By Trish Thrush, Health Law Advocate/Insurance Navigator
* This is intended for informational purposes only and is not medical or legal advice.*
What does this mean?
Developmental Disabilities Administration Waiver Funds/Services must only be used after you have exhausted all other funding sources. This means that you must provide proof that you cannot get a service/therapy from your insurance company before using DDA waiver funds.
What Services might be first accessed through Private insurance or Medicaid before using DDA funds?
Behavioral Support & Consultation (might include ABA), Staff and Family Consultation & Training, Nursing Services, Physical Therapy, Occupational Therapy, Speech Therapy, Durable Medical Equipment & Services (might include incontinence supplies), Peer Mentoring and Specialized Psychiatric Services.
Providing Proof that you cannot access services through Private Insurance:
- Find out if you have coverage in your Plan. To do so you can request a copy of the Plan Document (also sometimes called the Summary Plan Description-SPD or Benefits Booklet). This is the contract between the employer (or yourself if you purchased the plan) and the insurance company detailing the benefits of the Plan. Click here for instructions on how to obtain a copy.
- Check the Plan Document for coverage or exclusions. The Plan Document is the contract between the employer (or yourself if you purchased the plan) and the insurance company detailing the benefits of the plan. Click here for instructions on how to obtain a copy. If you are unsure or cannot locate the information please give the WAAA office a call. We can help! One of our advocates loves big Plan Documents and cannot lie (it’s awful and I’m sorry but I’m not taking it back).
If you have coverage but there are no providers in your area that can provide services within a reasonable amount of time (30 days):
- Call your insurance company and ask for a list of all the in-network providers within a reasonable distance of your home – we suggest 30 miles. If you get stuck in the time vortex that is “let me transfer you to another department so they can transfer you back” give us a call! We can’t restore your sanity after being on hold for 30 minutes listening to a monotone voice tell you that you can go to the insurance company’s website – that you’ve already used to unsuccessfully find providers – but we can help!
- Use this Blank Call Log to document the responses of the providers.
- Provide a copy of the completed Call Log to your DDA Case Manager.
- Please consider sharing a copy of the call log with WAAA. It helps us to know when networks are not meeting our community’s needs.
- Then it’s dance party time because you just did insurance stuff.
If you don’t have coverage:
- Request that your child’s pediatrician or general physician submit a request for prior-authorization of the service. This should result in an official approval or denial of coverage.
- Give a copy of the Plan Document and the letter of denial to your DDA Case Manager.
- Please consider sharing these with WAAA as well. We can use them to help you appeal for coverage through your private insurance. Also, reading Plan Documents keeps our insurance advocate from making up more “songs” (see below).
If there are no providers that can provide services within a reasonable amount of time:
- Call your Medicaid/Apple Health Managed Care Plan and request a list of providers of the service within a reasonable distance of your home. For ABA use this blank Call Log to call each Medicaid/Apple Health ABA provider and ask them the questions in Column I “Call Summary”. For other services use this Blank Call Log.
- Once you have completed this provide a copy to your DDA Case Manager.
- Please also provide a copy to WAAA. We love collecting documentation. Seriously we’re like documentation hoarders. Thank goodness for electronic storage or we would be swimming in paper right now. And I swear we will use them for good – to improve access to treatment. You have my word as an advocate and a banana intolerant coffee lover (hey it’s a good oath-have you had a better one today? I think not).
If you have any trouble please…
Call WAAA (call WAAA) on the line
Call us, call us any, anytime
Call WAAA (call WAAA) my friend
You can call us any day during business hours (business hours)
See, she has too much time on her hands. For the love of all that is good in the world give her your documents people!
Premium Payment Program
If you have private insurance and Medicaid, you can apply to the HCA’s Premium Payment Program, which helps with out of pocket expenses. Also, if you have dual insurance (private and Medicaid), you can apply to Hogwarts. Obviously, an owl has to bring you an invitation first, but until then you can apply for the Premium Payment Program, which is nearly as cool as magic because it helps pay for your insurance premiums. Find out more about it by clicking here.