Pediasure

Today Robby was denied Pediasure supplements through our primary health insurance company Choiceplus.
I am one VERY angry mother!!!

Robby has not been gaining weight for a few months and is hanging in there at 33-34 lbs. We have been boosting his caloric intake with Pediasure for at least a year now and it is very expensive. Long story short I asked around at work on our online bulletin boards for coupons to help offset the cost, which is $10 for 6 cans. I have seen coupons in our local paper and save every one of them. One mother in our lab called and left me a voicemail to call her right away. I did and she told me that her child who is medically fragile receives pediasure monthly and the insurance covers it if medically necessary. So I though why not get the ball rolling, I also told her how the diapers were free if they were past three and not patty trained due to medical circumstances. She also gave me a month supply of vanilla pediasure that her son did not like, Robby’s favorite, thank you Jana!
My Drs. office wrote a great letter and my primary insurance denied it because it is not half his daily intake needs, I was so flipping mad because I work for this hospital, have hospital insurance and they constantly deny Robby medically necessary items because it is excluded through our policy. I told the case manager at Choiceplus “wouldn’t it be better for the insurance co. to pay for the monthly pediasure rather than pay for a G-tube in the future?” Why would the insurance deny a little boy who needs the caloric intake to prevent tube feedings in the future? Wouldn’t that make sense? I then asked her if the insurance co. would pay for Robbys G-tube placement if needed in the future. I got no response. She just said I could appeal it. And so I did!

She then had the audacity to tell me they have paid for many things for him. I said “Oh really, like what?” “You haven’t paid for the home health aide, or the nursing agency that cares for him because the policy considers that custodial services” They have refused to pay for the new leg braces because they are out of network and we can get them done in network, even after I explained the mess that happened with the last in network provider, not too mention he has already been casted for the new braces, thankfully if they do not pay it is through Shriners and that is something I am so grateful for.

Most parents might not understand or know the insurance system like I do, I was fortunate enough to work in the field for almost 5 yrs so I have a good background.

So I will fight for everything, we have had to pay out of pocket for some things but not too many because I just keep on fighting until it gets paid. What makes me most angry is that I have to go into work everyday and work hard to pay for health insurance that does not cover my child for anything more than some well and sick visits and some appointments to the local neurologist. Why do I even bother to work, if they do not want to cover him. Why should I pay for health insurance that does not work? We really have a broken system in America. How do others parents get covered through our system and not have to pay a dime or work for it.

The caseworker said “well you do have Medicaid” and I said right back to that “yes for now, what happens in the future with all this healthcare stuff going on?”
The problem is that no one really knows all the ins and outs of that new bill. What we do know is that we parents of medically fragile children are very scared for the outcome. They say that it will cover pre-existing needs but what if it doesn’t… I can’t even think about it.
Lookout Choice plus you have a battle on your hands with one very determined mother!



I found this on a father’s blog….. He said at the end to feel free to pass it on…. it fit so perfect for me so I changed some of the words to fit for us.

The health care issues at hand have gotten convoluted. We should not get so bogged down in the finger pointing, but focus on simplicity. Just as this country was founded and has evolved into the greatest in the world everyone has actually gotten too far ahead of themselves. Earning, accountability, repercussions and risk have been left to the way side as merely expected actions. In turn, those that take these actions, abide by the rules, and are productive in our society carry this burden everyday to provide for those that are less fortunate and those that do nothing. It is horrible that there are individuals that know someone will provide for them and they think it is their right of passage to get a hand out. I am all for helping those that have fallen on hard times, disabled, retired, etc., but to keep enabling our society is a crime in itself. This is exactly where this health care reform is headed. It’s just down right scary. In my specific situation with my son it is perplexing that my government thinks it’s okay for me to loose sleep, be a full-time caregiver & nurse, surrender time with my other children, become sequestered to the house, socially reclusive with our other children’s education and activities, a shower and brushing my teeth before noon is a luxury, pay a private caregiver to make doctor visits, and that a visit to the emergency room with Robby is considered a playdate for us. This is all because my income doesn’t make my son quality for the benefits I work so hard to provide others. Why are those that qualify for benefits any better than I? It’s not okay for them to loose sleep (so give them a nurse), miss spending time with their other children (so give them a nurse), go shopping (so give them a nurse), need to be hospitalized (so provide them insurance, no payment necessary, no haggling with the insurance company) or quit their job (so provide them funding and they don’t have to work), but it is expected of us? It is absolutely wrong that we are being treated like this when we are working to support these other folks that “qualify”. It’s been an adage within our society for many years that it’s more financially rewarding to stay home and collect a check than to get a job. It’s time for the party to be over. Our founding fathers would turn over in their grave. If I am correct the “us” makes up about 90% of the population. It’s pretty simple. When we colonized and built this country everyone worked in some capacity. If they didn’t work, then they starved. No one starved, because they knew they had to work; either with everyone or on their own. There were no hand outs and it was frowned upon not to be a productive individual. Why is today any different? I have a problem with giving, providing and rewarding those that do not contribute and penalizing those that do contribute everyday, every hour and every minute. My particular situation is plainly a text book example of why our system does not work. My government has failed me. My son is broken. It is not his fault, nor mine. If he could choose I guarantee he would like to be able to walk, talk, see and be totally cognitive of his surroundings to enable him to excel in society. Instead, he will never run on a playground, drink from a cup, eat at the dinner table, say a prayer, ride a bike, play baseball, read a book, graduate, drive a car, work, or walk down the aisle. This is the question, “If we cannot provide the necessities to the producers of this country and we cannot adequately administer our current government programs (SS and Medicare), then why should we GIVE anyone anything when we cannot afford what we already have?” It sounds like the housing crisis, when everyone took out equity lines and lived beyond their means. I know you understand all of this, but it is unconscionable that our nation continues down this path. We have to correct the current system first.
Feel free to pass it on

We have a sleep deprived EEG at 8 a.m. tomorrow. I'll post updates soon!

That's it for now, glad I vented!