5343.01
December 2002
This is a summary of a chapter from PAI’S Accessing Assistive Technology Manual. If you would like more information on this topic, ask us to send you the chapter (or the entire manual).
Rights
The terms of your policy will determine whether a private health benefit plan is required to buy assistive technology for its beneficiaries. Neither the Knox-Keene Act covering most California health plans nor the federal HMO Act requires coverage of durable medical equipment or prosthetic devices.
Most plans do not list specific devices or equipment as plan benefits, but instead give a definition with some examples. Some plans give examples of what is not covered. You would argue that the necessary assistive technology you need fits within the plan definition of durable medical equipment, prosthetic devices, or equipment associated with physical, occupational or speech therapy.
Your health benefit plan should set out the process for requesting assistive technology. It should also set out what supporting information you need to submit. Many HMO plans say that your primary care doctor must refer you to a specialist – such as an orthopedist, physical therapist or speech therapist. The specialist will then prescribe the equipment. Before you go to be assessed, make a list of your needs and concerns – for example, your need to be able to lift your wheelchair to put it in the back seat of a car. It is important to follow the process and document your need for the technology as required.
Health benefit plans will only buy technology services and equipment that are medically necessary. Your plan should define medically necessary. The definition of medically necessary usually says that the requested service or equipment must cure or alleviate a medical condition, reduce pain, or help maintain or obtain more normal function.
Many health benefit plans do not cover benefits that are the responsibility of another entity. However, state and federal law says that you only go to Medi-Cal, Medicare, CCS, or the regional center for co-payments or things the private health plan does not cover. Your plan cannot contradict this law. School districts cannot make you use health benefits to get a device that your child is entitled to through special education. If the school district refuses to provide the device, you will need to decide whether to appeal the denial or ask your health plan to provide the device.
Health benefit plans often try to deny coverage for a "pre-existing condition." In California, most group health plans other than HMOs can impose a 6-month exclusionary period. Group HMOs cannot impose any pre-existing condition exclusion. To avoid a pre-existing condition exclusion in group health plans under California law, you can use six months of prior private health plan coverage, as long as the gap between group plans is not more than 180 days. Under the federal Health Insurance Portability and Accountability Act there cannot be a gap of more than 63 days with at least 12 months of prior coverage but that prior coverage can include Medi-Cal and/or Medicare (unlike California law). Under some circumstances, this may be discrimination. Both the Americans with Disabilities Act (ADA) and California law say that a health benefit plan may not, solely because of a physical or mental impairment:
The benefit plan must show, using real facts and statistics, that the disability leads to higher health care costs. Otherwise, the plan cannot justify treating people with disabilities differently.
Under COBRA (the federal Consolidated Omnibus Budget Reconciliation Act), you have the right to continue your health benefit plan for 29 months after you leave your job if you have a Social-Security-eligible disability and that fact is established within the first 18 months of COBRA coverage. There are procedures through Social Security for establishing a Social Security level disability even when you do not seek or qualify for Social Security disability benefits. You must pay the benefit premiums at the group rate paid by your employer for the first 18 months with a slightly higher rate for the next 11 months.
Appeal
Almost all health benefit plans provide for an internal appeal. If you are persistent, you may get a decision reversed. This is especially true if you can provide more documentation of medical necessity or information that the health benefit plan has purchased similar devices in the past. The appeal is often informal. It consists of explaining the need and justification for the device in writing.
If the policy has a provision for arbitration, you must follow it. In arbitration, you and the plan present your arguments to a third party who will decide which of you is correct. It is important that all the evidence supporting your claim be submitted in the appeal process before you get to arbitration.
The California Department of Managed Health Care is the agency that monitors most private health benefit plans in California. Not covered are self-insured employer health plans or Union-Employer welfare trusts. The Department has a toll-free consumer information and complaint line: 1-888- HMO-2219 (voice) and 1-877-688-9891 (TDD). Among the options available through the Department are Independent Medical Reviews when you are challenging the refusal to authorize equipment or services.
The Equal Employment Opportunity Commission (EEOC) can look into complaints against an employer-provided health plan alleging discrimination on the basis of disability in violation of the ADA. Their telephone number is 1-800-669-4000 (voice) and 1-800-669-6820 (TTY).