This Web Site is committed to the memory of Janis Morrow.
Insurance & Financial Aid
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On
The Way To The Social Security Office Disability & Benefits:
HCV Meets HMO 2008 Although they are not as popular as they once were, Health Maintenance Organizations (HMOs) and their close relatives, Exclusive Provider Organizations (EPOs) and Point of Service (POS) Plans, still provide coverage to the majority of people with health insurance. While these plans have worked well for people who are generally healthy and have only temporary or minor medical problems, they can be a real challenge for persons dealing with chronic or catastrophic medical conditions, such as HCV. The basic principle of HMOs is that, in return for a flat fee called capitation or premium, as well as nominal co-pays for services, they will provide all your medical needs. However, to make sure you get the “quality of care you need,” and, coincidentally avoid “unnecessary” and expensive “over-utilization,” a Primary Care Physician (PCP) must coordinate all your treatment. Regardless of what treatment you may need, you must first go to your PCP, who will usually be a general practitioner, possibly an Internist or Family Practice specialist. This Primary Care Physician is also called the “Gatekeeper” – an extremely descriptive title. If you believe you should see a specialist, it is the Gatekeeper who decides whether or not you get to see the specialist, and, if so, which specialist you will see. Remember the game of “Simon Says?” In the HMO world, it is “PCP Says.” Unless the PCP says you need a specialist, you will have to rely on the PCP to provide your care, whether it is something he/she is familiar with or not. Keep in mind that the fewer doctor visits, tests, and treatment you undergo, the bigger an HMO’s profits and the more the doctor/clinic will earn. With a set-up like this, it makes you wonder if anyone ever gets good care from an HMO. Health care from an HMO does not have to be inferior. Thanks to the public outcry about HMOs skimping on care to increase their profits, Congress and many state legislatures have tightened regulation of this industry. Publicity by the media of problems with care from HMOs and the frequency of large jury awards have forced HMOs to make an effort to improve the quality of their care, or at least improve the image of their quality of care. In fact, medical care can be excellent in an HMO. This is due in part to stricter oversight and regulation. It is also due to the doctors and other medical providers actually treating patients who still care about providing quality care to people who need it. However, the key to the quality of the care you receive is you and how actively you participate in the decisions about your healthcare. There are a lot of excellent and caring medical providers working with HMOs, but you will have to seek them out. You will also have to make sure they continue to focus on your medical care, despite the bureaucratic barriers built into the HMO system. In reality, the HMO is not that different from any other type of healthcare delivery system. You are the person who is ultimately responsible for seeing to it that you get the best care available. It is up to you to know the level of care you are actually receiving and to determine what quality of care you should be receiving. It is up to you to take control of your medical care, and, to do that, you need to become more knowledgeable about all areas of your medical condition and its treatment. Know your medical condition. Thanks to sites like the HCV Advocate and others on the web, there is a lot of information about hepatitis C and its treatment. Thanks to the Internet, you can stay current on new treatments, clinical trials, and new diagnostic methods. HCV is a relatively recent discovery. There is a lot of information available about it, and there is a lot of research being done to learn more. It would be nice if everyone could find a physician whose practice consisted only of HCV patients, but that is not possible. You can become one of your physician’s sources of new information about HCV treatments and trials. You should feel free to print out information, cut out articles and take them to your physician. Hopefully, he/she is already current, but you may be providing new information. If your doctor is not the type that welcomes such input from the patient, you may be seeing the wrong doctor. Find a knowledgeable Primary Care Physician. The Centers for Disease Control states: “Any physician who manages a person with hepatitis C should be knowledgeable and current on all aspects of the care of a person with hepatitis C.” Following this statement means that in an HMO, your Primary Care Physician should be “knowledgeable and current” in HCV and its treatment. Within virtually all HMO networks, you are able to select your own Primary Care Physician. Your selection of a PCP will determine not only who provides the majority of your care, but will also determine which specialists will be utilized when needed. However, the HMO directory will give you only minimal information about your choices, and it won’t tell you which PCPs frequently treat patients with HCV or stay current about it. Clearly, you will need to do some research. If you attempt to call the HMO itself, it will not provide much information, as they are prohibited from “steering” patients to particular clinics or doctors, even if it would mean better health care. You may have to call several doctors’ offices to learn more. Keep in mind the chances that you will actually get to speak to the doctor are very slim, but his nurse should be able to handle the questions as well. Some questions you may want to ask include: • What is the doctor’s specialty? Is he/she board-certified? Many PCPs are internists, which may give them more experience with HCV. • What chronic medical conditions does the doctor treat most frequently? • Does the doctor treat other patients with HCV? How many? What percentage of their practice is HCV? • What has been the doctor’s experience with HCV treatment? Do not hesitate to ask very specific questions, referring to treatments and using terms you have learned in your research on HCV. If they don’t know what you’re talking about, scratch them off your list and move on. • Who are the gastroenterologists, hepatologists, infectious disease specialists, or other HCV knowledgeable specialists that the doctor works with and refers patients to? You may want to talk to their offices as well. • How long does it take to get a referral once the PCP requests one? Some PCPs even have the ability to permanently refer you to a specialist for treatment of chronic conditions such as HCV. In those cases, the specialist effectively becomes your PCP. Ask your prospective PCPs if this is a possibility. This is particularly important if you can’t find a PCP knowledgeable in the treatment of HCV. These are a lot of questions, I realize. However, neither the HMO nor your physician has as much at stake as you do in your medical care. This is your health and your life you are protecting, so spending some time and energy on this now can give you piece of mind and better healthcare later. Medical office personnel are not always as helpful to prospective patients as you may think. One alternative is to learn as much as you can about your PCP choices, select one and schedule an appointment. Then you can ask the doctor directly and decide whether you want to stay with that PCP or switch to another. This will give you an excellent idea of how well they listen to you, how much time they are willing to spend with you, and their general “bedside” manner as well as their knowledge and experience of HCV. Know your plan and your rights. You should spend some time with your Plan Document, the booklet that describes the provisions of your HMO coverage. While it is important to have a good idea of what is and isn’t covered, it is even more important to understand your rights under the plan. Not everything you need to know about your plan will be in the document. You may have to talk to a representative at the HMO itself or at the state regulatory agency, either your state’s Department of Insurance or Department of Managed Health Care, for information. Things you should know about your plan include: • How do you change your PCP and how often can you do it? Be aware that if you are totally dissatisfied with your PCP, an HMO will often accommodate your request for a change regardless of their “rules.” • What right do you have to appeal the denial of a referral or of a particular course of treatment? What are the time limits on such appeals? How does the appeal process work? • What is the timeline for an expedited appeal if medical treatment is being withheld pending the appeal? Many states have enacted laws which require such appeals to be handled within 24 or 48 hours. • Does the HMO offer Nurse Case Management for patients with chronic diseases such as HCV? Case Managers have an underlying purpose of saving the HMO money, but most of these case managers are trained nurses, and can be a valuable source of information about the HMO’s policies and rules and may even be an ally for you when “fighting the system.” The days are long gone in any healthcare delivery system when patients could put themselves in the doctor’s hands and rest assured that they were getting the best and latest treatment. However, in the HMO system of healthcare, where the providers can increase profits by withholding care, it becomes even more important that you stay actively involved in your medical care. To do that, you must find knowledgeable medical providers who not only know about HCV, but who will listen to you and answer questions candidly about the input of the HMO in determining the direction of your care. On The Way To
The Social Security Office 1. Whatever you do don't believe anything the folks at the Social Security Office tell you. They don't have the authority or the knowledge to give you advise about your claim. In most cases your claim will be forwarded for review by a Medical Board usually made of of a couple of Drs. They make the determination. The primary job of the folks that work the counter at Social Security Offices is to say "no" when applying for benefits. Don't let them fill out some computerized form for you either. They don't know you, they don't know your symptoms and they are just trying to speed up the process so they can say no quicker any way they can. Get the form from them. Fill it out yourself. Make copies and proof-read it for accuracy. You may be asked to see a Doctor at their expense, I was never asked because my documentation was complete. 2. Hand print or type (I typed mine on a regular typewriter) the application. Don't believe any stories you hear that claim if you type they will consider you not disabled because you can type. They will thank you for taking the time to making sure they can read it. If you print it by hand, print legibly . Use a dictionary if you have to. 3. Don't leave any blocks blank and don't put "don't know" or "NA" in any block. If you don't know the answer you can bet they don't know and you've given another person in the paper chain a chance to knock it down and return it disapprove your application. Be thorough in answering all questions. Use a separate sheet of paper if necessary to elaborate your point. Make sure that if you use a separate sheet of paper that the item on the form that you are trying to explain corresponds with the same number on the original form. Be exact, be complete. Include your complete medical history with the exception of minor illnesses such as the "flu" or cuts and scraps on the form. When your done completing the form get someone else to look it over. Preferably someone who is a third party to your illness. a spouse or parent might be too sympathetic to provide constructive criticism. If the third party doesn't understand what is on the form then you can bet the folks down at the Social Security Office won't either. 4. Ask for extra forms in case you screw it up or make copies of the original and make a draft before preparing the final form for submission to the Social Security Office. In addition to the main form you'll be given medical release forms asking you to give the name of your doctor, his or her address and the names and addresses of any hospital where you have ever been treated. Be complete and don't leave anything out even if you think it's not related to your claim. There is a lot about this disease that the medical community doesn't know and no one can say for sure that something that happened to you previously before being diagnosed isn't a symptom or a warning sign of this disease. The more ammo you give them the better your chances are of getting approved. 5. Now here's where the big secret is: When I filled out the medical release forms I was told it might take anywhere from 30 days to 3 months to get all the medical info from the doctors and the hospitals and that would delay the processing time. No way I said. I made a personal trip to each Drs office and hospital and made complete copies of everything they had on file on me. In some cases you may have to pay for the copies and in some cases you won't but it depends on who you are dealing with. If you let the Social Security folks and the medical records clerks at Drs offices and hospital do the work you're letting them decide which info is relevant to your condition and what info isn't. I personally don't trust their judgment. I want all the info with nothing left out. So make complete copies front and back of everything they have on you. If you can get your hands on xrays get them. I went to the hospital and went to the radiology lab and told them I had an unscheduled appointment with my Doctor and he was asking me to see if they would let me pick up the xrays to speed things up. The clerk just handed them to me and off I went. I had copies made from them and returned the originals in a couple of days. Not exactly honest way of doing things but it worked and they did get the original back. But if you just go in there and say give me my xrays they are going to laugh at you. In some cases the hospitals will be willing to make copies for you at a small charge. This applies to ultra-sounds, endoscopies, e.t.c.... When they do an endoscopy they make a video and have prints of your esophagus and stomach. These are important to include in your package. Make sure that results from any biopsies and all blood tests are included in the package. If you haven't had a recent liver panel done, get one done and include it. But I suspect most of you have had this done on a routine basis as it is. Another point to remember is never to let a hospital employee, or a clerk in a Drs office tell you "no" or that something can't be done or provided. Ask to speak to their supervisor if you run into a stone wall and if you don't get any satisfaction from the supervisor ask to speak to the supervisors supervisor. Keep going until you get results. Don't take no for an answer. Also I would include receipts for medication to document the cost of treatment as well as receipts from paying the medical bills even if you filed it with your insurance carrier. You should have these anyway because they are a tax deductible item and unless you guys are wealthier than I thought these expenses are legitimate deductions. Make your own personal copies of all pertinent medical documents, put the copies you are forwarding with your claim in chronological order, keeping it together by stapling or a binder. Here's a hint that might help. Make single sided copies instead of two sided. The reason is that it will make your packet much larger and less likely that they will want to read through the whole damn thing just to get to the bottom line. My records I submitted were in excess of 750 single sided pages and I put them in a box and taped my application to the outside of the box. I really don't think they ever looked at any of it because it was too damn big. Also tell them they can keep the copies you provided them. They will be thankful that they don't have to copy the entire package which could eat up a whole days work. If they have to make a copy so they can return copies to you it will go into the back of someone's desk to be done on a slow day, delaying your processing. 6. Get statements from friends, families and co-workers, clergy and who ever to document your case. Ask them to provide you a simple handwritten letter to "Whom it may concern" what they have noticed about you since learning of your condition. Have them be explicit, your temperament, your lack of energy, your depression etc and what effect this has had on them in their relationship with you. Also personal letters from your physicians will be of great help. Most MD's are sympathetic toward your condition and are more than willing to go the extra mile to help you get SS. 7. You'll be asked to provide your original birth certificate and a few other things in original form. Get them and provide them they will return them after they cite them and make copies of them. 8. The hardest part for some of you will be meeting the "means test" on income. Be honest, they have access to IRS files and if they catch you lying about how much you make they will quickly turn you down. The only expectation to this is if you have changed jobs during the last fiscal quarter and the IRS files aren't updated. In that case ask your payroll office to provide you a letter stating your income before and after taxes and include any deductions or contributions you are making to retirement plans. They base their income qualification decision on a scale over the last 3 quarters so make sure you provide them with current info especially if you've taken a pay cut or went on reduced hours due to your condition or a work slowdown. 9. You'll have to wait 6 obligatory months from the date you filed until you get your first check. Regardless of how fast your application is approved. That's the law and there is no way around it. It's there way of making sure that someone doesn't come up with a miracle cure or that you were visited by the Virgin Mary and healed mysteriously. If at anytime during the waiting period you make additional trips to your Dr. or have anything done in a hospital, get copies and take it promptly to the SS office to be included in your application. You will get your final approval/disapproval notice from the SS office in Baltimore, Md. If they send you a letter asking for more info, get it right away and make copies and forward it to them as not to delay your application. Most of all pray and be patient. Don't yell and scream at any SS employee it will only make matters worse. Be cooperative. I spent 23 years in the Military doing admistrative work filling out government forms and processing claims of all sorts. My thoroughness in this application only expedited the processing. No one ever came back to me and said, "Hey you did such a good job you can't be possibly disabled." But I bet you if you play it the way I spelled it out here they won't look real hard to find a reason to disapprove your request. It will be easier for them to stamp it "approved" and get it off their desk. Good luck and if you have any questions I can help you out with in specific in completing the forms email me privately and I will help you the best I can. Like I said I got my approved in a little under 3 months and I hope the same for you. Take care, God bless. Be well!!! Larry Wagner lwagner@ix.netcom.com Maple Valley, Wa This piece came from Hepatitis Haven http://www.hcvadvocate.org/news/newsLetter/2008/advocate0308.html#6 Crucial Information From HCV ADVOCATE:
Getting the Most from Your Health Insurance  PDF
(download)Understanding Your Health Insurance PDF
(download)Taxing Disability Benefits PDF
(download)Life Insurance: The Basics PDF
(download)Doctors and Disability Forms PDF
(download)Can a Person With Hepatitis C Purchase Insurance? (2005) PDF
(download)A Final Word on Medicare Prescription Drug Benefits PDF
(download)Guarantee Issue Health Insurance (2005) PDF
(download)Medicare Drug Coverage Part 2 PDF
(download)Medicare Part D – The Prescription Drug Plan Additional Help for Low Income Beneficiaries PDF
(download)Working When Collecting Disability Benefits PDF
(download)Getting Health Insurance after Diagnosis PDF
(download)Preparing to Leave Work on Disability PDF
(download)Presumptive SSI (and Other Fantasies) PDF
(download)Timetable for Leaving Work Due to Disability PDF
(download)Medicare Part B and Other Health Insurance PDF
(download)Completing Social Security and Insurance Questionnaires PDF
(download)2005 Changes to Social Security & Medicare PDF
(download)An Overview of Disability Insurance Coverage PDF
(download)Short Term Disability Benefits
PDF (download)Medicare Prescription Drug Discount Cards (and Other Changes to Medicare)
PDF (download)Tips When Filing For Disability Benefits
PDF (download)First Annual State of Health Insurance Address
PDF (download)Cleaning up Benefits Odds & Ends: Issues of Note for 2004
PDF (download)Social Security Continuing Disability Reviews (CDRs)
PDF (download)
Appealing a Denial
Medicaid Disability* Social Security Consultative Examinations PDF
(download)American with Disabilities Act: What It Does, and Doesn't Do PDF
(download)Family and Medical Leave Act (FMLA) PDF
(download)Determining Financial Eligibility for SSDI PDF
(download)Fibromyalgia, CFIDS, HCV and Social Security Disability PDF
(download)
When Should You Leave Work on Disability? |
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SOCIAL SECURITY DISABILITY FAQs
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Handling Disability Examinations www.cfsdoc.org/disabil.htm Social Security Admin. Online www.ssa.gov/SSA_Home.html SSA Disability Information www.ssa.gov/odhome/odhome.htm SSA How To Apply www.ssa.gov/howto.htm SSD Reviews www.ssa.gov/pubs/10068.html SSD's CFS Fact Sheet www.ssa.gov/odhome/cfsfacts.htm Toll Free Numbers To Agencies http://macdds.org/m_toll.htm When we emailed Mike to ask him if we could use his information. He was more then happy to share it will all. This is only a example of all the great people out there helping those with Hepatitis. Thank you so much Mike, you are one in a million. Please visit Mikes site http://heppie2000.tripod.com/index-3.html |
AMERICANS WITH DISABILITIES
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What follows is from the SSDI
regulations. These are the some of the parts which can be relevant to
filing for hepatitis.
105.00 Digestive System A. Disorders of the digestive system which result in disability usually do so because of interference with nutrition and growth, multiple recurrent inflammatory lesions, or other complications of the disease. Such lesions or complications usually respond to treatment. To constitute a listed impairment, these must be shown to have persisted or be expected to persist despite prescribed therapy for a continuous period of at least 12 months. B. Documentation of gastrointestinal impairments should include pertinent operative findings, radiographic studies, endoscopies, and biopsy reports. Where a liver biopsy has been performed in chronic liver disease, documentation should include the report of the biopsy. C. Growth retardation and malnutrition. When the primary disorder of the digestive tract has been documented, evaluate resultant malnutrition under the criteria described in 105.08. Evaluate resultant growth impairment under the criteria described in 100.03. Intestinal disorders, including surgical diversions and potentially correctable congenital lesions, do not represent a severe impairment if the individual is able to maintain adequate nutrition growth and development. D. Multiple congenital anomalies. See related criteria, and consider as a combination of impairments. 105.01 Category of Impairments, Digestive. 105.03 Esophageal obstruction, caused by atresia, stricture, or stenosis with malnutrition as described under the criteria in 105.08. 105.05 Chronic liver disease. With one of the following: A. Inoperable billiary atresia demonstrated by X-ray or surgery; or B. Intractable ascites not attributable to other causes, with serum albumin of 3.0 gm./100 ml. or less; or C. Esophageal varices (demonstrated by angiography, barium swallow, or endoscopy or by prior performance of a specific shunt or plication procedure); or D. Hepatic coma, documented by findings from hospital records; or E. Hepatic encephalopathy. Evaluate under the criteria in 112.02; or F. Chronic active inflammation or necrosis documented by SGOT persistently more than 100 units or serum bilirubin of 2.5 mg. percent or greater. ***from an additional section listing various systems.*** ... 5.05 Chronic liver disease (e.g., portal, postnecrotic, or biliary cirrhosis; chronic active hepatitis; Wilson's disease). With: A. Esophageal varices (demonstrated by X-ray or endoscopy) with a documented history of massive hemorrhage attributable to these varices. Consider under a disability for 3 years following the last massive hemorrhage; thereafter, evaluate the residual impairment; or B. Performance of a shunt operation for esophageal varices. Consider under a disability for 3 years following surgery; thereafter, evaluate the residual impairment; or C. Serum bilirubin of 2.5 mg. per deciliter (100 ml.) or greater persisting on repeated examinations for at least 5 months; or D. Ascites, not attributable to other causes, recurrent or persisting for at least 5 months, demonstrated by abdominal paracentesis or associated with persistent hypoalbuminemia of 3.0 gm. per deciliter (100 ml.) or less; or E. Hepatic encephalopathy. Evaluate under the criteria in listing 12.02; or F. Confirmation of chronic liver disease by liver biopsy (obtained independent of Social Security disability evaluation) and one of the following: 1. Ascites not attributable to other causes, recurrent or persisting for at least 3 months, demonstrated by abdominal paracentesis or associated with persistent hypoalbuminemia of 3.0 gm. per deciliter (100 ml.) or less; or 2. Serum bilirubin of 2.5 mg. per deciliter (100 ml) or greater on repeated examinations for at least 3 months; or 3. Hepatic cell necrosis or inflammation, persisting for at least 3 months, documented by repeated abnormalities of prothrombin time and enzymes indicative of hepatic dysfunction. ***From life style changes for HIV because part of the need is to make a comparison between a listed and approved condition and Hepatitis*** N. Repeated (as defined in 14.00D8) manifestations of HIV infection (including those listed in 14.08A - M, but without the requisite findings,..... resulting in significant, documented symptoms or signs (e.g., fatigue, fever, malaise, weight loss, pain, night sweats) and one of the following at the marked level (as defined in 14.00D8): 1. Restriction of activities of daily living; or 2. Difficulties in maintaining social functioning; or 3. Difficulties in completing tasks in a timely manner due to deficiencies in concentration, persistence, or pace. Posted by Peppermint Patti on the Hep C Alert http://www.hep-c-alert.org/links/info/1909.txt
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Reviewed Mar 16 2009