Insurance problem with incontinence product coverage.

[foton]

Hello,
This post is more to get an advice what should I do. I am T12 complete para with incontinence problems. Up to 2 years ago I was fine with incontinence product coverage, but I was forced to change jobs. My new company is very interesting and I am very happy with new job, but problem is with health insurance. The company is very small and we have, what I would call... basic, health insurance. The problem is with any incontinence products, disposable or reusable, which are exempted from my plan. I did try to appeal twice: in person and through Edgepark with no avail. Both times the response was the same: plan exemption.
I just got another letter which states I have right to appeal again with UnitedHealth or: State Corporation Commission, and Office of the Managed Care Ombudsman.
I did try once before, a year ago, with appeal ( I think it was State Insurance Commision), but UnitedHealth did not even bother to return the call. It looks like my problem is an exemption of incontinence products from my plan.
Does anyone of you have an idea what can I do? The products I use are: external catheters, leg bags, and night bags. The two latter ones I can get reusable, but I need external catheters which are expensive.

Thanks for the help.
Tom

[Mystery]

Can you get a letter of medical necessity or look for something that would be in the "durable medical equipment" or "prosthetic" category? I know that ostomy supplies are covered as DME / Prosthetic's and I would make the assumption (no clue here) that caths would be the same way.

Also, according to the ACA (Affordable Care Act), I thought these were covered (I know ostomy stuff is). So organizations covered by ACA rules for insurance had to accept the rules on ostomy DME/P at least, and start covering them.

Sorry, I have lots of experience with ostomy supplies...not with cath stuff though.

If you need to, in the meantime, call around and talk to the manufacturer of your supplies - they may have a program to assist you if you have no insurance coverage. Some manufacturers or suppliers do, and there are a couple groups for ostomy supply exchange, again not sure about cathing stuff but I'm sure there would have to be, so that could help tide you over in a pinch if you run low on supplies.

Post back or PM me if you need more info / think I can help.

Good luck, and let us know how it goes!
Mystery

[foton]

Hello Mystery,
Thank you very much for the response.
The situation is not easy... I was able to check your response earlier and first called UnitedHealth. The helpdesk representative was not very helpful. The ACA does not apply here and exemption of urinary products, and other services as the matter of fact, was agreed upon contract signed up.
The main supply I need is Clear Advantage external catheter made by Coloplast. I did call them, but the only advice was to call four of their product distributors. None of them offers additional incentive for lack of insurance coverage and their prices are on the higher spectrum ( one of them had prices higher than my local drugstore). I need around 30 catheters per month times $2.25 per each...... that I cannot afford. Plus, I even cannot use it against my deductible. Tomorrow I will call UroMed's sister company ( AtHome Medical ), but I doubt it will do anything good. I was not aware that company which owns Edgepark bought last year UroMed. So, here competition goes down the tube. I have spoken with my doctor, but she said nothing can be done. The plan does not cover it and this will be used during any appeals. I am not sure my case was really discussed during contract negotiations. Probably, I would be told how much it would raise the total insurance cost, but no mention of this issue.
Anyway, I really have a problem now and not sure what to do. Whatever catheter prices were given to me they are too much for me to pay on monthly bases.......
Regards
Tom

[Mystery]

I read through what you said. Again, my understanding is not 100% because I am not familiar, but I can see some issues.

My ostomy supplies are also through Coloplast. To the best of my knowledge, you are correct, when I inquired about a needs program from them (in case I lost my insurance), they said no. Hollister, on the other hand, does have one of these programs to the best of my knowledge (a discount type program). I'm not sure about ConvaTec, and those are the three ostomy supply manufacturers that are big and that I know (I assume they carry caths too).

There are several sites online that stock this when I ran it online. I did a Google (then click on Shopping) search for the name you gave. Found them down to $1.56 to my zip code, sometimes $1.77. That is a difference from what you were quoted, although I will tell you that internet prices vary depending on where you search from (so your quotes may be higher). Do be sure to sort the Google Shopping list Price: Low-High. I would also suggest running variations of the names to see if you get different results in case a different site lists it differently.

There are also lists of out-of-pocket suppliers (for ostomy supplies, but most sell caths too) - on the UOAA Discussion Boards. There's several ads on the top of the page and then there have been many discussions on the cheapest / best place to get supplies.

In my (ostomy) experience, Edgepark is known as the most expensive, Byram is known as expensive (but I use it because they are the most accurate, and when I order I want what I ordered, not a substitution!! (I'm terribly allergic to most stuff...)), and then many people use Sterling for out of pocket. Byram does give a 10% discount if you pay out of pocket, but I find that to be too expensive.

Another place you might check is IndeMedical. I stumbled onto this site one time while looking for wheelchair parts and they beat a price quote (without me even saying anything about a previous quote for the part) by about $100. For the caths, I get the price down to $1.44 for singles, and then a box of 100 should be $144 or less, but it's $154...so if I were you, I'd just order 100 singles and save myself the $10, (away before someone me, laugh).

There are probably many other sites out there, not sure what is the least price...but it can't really hurt to spend time looking for the best price, especially if you can get it down to $1.44 from $2.25. That's a huge price difference, about 64% if I did the math right?

If I were you, I'd also consider talking to an insurance advocate at your state level, and seeing if there is anything you can do. It may be unlikely, but I think it would be worth a call. The worst answer that you can get is "that's correct, we can't do anything" - but at least you would know.

Again, PM me or post back to let me know how it's going and if there's anything more someone can do to help.

Take care and good luck! I'm sorry the news wasn't better, but if you could get the same price quotes I got, and find the caths for $1.44 or even cheaper, that would at least be a start.

Mystery

[ekephart]

Tom,

While this does not solve your long term problem, I have a stash of supplies that Ryan does not need that should go to someone who does need them. We have close to 100 condom cath's and several night bags. I do not have any leg bags since Ry only used the deal at night. He is able and prefers to use a urinal do PM me and if you can use what I have, you can have them. I am in southern VA but my older son and grandchild live in Woodbridge so we can make something happen.--eak

[Brent K]

If they are still usable I have a bunch that you're welcome to. I've had them for about 10 years that's why I question if they are still usable. You might check this website out also. I buy a lot of supplies from it. Their prices are the cheapest on incontinence and urological products that I have found.

http://www.blowoutmedical.com/catalo...ernal+catheter

Also found some on ebay. http://www.ebay.com/sch/i.html?_from...heter&_sacat=0

[foton]

Hello,
Sorry for the late response and thank you very much for your help.
As per Mystery advice I have started to look for any information, which could help me to solve my insurance issue and contacted State Corporation Commission Bureau of Insurance ( for those interested: 1-800-552-7945). I was able to talk to advocate and the news is not good. Whatever has been agreed upon and signed.... stays. No one can help with any appeals, but my employer. And that can probably be done when new contract will be discussed. Not good news for me, but I thought I am in big trouble anyway and this news is not a surprise.

Ekephart, thank you very much for your offer. Can you tell me what type of catheter and their size you have? The one I use are Clear Advantage with Aloe ( size Medium (28mm) or Small (23mm)). I think, original producer was Mentor and now they are being made by Coloplast. Importantly, they are being made of silicon ( not latex rubber) and have adhesive already applied inside.

The same question would go to Bryant K.

With leg bags and night bags..... I have checked UroCare and I will go with their reusable products. The only issue is... their leg bags are made of latex and this is my concern.
I have also checked suggested websites and the cheapest one is IndeMedical.

Regards,
Tom

[triumph]

Sorry if I missed this point: Have you already met with your employer to discuss this? Might be uncomfortable idea, but it seems they hired you - they want you - thus it's worth letting them know how much you now must spend, for example, on a monthly basis. Money talks. Maybe they can finagle a higher wage if they can't convince their insurance plan to cover your needs.
IMO they need to know about this, to join in on a solution.

[Smashms]

I read through what you said. Again, my understanding is not 100% because I am not familiar, but I can see some issues.

My ostomy supplies are also through Coloplast. To the best of my knowledge, you are correct, when I inquired about a needs program from them (in case I lost my insurance), they said no. Hollister, on the other hand, does have one of these programs to the best of my knowledge (a discount type program). I'm not sure about ConvaTec, and those are the three ostomy supply manufacturers that are big and that I know (I assume they carry caths too).

There are several sites online that stock this when I ran it online. I did a Google (then click on Shopping) search for the name you gave. Found them down to $1.56 to my zip code, sometimes $1.77. That is a difference from what you were quoted, although I will tell you that internet prices vary depending on where you search from (so your quotes may be higher). Do be sure to sort the Google Shopping list Price: Low-High. I would also suggest running variations of the names to see if you get different results in case a different site lists it differently.

There are also lists of out-of-pocket suppliers (for ostomy supplies, but most sell caths too) - on the UOAA Discussion Boards. There's several ads on the top of the page and then there have been many discussions on the cheapest / best place to get supplies.

In my (ostomy) experience, Edgepark is known as the most expensive, Byram is known as expensive (but I use it because they are the most accurate, and when I order I want what I ordered, not a substitution!! (I'm terribly allergic to most stuff...)), and then many people use Sterling for out of pocket. Byram does give a 10% discount if you pay out of pocket, but I find that to be too expensive.

Another place you might check is IndeMedical. I stumbled onto this site one time while looking for wheelchair parts and they beat a price quote (without me even saying anything about a previous quote for the part) by about $100. For the caths, I get the price down to $1.44 for singles, and then a box of 100 should be $144 or less, but it's $154...so if I were you, I'd just order 100 singles and save myself the $10, (away before someone me, laugh).

There are probably many other sites out there, not sure what is the least price...but it can't really hurt to spend time looking for the best price, especially if you can get it down to $1.44 from $2.25. That's a huge price difference, about 64% if I did the math right?

If I were you, I'd also consider talking to an insurance advocate at your state level, and seeing if there is anything you can do. It may be unlikely, but I think it would be worth a call. The worst answer that you can get is "that's correct, we can't do anything" - but at least you would know.

Again, PM me or post back to let me know how it's going and if there's anything more someone can do to help.

Take care and good luck! I'm sorry the news wasn't better, but if you could get the same price quotes I got, and find the caths for $1.44 or even cheaper, that would at least be a start.

Mystery

byram is not most accurate! I had nothing but issues with them both with their billing depts and also subbing products as well. I use sterling medical for my ostomy supplies they are the absolutely best. As far as getting caths sterling also does them and i think hollister makes something that you could use as well.

[foton]

Hello triumph,
It was an extending talk even before the end of the contract last year. I did not mention the problem when my first claim was rejected and Edgepark failed the appeal on my behalf. I informed my HR person, also liaison between my firm and UnitedHealth, about my SCI need coverage problems. The information about product codes and Edgepark appeal letter were sent to the broker's office. They were surprise this was an issue and asked to fail another appeal. I got a new letter of medical necessity from my doctor and filed new appeal by my self. Of course, this one was denied, either. At this point I have asked then and later few times during time of new contract negotiations. Unfortunately, my HR person is not the easiest to talk to. She knows exactly what I need, but I think the cost of new contract was more important that the need of one person. Until the last moment we did not know whom we get the new insurance through and the time delay was due to much higher costs. Finally, we got an e-mail the contract will not change and we go with UnitedHealth again. But, this time deductible will be higher $200 (from $1000). I will try again, this time with even stronger pressure, by the end of current contract. So, I need somehow to survive at least this year.
On the other note...... I am not first and last in this matter. Employers have and will have real problems to maintain health insurance as a part of benefits. My entire last year deductible was covered by my employer what was very nice gesture. This year only $600, which is half of the current sum. Expenses are going high, but many current contracts are being given to the lowest bidders. Everyone knows no one can deliver at these costs, but.... no one cares.