Monday, January 28, 2008


I think I'm in the dog house for not posting recently. It's only been 8 days! Life is pretty much same-old, same-old. No new Evan tricks. He has stayed healthy since his illness at the beginning of the year...I guess that's a pretty neat trick!

I've been busy trying to find a happy ending to our out-of-pocket medical expense woes. Twenty percent plus whatever exceeded the $5,000/yr limit on durable medical equipment (feeding and respiratory supplies) added up to $4000 and some change.

In the past, we have been able to accumulate enough expenses to qualify for a secondary medical coupon for Evan. Our family is on "spend-down" which is the dollar amount of medical expenses we have to prove to DSHS that we owe before Evan is issued a coupon. The coupon is usually back-dated several months and our costs are reduced significantly. For the past 3 spend-down periods, the person working Evan's case has applied a special rule called the "Sneed-Kaiser" which bases the spend-down on the child's resources (less on the parents') and cut the spend-down to a third of what it would have been. I was under the impression this rule could be applied to our family because of Evan's special health needs. Well, I found out that evidently in the past it was applied incorrectly--it can only be used if the child's resources would make another family member inelligible for a coupon. Since the spend-down starts over again at the beginning of Feburary, there is no way we are going to meet it...even with that $4,000 worth of DME. If there is a silver-lining to this situation, I guess it is that we don't have to "pay back" any of the assistance Evan received on the coupon in the past.

I next looked into switching Evan to SHIP (State Health Insurance Pool). Washington State Law allows insurers in the individual plan market to refuse to insure the most costly 8% of potential applicants based on answers to a standard health questionaire. If you get rejected when you apply for an individual plan, then you can get medical insurance through the state pool. The premiums are higher, but we thought it might reduce our out of pocket expenses. The first problem I ran into was that Evan needed to be rejected by the insurance company to be eligible. I would have to try and apply for a higher level of benefits through our insurance company--they would make us fill out the questionaire and chances are he would "fail." When I started looking at the plan, I saw that the deductable was lower, the out of pocket maximum was lower, but the premium was higher and there was still a 20% co-insurance. The life-time maximum was $1 million--lower than what his current insurance is (we estimate is is between 1-1.5 million out of his 2 million lifetime max). We decided that it would be better to stay on the current plan for now, rather than risk becoming "uninsurable" by any plan besides the state pool.

Finally, I applied for "Financial Assistance" through Children's Hospital. Evan though what we owe them is minimal in comparison to the DME, every little bit helps. Because Children's income limits are pretty generous, we do qualify for assistance through the hospital. Basically, they accept what our insurance pays as the limit of our responsibility--and this extends to the physician's medical group, the dental clinic, anything Children's runs. While I was talking to the out-patient financial coordinator, she mentioned transferring all of Evan's prescriptions to Children's pharmacy to cut down on medicine expenses. Half joking, I asked if they happened to do medical supplies. Well, it turns out there is a Children's Home Health. After a few phone calls, I learned even though we are outside their service area, we can have supplies UPSed to us. The only issue is training on the new oximeter we are getting, but Evan has an appointment on Wed at the hospital so the respiratory therapist is going to meet Jeremy to go over the instructions. We have rented the other equipment so long, we own it now.

We still have that large bill from our previous DME supplier to pay off, but at least we don't have to worry about any more surprise bills in the future. I am so thankful that Children's has so many donors that enable them to provide this help.


Mary said...

Evan looks so grown up! I was getting concerned since you had not posted for so long. I was in a panic when I read about the forms being completed incorrectly. Thank God you don't have to go back and pay those costs!

PS - How does Jeremy do getting up from Evan's table?

Eva Nichole said...

I will keep my fingers crossed that everything works out for you all with the expenses!!
Crystal and Eva

Mighty Max! said...

LOVE the photo of Jeremy as the itty bitty table...very cute!

As far as the insurance, sounds like quite a mess. But am relieved that Children's is able to help. Didn't know about the equipment company, that is wonderful! I'm confused about the others you rented long enough that you own them? How did you find that out?

Talk with you soon...Amy