How to learn more about your insurance coverage Healthcare insurance companies differ dramatically in their provision of services. Therefore, it is often difficult for your medical team to know exactly how your policy will support your changing needs or how to activate the policy for reimbursement of basic services. Most medical consumers have one or more of the following types of coverage: 1. Fee-for-service (commercial) insurance with 80% coverage 2. Health maintenance organization (HMO) 3. Managed care insurance (POS, PPO, etc) 4. Medicare 5. Medicaid If an HMO, managed care organization, or commercial insurance covers you, it is essential for you to have a full understanding of your insurance policy and how to access covered services. This is important even if you do not now need to access specific services other than general medical appointments. You should identify your primary insurance provider and any secondary insurers. Given the current Medicare waiver, more patients with ALS have Medicare insurance (bill H.R. 4577) and therefore need to further explore the relationship between their commercial insurance (i.e. Oxford, BC/BS) and the newly obtained Medicare. Once simple way of doing this is to ask the SS Disability claims representative or call the Human Resource Manger (at the employers organization) of the commercial insurance. Also, review organizations that you are affiliated with that may provide additional services (eg, veterans are entitled to pharmacy coverage at their local VA hospital). Since ALS is a progressive disease, it is likely that you will need additional services in the future. Having information about your policy coverage now will facilitate obtaining those services and products at the time of their need. We therefore encourage you to do the following at your earliest convenience: 1. If you have a commercial insurance as your primary or secondary, call the commercial insurance to establish contact (identify your primary or secondary status with them). Tell them your diagnosis of ALS (diagnosis code 335.20) 2. Request a case manager. Request that a case manager be assigned to you. (Some companies no longer provide this service unless there are complicated medical issues to manage.) This is a person within the insurance organization who will exclusively manage your medical care and process all of your medical claims. This person will serve as the primary insurance company contact for you and your medical team. 3. Request information on rehabilitation and home care services. Have the insurance company identify the number of rehabilitation--physical therapy (PT), occupational therapy (OT), and speech therapy (ST)-- appointments you are entitled to each calendar year. Ask if the number provided is for both in-patient and outpatient service locations. Request a listing of the rehab organizations you may use in your area. Have the insurance company identify the number of home care visits you are entitled to under your policy. This may include the use of a registered nurse (RN), home health aide (HHA), and rehabilitation (PT, OT, ST). How many visits per year are you entitled to and what number of hours constitutes a visit? What are the requirements to get home services (skilled care vs. unskilled care) and does this referral need to follow an in-patient hospitalization? Have the insurance company identify if you are entitled to hospice services in the home and the number of days within this entitlement. Have the insurance company identify if you are entitled to skilled nursing care if you decide to be mechanically ventilated (MV). How many visits per year are you entitled to, what constitutes a visit, and does the number of visits renew itself each year? 4. Request information on durable medical equipment (DME) entitlements. Have the insurance company identify DME coverage. This includes walkers, wheelchairs, orthotics (splints and braces), and augmentative communication devices. Have the insurance company identify what DME providers you are allowed to use. 5. Request information on what hospital or local laboratories you are allowed to use for blood tests and pulmonary function tests. 6. Request information on who is allowed to write prescriptions for medications, treatments, and medical equipment (e.g., HMOs--GHI, US Healthcare, etc.--require that all prescriptions be writ ten by your primary medical doctor rather than your specialty neurologist). If you have Medicare primary, review the written materials provided regarding the above issues. If you need further information the Medicare web site is www.medicare.gov. There are specific issues for commercial insurance coverage if Medicare is your primary insurance, as the commercial benefits often mimic what Medicare offers. Once you have answers to some or all of these questions, please communicate them to the members of the clinical staff caring for you. Homebound Care Services: Clarification On July 26, 2002, the Center for Medicare issued "more flexible" guidelines for home health agencies and contractors in determining whether severely disabled Medicare beneficiaries qualify as homebound. For more information go to http://www.hhs.gov/news/press/2002pres/20020726d.html.