Friday, May 6, 2011

Dear Texas Legislature, Thanks for requiring insurance companies to cover elemental formulas...

Just this week, I finally got all the insurance claims settled and pharmacy paid for Bo's formula (don't even get me started on how inefficient some doctors and pharmacies are with billing).  

First of all, it took awhile to get the insurance company to cover the formula.  It took letters from our pediatrician, letters from our gastroenterologist, and some reminding about the bill our legislature passed effective September 1, 2009 (the timing is not lost on me since Bo was born in Nov. 2009).  Then it took forever for the pharmacy to run and reconcile the claims.  Finally, we have our total, and I'm blown away...

We did a trial run of elemental formula (Nutramigen AA) in February when Bo was about 8 weeks old, weren't impressed, and  went back to nursing.  I stopped nursing Bo just shy of 6 months.  When I quit nursing, we went back to the elemental formula (even though we weren't impressed the first time, we really didn't know what else to do).  For whatever reason, this time, it did the trick.  In his twelfth month, we transitioned to hemp milk, and by 15 months, he accepted whole milk without issue (though even today, he is the gassiest little thing; it just doesn't seem to bother him).  All told, we went through 10 cases of elemental formula (a case equals four 14.1oz. cans).

The math:  if we had to order these 10 cases through Enfamil (like families who don't have the luxury of living in a state that requires insurance companies to cover elemental formulas), our total cost would be $1,560 (as of today, it's $156/case).  With our insurance coverage (an 80/20 plan for which we met our out of pocket max half way through the year), our total cost was a mere $158.40!  Almost right at 10% of what it would be otherwise!  

Currently, there are just fourteen states that provide some sort of reimbursement for elemental formulas.  That makes my heart ache.  While only paying 10% of the full cost of elemental formula was a huge blessing for our family, we are blessed to have the resources that could have covered the total amount without creating a hardship for us.  But many families don't.  I remember being in that place where I was scared to feed Bo anything because of how ill everything made him.  While it didn't work miracles (at least not the first time around), elemental formula was the safest option (and only one left really).  I can't imagine needing it but not being able to provide it because of the cost, but I know that is many families' reality.

That's why I'm so thankful Texas is one of the fourteen states that provides reimbursement for elemental formulas!  If you live in Texas and are having trouble getting your elemental formula covered, keep at it.  It  took us five months before they approved the first claim (and many, many letters, phone calls, etc.).  Here is the information about the Texas Bill:

HB 2000

Legislative Session: 81(R)-2009

Bill Summary: House Bill 2000 amends the Insurance Code to require certain health benefit plans to provide coverage for amino acid-based elemental formulas, regardless of the formula delivery method, that are used for the diagnosis and treatment of certain congenital allergies and related diseases.  The bill requires such coverage if the treating physician has issued a written order stating that an amino acid-based elemental formula is medically necessary to treat an enrollee who is diagnosed with such a disease and requires the coverage to include any medically necessary services associated with the administration of the formula.  The bill authorizes a utilization review agent acting on behalf of a health benefit plan issuer to review a treating physician's determination of the medical necessity of such a formula.  These changes apply to a plan that is delivered, issued for delivery, or renewed on or after January 1, 2010.

Go here to look up the full text of the bill. 

This bill is now codified in Chapter1377 of the Texas Insurance Code

Thank you Texas Legislature!

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