CKSN UPDATE for July 1, 2003			ABC for Health, Inc.

IN THIS ISSUE:

1. CASE TIP: Request a Written Explanation of Denial of Coverage 
2. CASE TIP: Building a Paper Trail
3. CASE TIP: Follow Up Phone Conversations in Writing
4. Public Health Conference in October
5. Guardianship and Healthcare Workshop at the Waisman Center
6. SSI/Managed Care Mandatory Enrollment on Horizon
7. HealthWatch Updates



1.CASE TIP: REQUEST A WRITTEN EXPLANATION OF DENIAL OF COVERAGE

Children with special health care needs require more services, which are often provided by a variety of providers and funded through different sources of coverage.  Sadly, with today's rising health care costs and tightened budgets, families are finding that insurance providers are denying coverage for benefits more frequently. 
 
An insurer that denies coverage for a benefit is legally required to provide you with a prompt response in writing explaining why a service has been denied or not covered.   When requesting an explanation for the denial of a benefit, ask the insurance representative to direct you to the section of the policy they're relying on to make the denial. 

An important feature of the law to remember is that ambiguities in the policy (terms that can be interpreted multiple ways to the average reader) are interpreted in favor of the insured.



2. CASE TIP:  BUILDING A PAPER TRAIL  
 
For parents of children with special health needs, keeping a good set of written records-a paper trail-can help in communicating effectively with insurance and medical providers. 

A paper trail consists of any and all records to verify your contacts with your provider and your insurer. Consider using a multi-pocket file folder to keep all the documents together in one place.  Elements of a good paper trail include:

* Insurance plan-the booklet that describes your benefits in detail
* Bills
* Records of the dates of all your medical procedures and any procedures performed
* A contact log listing time and date of phone conversations, name of person you spoke with, and notes on the conversation.  
* Correspondence
* Medical records
* Explanation of benefits (EOB) forms
* Denial letters
* Grievance requests
* Grievance decisions
* Insurance applications
* Premium payment records
* Office of the Commissioner of Insurance correspondence

These records can be extremely useful should you need to build a case for getting the care that you need.  Keep a file and perhaps a journal to document your activities.  This up front work can prevent a lot a health care coverage snags down the road.


3.  CASE TIP:  FOLLOW UP PHONE CONVERSATIONS IN WRITING

Have you ever had an insurance provider agree to cover a service over the phone, only to find that later the service is denied?  One way to protect yourself is to write a follow-up letter to the insurance provider immediately after the phone conversation.  Include the time and date of the conversation, the name and title of the person you spoke with, and the details of the conversation.  Ask for a written confirmation in response. That way you'll have an accurate record of what was promised, which will help you if a problem arises with the promised service.  


4.  PUBLIC HEALTH CONFERENCE IN OCTOBER

October 3 at the Madison Concourse Hotel:  Health and Health Care in
Wisconsin:  How Good? What Works? Who Pays? Who Decides?

This conference is being produced by the Wisconsin Public Health and Health
Policy Institute in partnership with the Marshfield Center for Health Systems Research and the Milwaukee Center for Urban Population Health.  The keynote speaker will be Dr. James S. Marks, MD, MPH, Director, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention.  There will also be panels and sessions with leaders from the Legislature, private industry, and the Doyle
Administration.

Details will be posted on the Institute's web site at www.pophealth.wisc.edu/wphi Registration forms should be in the mail by late July.
(Source:  Jon Peacock, Wisconsin Children and Families)


5. GUARDIANSHIP AND HEALTHCARE WORKSHOP AT WAISMAN CENTER

Decision-Making, Guardianship Options And Health Care: A Workshop for
Health Care Providers

Tuesday, July 29, 2003
6:00-8:30pm
Waisman Center
1500 Highland Ave.
Madison WI 53705

*  When is Guardianship Needed?
*  An Overview of the Guardianship Process
*  Options for Decision-making and the Impact on Health Care
*  The Role of the Health Care Provider
*  Young Adult and Parent Perspectives on Guardianship: Decisions that
surround the issue.

Presented by: Dr. Bill Schwab, Roy Froemming, J.D., Young Adults with
Disabilities and Parents

Sponsored by: Wisconsin Healthy & Ready to Work Project & Southern Regional
Center for Children with Special Health Care Needs, Waisman Center, UW-Madison

Refreshments will be provided.
There is no fee to attend the presentation.

6. SSI/MANAGED CARE MANDATORY ENROLLMENT ON HORIZON

Mandatory enrollment in managed care plans for MA recipients who receive SSI?
In the current budget being reviewed by Governor Doyle is a provision to require DHFS to submit a waiver to the federal government to require adults who are eligible for SSI to enroll in managed care plans, including recipients who are in a geographic region that contains only a single managed care organization. Current estimates assume that 90% of the SSI-only adult MA population would be required to enroll in managed care plans and that 40% of dually eligible individuals and 40% of all eligible children under age 18 would voluntarily enroll. For more information on this, visit http://www.legis.state.wi.us/lfb/2003-05budget/2003-05BudgetPapers/393.pdf

In addition, if you're interested in learning about developing a system of managed advocacy in response to managed care delivery systems for persons with disabilities, see the ABC report Managed Advocacy in Action found at www.abcforhealth.org


7.  HEALTHWATCH UPDATES
 
The next Southern Regional HealthWatch will be held on Thursday, July 17 from 11:30 - 1:00 pm at the Harambee Center, 2202 South Park Street, Madison. There will be a training offered by Jon Cope, staff attorney at ABC for Health on Fighting Back Health Insurance Denials.  For more information, and to RSVP, contact Dana McElmury, 608-261-6939, ext.208 or email, danam@safetyweb.org

If you are interested in joining your regional HealthWatch committee, or want more information about their work, please contact the following people:

Southern Region:  Barbara Katz, ABC for Health, Inc., 608.261.6939 ext 207, barbk@safetyweb.org
Southeastern Region:  Brad Holman, Children's Hospital of Wisconsin, 414.266.3189,
bholman@chw.org
Northern Region:  Deb Blackstone, Family Resource Connection, 715.365.8030,
dblacks@shsmh.org
Northeastern Region:  Steve Gerczak, St. Vincent Hospital, 920.433.8154,
sgerczak@stvgb.org
Western Region:  Rose Marsh, Chippewa County Dept of Public Health, 1-800-400-3678, rmarsh@co.chippewa.wi.us



ARE YOU SHARING THE UPDATES WITH FRIENDS OR COLLEAGUES?  

We need your help to better track the distribution of the CKSN update.  Please let us know the names and email contact info of people you forward the email to so we can send them the update directly.  Direct replies to barbk@safetyweb.org 

The CKSN Update is a bi-weekly electronic newsletter of the Covering Kids with Special Needs project that ABC for Health, Inc. is implementing with its partners, the Title V Children with Special Needs Regional Centers and Family Voices - Wisconsin.  If you would like to submit news and information in future CKSN Updates, please send it to the attention of Barbara Katz.  All submissions should be limited to 150 words.

Barbara Katz, moderator
Parent Consultant
ABC for Health, Inc.
608.261.6939 ext. 207
barbk@safetyweb.org