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News & Views - Feb, 1995 Issue #32 

by: Tom Croke, Educational Consultant
Latrobe, Pennsylvania & Anchorage, Alaska
1-800-PARENTing (800-727-3684) 

(Tom Croke has had an independent educational consulting practice for several years, working with adolescents and their families. This article continues his survey of the possibilities of finding financial help with school and program tuition.) 

Two issues ago, in the first article in this series, I said, "Almost every client expresses some kind of 'sticker shock' when I first speak of the cost of special purpose schools and treatment centers," then went on to describe ways of offsetting these costs. In this article, I will describe accessing benefits from a basic health care plan in some detail. 

Again, it is important as you read this article that you use the information with caution. What follows should be taken as ballpark suggestions to explore, not as bottom line assertions as to what works. 

In order to clarify when benefits might be available, it may help to sort out the different kinds of health care plans and who makes the decisions. Health care plans are generally one of the following: 

(1) Indemnity insurance ?? traditional insurance which pays a benefit in case of illness and associated medical expense. This type of plan usually traditionally did not (and usually still does not) cover such predictable costs as preventative care, routine examinations and maternity care. 

(2) Prepaid health care plan ?? benefit plan to cover the costs of staying healthy: Usually a Health Maintenance Organization (HMO) plan (doctors salaried to the plan itself) or a Preferred Provider Organization (PPO) plan (doctors in private practice paid per patient by the PPO). 

(3) Direct employer benefit package ?? coverage for health care absorbed directly by the employer with no insurance company cushioning the expense to the employer. May resemble either (1) or (2) above in the benefits provided. 

(4) Government benefits (Medicare, Medical Assistance, Medicaid, Champus, etc.) These will be explored in a separate, later article, but eligibility should be explored even for people of significant income. 

With each of these plans, there are a variety of different people who must be dealt with in order to obtain benefits. These may include: 

(1) Payor ?? The actual source of funding of the health care services: the insurance company in the case of plan type (1); the HMO or PPO in plan type (2); the employer in plan type (3); and the government in plan type (4). 

(2) Managed care company ?? a company usually separate from the payor which has the function of determining when and if there is a true need to access the health care benefits. The representative whom the patient or provider deals with would usually be known as a "case manager," but might travel under a euphemism, such as "patient advocate." In the case of a type (2) plan the managed care company may be the payor. On a benefits identification card or certificate, there is usually a phone number to call to notify or request advance clearance prior to a hospitalization and/or other procedure. That is almost always the phone number of the managed care company. That prior approval is called a "pre-certification." 

In dealing with managed care companies, remember that their responsibility is to keep costs down, not to provide extra help for the patient or client. They will generally approve use of benefits only when it is clear that to do so is the lowest cost option available to the payor. 

(3) Employee benefits office or personnel office ?? The final decision maker on type (3) plans and a source of great influence in decisions on plan types (1) and (2) when the plan is purchased through an employer. 

(4) Primary care physician ?? the doctor who provides routine, non-specialized health care. In type (2) plans a primary care physician authorization is usually a prerequisite to access any benefit, and whose support may be a necessity or a great help with other plans. 

One consequence of this combination of cooks spoiling the stew, is that the payor can advise you that you have coverage, and the managed care company can deny your eligibility to use it. Or the managed care company can acknowledge your need for a category of care, while a the payor denies that it is a covered service. Verify from at least both of these sources that you have coverage, before you count on it. A denial from either, overrules an acceptance by the other. In the case of an HMO or PPO, you also need your primary physician's approval. 

Health care coverage from non? government sources for a special purpose school, if available, will be available as part of the psychiatric or "mental and nervous" conditions benefit. Direct benefits on those plans are usually limited to psychiatric hospitalization, within stated limits, and sometimes admission to psychiatric residential treatment facilities. In some cases, plans which cover non? residential benefits will cover therapy ?? but not room and board or general supervision ?? in a residential setting or at special purpose school. 

With few exceptions, broader coverage than outpatient therapy will occur only when an exception is made to the contractual terms of the coverage. Usually that happens for either one of two reasons: (1) The health care carrier is at risk for needing to pay much larger benefits for psychiatric benefits in a hospital setting or (2) the employer makes the case for an exception. If reason (1) applies the decision maker will be the case manager from the managed care company, or a person supervising the case manager. If reason (2) applies, the decision maker will be accessible only to the employee benefits staff. 

Accordingly, to get access to health care benefits from non-government plans, the strategy is (1) to access outpatient benefits to cover the counseling component of a special purpose school, or (2) convince the case manager from the managed care company that paying for the special purpose school "off contract" or as a "flex benefit" would be in their best interests, or (3) find a basis for gaining support from the employee benefits office for getting special consideration. One family I recently dealt with knew that the student's father was eligible for a six figure signing bonus if he resigned and went to the competition. He also knew his own company would need to pay that kind of signing bonus to replace him. Hence, his benefits office was easily persuaded to provide $50,000 in extraordinary funding for his daughter. 

Several final points: 
The details of how to deal with government programs remains for another article, but middle and upper income families should not rule out access to Medicare and Medicaid without checking eligibility carefully. Many of the youngsters we refer to special purpose schools are eligible for disability benefits and many others are subject to adjudication for juvenile offenses, truancy or incorrigibility. Disabled persons are eligible for Medicare after one year and in most cases are eligible for Medicaid or medical assistance as soon as the federal SSI authorities declare the person disabled. In many states, all adjudicated youngsters are eligible for Medicaid or medical assistance, regardless of family income. Educational benefits through your public schools system, closely coordinated with Medicaid, may also apply. This source, too, will be discussed in a later article. 

Blue Cross/Blue Shield plans and HMOs will be the hardest targets for help with costs of special purpose schools. The Blues will likely cooperate with payment for counseling through its outpatient benefits if the providers of the counseling are properly credentialed; HMOs probably will not even do that. 

Blue Cross programs rarely go beyond the most expensive care for very short periods of time, and are of little help with cost effective long term care. Other psychiatric benefits generally support relatively expensive levels of care, such as acute care psychiatric hospitalization and psychiatric residential treatment. Coverage is the exception rather than the rule, when facilities are not accredited by JCAHO (the Joint Commission on Accreditation of Health Organizations). One exception is U.S. Behavioral Health (USBH), managed care company which is a subsidiary of Travelers Insurance and covers most Travelers Health Insurance policies. USBH has a particularly good track record in supporting payment for care in facilities which lack the sophistication ?? and cost ?? of the more purely psychiatric facilities, while utilizing less costly facilities with care comparable to the structured boarding schools. They do not always insist on JCAHO accreditation. Several other national managed care companies have shown flexibility on this point. 

One recent client was in the process of changing jobs, from a company providing health care through USBH to a Blue Cross covered company. On my advice, he used the "COBRA" law, to maintain his old coverage after changing jobs. That law keeps most employees eligible for continuing health insurance from a former employer for eighteen to thirty six months at a cost which is limited by federal law. 

Any employee considering a job change or with an opportunity to choose health care plans should seek out very carefully information about the formal limits of behavioral health care, and the TRACK RECORD AND REPUTATION OF THE MANAGED CARE COMPANY GOVERNING THE USE OF BENEFITS. 

Another recent client was told they had coverage for a well known wilderness program, then the company subsequently denied having approved the coverage. The question of payment is now before the courts. Moral: Get approvals in writing or record the telephone conversations. The issues of health care coverage are confusing at best. You are wise to seek professional advice when approaching the use of behavioral health benefits. 

Copyright 1995, Woodbury Reports, Inc. (This article may be reproduced without prior approval if the copyright notice and proper publication and author attribution accompanies the copy.)

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