cal
reported it was willing to settle because cost of dispute was stated to be
less than cost of litigating the case.
We’ve seen these before. Adverse ‘fit’ determinations are anoth=
er way
to say what you want is not on the menu.
These are the same excuses Medicare & Medicaid programs have us=
ed
over the years to deny SGDs.
These require a somewhat different
approach than adverse fit determinations, but they too can be overcome.
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function _IBSetD()
{
obj=3Dthis.ChgState( gFaceClr,gFaceClr,0 )
obj.style.posTop=3D0
}
function _IBSetE( state )
{
var t=3Dthis
GetObj( t.mBorderId ).style.visibility=3D"visible"
if( state !=3D t.mIsOn ) {
t.mIsOn=3Dstate
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t.SetInactive()
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t.SetDisabled()
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}
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{
var t=3Dthis
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t.SetActive()
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var t=3Dthis
SetBorder( GetObj( t.mBorderId ),clr1,clr2 )
obj=3DGetObj( t.mObjId )
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t.mCurState=3DnextState
return obj
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function TxtBtn( oId,oeId,action,chkState )
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var t=3Dthis
t.Perform =3D _TBP
t.SetActive =3D _TBSetA
t.SetInactive=3D _TBSetI
t.SetPressed =3D _TBSetP
t.SetDisabled=3D _TBSetD
t.SetEnabled =3D _TBSetE
t.GetState =3D chkState
t.UserAction =3D action
t.ChgState =3D _TBUI
t.mObjId =3D oId
t.m_elementsId=3D oeId
t.mIsOn =3D 1
}
function _TBSetA()
{
var t=3Dthis
if( t.mIsOn && !t.GetState() )
t.ChgState( gHiliteClr,gShadowClr,0,0 )
}
function _TBSetI()
{
var t=3Dthis
if( t.mIsOn && !t.GetState() )
t.ChgState( gFaceClr,gFaceClr,0,0 )
}
function _TBSetP()
{
if( this.mIsOn )
this.ChgState( gShadowClr,gHiliteClr,1,1 )
}
function _TBSetD()
{
this.ChgState( gFaceClr,gFaceClr,0,0 )
this.mIsOn =3D 0
}
function _TBSetE()
{
var t=3Dthis
if( !t.GetState() )
t.ChgState( gFaceClr,gFaceClr,0,0 )
else
t.ChgState( gShadowClr,gHiliteClr,1,1 )
t.mIsOn =3D 1
}
function _TBP()
{
var t=3Dthis
if( t.mIsOn ) {
if( t.UserAction !=3D null )
t.UserAction()
if( !t.GetState )
return
if( t.GetState() )
t.SetPressed()
else
t.SetActive()
}
}
function _TBUI( clr1,clr2,lOffset,tOffset )
{
SetBorder( GetObj( this.mObjId ),clr1,clr2 )
Offset( GetObj( this.m_elementsId ),lOffset,tOffset )
}
function Offset( obj, top, left ){ obj.style.top=3Dtop; obj.style.left=3Dle=
ft }
function SetBorder( obj, upperLeft, lowerRight )
{
s=3Dobj.style;
s.borderStyle =3D "solid"
s.borderWidth =3D 1
s.borderLeftColor =3D s.borderTopColor =3D upperLeft
s.borderBottomColor=3D s.borderRightColor =3D lowerRight
}
function GetBtnObj(){ return gBtnArr[window.event.srcElement.id] }
function BtnOnOver(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetActive() }
function BtnOnDown(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetPressed() }
function BtnOnOut(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetInactive() }
function BtnOnUp()
{
b=3DGetBtnObj()
if( b !=3D null )
b.Perform()
else
Upd()
}
function GetNtsState(){ return parent.gNtsOpen }
function GetOtlState(){ return parent.gOtlOpen }
function GetOtlTxtState(){ return parent.gOtlTxtExp }
function NtsBtnSetFlag( fVal )
{
s=3Ddocument.all.item( this.m_flagId ).style
s.display=3D"none"
if( fVal )
s.display=3D""
else
s.display=3D"none"
}
function _BSetA_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etActive() }
function _BSetI_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etInactive() }
var gHiliteClr=3D"THREEDHIGHLIGHT",gShadowClr=3D"THREEDSHADOW",gFaceClr=3D"=
THREEDFACE"
var gBtnArr =3D new Array()
gBtnArr["nb_otl"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOtlPan=
e,GetOtlState )
gBtnArr["nb_otlElem"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOt=
lPane,GetOtlState )
gBtnArr["nb_nts"] =3D new TxtBtn( "nb_nts","nb_ntsElem",parent.ToggleNtsPan=
e,GetNtsState )
gBtnArr["nb_prev"]=3D new ImgBtn( "nb_prev","nb_prevBorder",30,parent.GoToP=
revSld )
gBtnArr["nb_next"]=3D new ImgBtn( "nb_next","nb_nextBorder",30,parent.GoToN=
extSld )
gBtnArr["nb_sldshw"]=3D new ImgBtn( "nb_sldshw","nb_sldshwBorder",18,parent=
.FullScreen )
gBtnArr["nb_sldshwBorder"] =3D new TxtBtn( "nb_sldshw","nb_sldshwBorder",pa=
rent.FullScreen,null )
gBtnArr["nb_sldshwBorder"].SetActive =3D _BSetA_Border;
gBtnArr["nb_sldshwBorder"].SetInactive =3D _BSetI_Border;
gBtnArr["nb_sldshwText"] =3D new TxtBtn( "nb_sldshw","nb_sldshwText",parent=
.FullScreen,null )
gBtnArr["nb_sldshwText"].SetActive =3D _BSetA_Border;
gBtnArr["nb_sldshwText"].SetInactive =3D _BSetI_Border;
gBtnArr["nb_voice"] =3D new ImgBtn( "nb_voice","nb_voiceBorder",18,parent.=
ToggleVNarration )
gBtnArr["nb_otlTxt"]=3D new ImgBtn( "nb_otlTxt","nb_otlTxtBorder",23,parent=
.ToggleOtlText )
gBtnArr["nb_nts"].m_flagId=3D "notes_flag"
gBtnArr["nb_nts"].SetFlag =3D NtsBtnSetFlag
gBtnArr["nb_otlTxt"].ChangeIcon=3D GetOtlTxtState
var sNext=3D"Next",sPrev=3D"Previous",sEnd=3D"End Show",sFont=3D"Arial",sAr=
row=3D"Arrow",sFreeform=3D"Freeform",sRect=3D"Rectangle",sOval=3D"Oval"
function ShowMenu()
{
BuildMenu();
var doc=3DPPTSld.document.body,x=3DPPTSld.event.clientX+doc.scrollLeft,y=
=3DPPTSld.event.clientY+doc.scrollTop
m =3D PPTSld.document.all.item("ctxtmenu")
m.style.pixelLeft=3Dx
if( (x+m.scrollWidth > doc.clientWidth)&&(x-m.scrollWidth > 0) )
m.style.pixelLeft=3Dx-m.scrollWidth
m.style.pixelTop=3Dy
if( (y+m.scrollHeight > doc.clientHeight)&&(y-m.scrollHeight > 0) )
m.style.pixelTop=3Dy-m.scrollHeight
m.style.display=3D""
}
function _CM()
{
if( !parent.IsFullScrMode() ) return;
if(!PPTSld.event.ctrlKey) {
ShowMenu()
return false
} else
HideMenu()
}
function BuildMenu()
{
if( PPTSld.document.all.item("ctxtmenu") ) return
var mObj=3DCreateItem( PPTSld.document.body )
mObj.id=3D"ctxtmenu"
mObj.style.visibility=3D"hidden"
var s=3DmObj.style
s.position=3D"absolute"
s.cursor=3D"default"
s.width=3D"120px"
SetCMBorder(mObj,"menu","black")
var iObj=3DCreateItem( mObj )
SetCMBorder( iObj, "threedhighlight","threedshadow" )
iObj.style.padding=3D2
CreateMenuItem( iObj,sNext,M_GoNextSld,M_True )
CreateMenuItem( iObj,sPrev,M_GoPrevSld,M_HasPrevSld )
CreateSeparator( iObj )
CreateMenuItem( iObj,sEnd,M_End,M_True )
mObj.style.visibility=3D"visible"
}
function Cancel() { window.event.cancelBubble=3Dtrue; window.event.returnVa=
lue=3Dfalse }
function Highlight() { ChangeClr("activecaption","threedhighlight") }
function Deselect() { ChangeClr("threedface","menutext") }
function Perform()
{
e=3DPPTSld.event.srcElement
if( e.type=3D=3D"menuitem" && e.IsActive() )
e.Action()
else
PPTSld.event.cancelBubble=3Dtrue
}
function ChangeClr( bg,clr )
{
e=3DPPTSld.event.srcElement
if( e.type=3D=3D"menuitem" && e.IsActive() ) {
e.style.backgroundColor=3Dbg
e.style.color=3Dclr
}
}
function M_HasPrevSld() { return( parent.HasPrevSld() ) }
function M_GoNextSld() { if( gIsEndShow ) M_End(); else GoToNextSld() }
function M_GoPrevSld() { if( gIsEndShow ) { history.back(); PPTSld.event.ca=
ncelBubble=3Dtrue; } else GoToPrevSld() }
function M_True() { return true }
function M_End() { window.close( self ) }
function CreateMenuItem( node,text,action,eval )
{
var e=3DCreateItem( node )
e.type=3D"menuitem"
e.Action=3Daction
e.IsActive=3Deval
e.innerHTML=3Dtext
if( !e.IsActive() )
e.style.color=3D"threedshadow"
e.onclick=3DPerform
e.onmouseover=3DHighlight
e.onmouseout=3DDeselect
s=3De.style;
s.fontFamily=3DsFont
s.fontSize=3D"9pt"
s.paddingLeft=3D2
}
function CreateSeparator( node )
{
var sObj=3DCreateItem( node )
SetCMBorder(sObj,"menu","menu")
var s=3DsObj.style
s.borderTopColor=3D"threedshadow"
s.borderBottomColor=3D"threedhighlight"
s.height=3D1
s.fontSize=3D"0px"
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function CreateItem( node )
{
var elem=3DPPTSld.document.createElement("DIV")
node.insertBefore( elem )
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function SetCMBorder( o,ltClr,rbClr )
{
var s=3Do.style
s.backgroundColor=3D"menu"
s.borderStyle=3D"solid"
s.borderWidth=3D1
s.borderColor=3DltClr+" "+rbClr+" "+rbClr+" "+ltClr
}
------=_NextPart_01C66B96.F540AA00
Content-Location: file:///C:/A67AA4F3/031306InsuranceFundingforSGDs_files/fullscreen.htm
Content-Transfer-Encoding: quoted-printable
Content-Type: text/html; charset="windows-1252"
Medicare, Medicaid & Insurance Funding for SGDs
------=_NextPart_01C66B96.F540AA00--
Must be a covered benefit and must “fit” within a covered benefit.
Must interpret all policy terms reasonably.
If copy Medicare in whole or part, not reasonable to reach interpretation =
contrary
to the way Medicare interprets the same terms.
Don’t assume person who signed the letter is the reviewer.
Don’t think that a doctor signed the letter makes the denial credible. Only neurologists and physiatrists typ=
ically
see patients who have conditions that give rise to SGD need and use. Is the doctor one of those?
Examp=
le:
Brian Rose. Doctor, but not AMA m=
ember;
not board certified in anything. =
No
relevant practice.
Less relevant education and experience, greater
expectation of fact search before decision.
Greater expectation a prudent person would conduct a more detailed =
inquiry.
Look at letter: does it say any investigation was conducted?
Ask for production of all documents that were investigated.
Insurers have been saying yes sin=
ce late
1970s. Has Insurer or Plan decide=
d an SGD
request before? Did it approve the
SGD?
Why does this matter si=
nce
each policy or plan can be different?
Because nothing requires them to be different. Make them show you they are different.=
Because if not different, results shou=
ld not
be different either. Looking at s=
ame information
on 2 separate days and reaching different conclusions is the legal definit=
ion
of capricious.
Insurer can claim not enough information to search. Rejoinder is that approval information=
came
from ATI, Dynavox/Enkidu, PRC and Words Plus.
Can ask each of them whether they have a prior “yes” from the insur=
er
or plan, and to help get the information.
Challenge the insurer or plan to get the data and point it on the
table.
Importance: these criteria answer=
many of
the excuses in the adverse fit determination list. Why would insurer or plan have bothere=
d with
these criteria? Also, criteria of=
ten
have information about specific impairments SGDs are known to treat, which
goes beyond criteria issued by Medicare or Medicaid programs.
Section 4G(2) of =
the
Model UTPA, which has been adopted in whole or in part by 49 states,
prohibits:
NAIC, Model Laws, Regulations and Guidelines, Volume IV (January 1993)
NAIC, Model Laws, Regulations and Guidelines, Volume IV (January 1993)
Attachment lists laws of 44 states that I’ve fo=
und
with the statute or regulation. O=
thers
also may have it, but I did not find it.
“Unfair
discrimination between individuals of the same calss and of essentially the
same hazard … in the benefits payable thereunder…”
=
Way to show discrimination is not “unfair” is to
provide actuarial or cost data
Actuary told me “can’t fathom the
question for which exclusion of SGDs is the answer”
' + ENDSHOW_MESG + '
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