Hi everyone! This is my first time dealing with Illinois Medicaid and I am hoping to get some advice. My father (58M) had a very severe left basal gangliar hemorrhagic stroke at the beginning of the year. He has been in the hospital since and has been making steady progress toward his recovery. He can now produce speech and engage in some conversation (though you cannot always make it out), he can eat a soft diet without assistance, he can breathe on his own, and he is participating in his therapies (speech, occupational, and physical) through the hospital. With the help of physical and occupational therapy, he has actually been practicing standing with assistance.
My father’s case manager recently brought my father’s case to his Medicaid plan (Blue Cross Community Health Plans) for their approval for him to be transferred to a higher level of care (acute inpatient rehabilitation). At this higher level of care, my father will receive increased rehabilitation attention (speech, occupational, and physical therapies). His current therapists and rehabilitation doctor at his current hospital have all stated (in writing) that my father could benefit greatly from acute inpatient rehabilitation. However, his Medicaid plan denied him coverage for this level of care.
Basically, their argument is that he could receive proper care at a lower level (skilled nursing). They argue that skilled nursing offers 2 hours of therapy a day, five days a week to patients at this level. However, in Illinois, this is not the case (as explained to me by my father’s case manager).
Apparently, this predicament happens when Medicaid plans (such as his Blue Cross Community Health Plan) delegate claims to a third-party company for preauthorization. Sometimes, and in this case, the individuals reviewing claims for preauthorization are in different states (and are thus not aware of the differences in Medicaid plans by state) or do not hold the proper medical credentials to make such a decision.
There is an appeal process, but honestly, I am nervous that my father is going to continue to be denied the care that he needs, deserves, and is ready for. After all, state-funded medical coverage (at least in Illinois) is not the best and I get the impression that they are interested in saving money rather than patients and quality of life. I love my father dearly and I will always advocate for him; I cannot sit back and let Medicaid deny him of care that he needs. Are there any other avenues that are available to me that I am not looking at? What are my options?
submitted by /u/t-bone06
[link] [comments]Hi everyone! This is my first time dealing with Illinois Medicaid and I am hoping to get some advice. My father (58M) had a very severe left basal gangliar hemorrhagic stroke at the beginning of the year. He has been in the hospital since and has been making steady progress toward his recovery. He can now produce speech and engage in some conversation (though you cannot always make it out), he can eat a soft diet without assistance, he can breathe on his own, and he is participating in his therapies (speech, occupational, and physical) through the hospital. With the help of physical and occupational therapy, he has actually been practicing standing with assistance. My father’s case manager recently brought my father’s case to his Medicaid plan (Blue Cross Community Health Plans) for their approval for him to be transferred to a higher level of care (acute inpatient rehabilitation). At this higher level of care, my father will receive increased rehabilitation attention (speech, occupational, and physical therapies). His current therapists and rehabilitation doctor at his current hospital have all stated (in writing) that my father could benefit greatly from acute inpatient rehabilitation. However, his Medicaid plan denied him coverage for this level of care. Basically, their argument is that he could receive proper care at a lower level (skilled nursing). They argue that skilled nursing offers 2 hours of therapy a day, five days a week to patients at this level. However, in Illinois, this is not the case (as explained to me by my father’s case manager). Apparently, this predicament happens when Medicaid plans (such as his Blue Cross Community Health Plan) delegate claims to a third-party company for preauthorization. Sometimes, and in this case, the individuals reviewing claims for preauthorization are in different states (and are thus not aware of the differences in Medicaid plans by state) or do not hold the proper medical credentials to make such a decision. There is an appeal process, but honestly, I am nervous that my father is going to continue to be denied the care that he needs, deserves, and is ready for. After all, state-funded medical coverage (at least in Illinois) is not the best and I get the impression that they are interested in saving money rather than patients and quality of life. I love my father dearly and I will always advocate for him; I cannot sit back and let Medicaid deny him of care that he needs. Are there any other avenues that are available to me that I am not looking at? What are my options? submitted by /u/t-bone06 [link] [comments]Read Morer/HealthInsurance