• Questions to Ask
• Funding For Medications: Rx & OTC
• Flexible Spending Accounts
• Understanding CPT and ICD-9 Codes
  • Things to Know
  • What ICD-9 is your health issue?
  • CPT CODES Tools & Info
  • ICD-9 CODES Tools & Info
    
    
• Tax Deduction - Medical & Dental Expenses
• Tax Deduction - Self-Employed Health Insurance
• Resolving Disputes
• Debt/Credit Help
• Medical Necessity
  

• Questions to Ask

Health insurance programs for children and adults are different. Between ages 18 and the early to mid 20s, most youth will change programs.

Some questions to ask about health insurance are:

• How do I pay for my medical expenses now?
• How much does my health insurance cost (monthly premium)?
• What does my health insurance pay for?
• What co-pays and deductibles do I have to consider?
• What items are not covered or only partially covered by my policy (for example, medications, lab tests, equipment, dental care)?
• What can I do if I have a lot of bills that are not covered by some health care plan?

• If I am on my parents’ policy, how long can I stay on and under what circumstances?
• Will I be able to get insurance through my job?
• Will I be able to get insurance through my college or technical school or the military?
• Am I now or will I be eligible for Medicaid? Medicaid waivers?
• Will I be eligible for Medicare as a disabled person or adult child of a disabled person?
• Does my state have any health insurance options?
• Are there services I can qualify under State Title V program (to age 21)?
• Are there services I can qualify under SCHIP?
• If I can not get typical insurance can I qualify for State High-risk insurance pool?

• Funding for Medications:
Prescriptions (Rx) & “over-the-counter”(OTC)

Do not skip your medication, or change the dosage (the amount you take at one time) or the frequency (the number of times per day/week you take the medication), to try to save money. Your health condition might get worse if you do this. Tell your doctor right away if you are having troubling paying for your medications.

CO-PAYS - Paying for the high cost of prescription drugs is a big problem for many people in the US now. If you have health insurance, most will have a “co-pay”, for example, $10-$50 for each prescription. Even people on public insurance programs may have co-pays. Under Medicare insurance, prescriptions are only covered while you are in the hospital- this may be changed by Congress.

NOT COVERED-EXCLUDED - In addition, your insurance company may not cover all of the medications that your doctor prescribes. Insurance companies (and state Medicaid programs) keep lists of “approved” drugs that subscribers may receive. Some drugs may be “excluded”- or not covered- even though your doctor prescribes them.

KEEP INFORMED - The most knowledgeable person who knows what is and is not covered is your pharmacist. Also call your insurance company or check their web site to get a copy of the approved drug list. Ask your doctor to prescribe medications that are on this approved list whenever possible and document well why a non-approved drug is prescribed.

SAMPLES - Remember to always let your doctor know if you do not have insurance coverage for the medications you need. Doctors can sometimes give you free samples of some medications and/or refer you to community programs for help.

NO INSURANCE and LACK OF MONEY
If you have no insurance, or have only Medicare insurance, here is a list of possible resources to help you pay for your medications.

The Medicine Program
www.themedicineprogram.com
The Medicine Program! This organization was established by volunteers dedicated to alleviating the plight of an ever -increasing number of patients who cannot afford their prescription medication. People who do not have insurance, and are not eligible for government programs can apply. The web site has a downloadable copy of the application form, or your can call their toll-free number. There is a $5 application fee for this program, for each prescription filled.

NeedyMeds
www.needymeds.com/
NeedyMeds is the place to learn about patient assistance programs and other programs designed to help those who can’t afford their medicines. NeedyMeds is not a program. It’s an information source. This site has lists of prescription assistance programs, lists of medications that may be covered, and also explains how to apply for government programs. It does not help individual people get prescriptions filled.

• Flexible Spending Accounts

• Cafeteria Plans/Flex Account
• What is it?
• Who qualifies?
• What it covers
• What it costs
• Impact for YOUTH
• How to Apply
• Resources

What it is: Employees set aside money from their paychecks throughout the year to use toward medical or dependent care expenses typically not covered by traditional health insurance benefits (Authorized under Section 125 of the Internal Revenue Code.) These may also be called cafeteria plans, choice spending accounts, section 125 plans, and/or reimbursement accounts. There are two types of spending accounts: one for medical reimbursement, the other for dependent care spending. Each has its own set of rules.

ADVANTAGES

Cafeteria plans provide employees with a convenient way to pay for certain expenses with before-tax dollars saving them FICA, federal, and sometimes state taxes. By setting aside money during the year for medical or dependent care services on a pre-tax basis, employees are able to reduce their taxable income, thereby increasing their level of take-home pay.

Money can be set aside for co-payments and deductibles for health insurance, a high selling point, given that co-pays for office visits and prescription drugs are increasing for most employees

The employer saves on FICA and workers compensation taxes.

ISSUES TO CONSIDER:

Flexible Spending Accounts are attractive for people who already has health insurance through another source, such as a spouse. The health insurance contribution from the employer can be put into a FSA and/or the employee can choose to put salary money into the account. An employee may choose to have both health insurance and an FSA.

Keep in mind, unspent funds will not be given back to the employee - AND – receipts in excess amounts of the yearly declaration will not be reimbursed.

To estimate your yearly medical expenses, think about how often in the coming year you will be going to the doctor’s office and what the co-pay will be for each visit? Are there yearly routine tests? Monthly prescriptions? During the next year, will you need to order some expensive equipment which will only be partially paid for by your insurance? New eye glass frames? Total these anticipated expenses.

Make an educated guess as to what your expenses might be and divide this by the number of paychecks you will receive.

Consider how much you are comfortable having deducted from your paychecks.

Set-up a file where receipts can be placed and not lost. Some employees choose to submit paperwork for reimbursements on a monthly basis, some do so quarterly, others wait until the end if the year.

Who qualifies: Employees who work for companies that offer these plans can elect to participate through payroll deductions. Check with the company department that manages the health benefits.

What it covers: These plans reimburse expenses that are not paid by your health care/dental or vision plans. Generally most plans will reimburse co-pays for office visits and prescription drugs. Each plan provides a list of approved expenses. Read the list of approved items ahead of time. You maybe surprised what is covered. Some health insurance plans do not pay for alternative medical treatment, yet this “flex” plan might reimburse your out-of-pocket expenses.

• Over the counter drugs are now eligible (9/3/03)

What it costs: The employee determines how much money they want to set aside per year to off set out -of -pocket expenses. There is usually a maximum limit of a percentage of gross pay.

Impact to Youth: There are two ways these plans can benefit youth. First, for those who remain on their parents’, step-parents’ health benefits plans, the reimbursements can be helpful in lowering out-of pocket expenses each year. For youth who have their own health benefit plans through their work they too can get reimbursed for services and products that are not covered by their plans.

How to Apply: Talk with your employee benefits representative and complete the necessary forms.

• Understanding CPT and ICD-9 Codes

Did you ever wonder how doctors got paid by your health insurance? - Or - Why a bill that should have been paid quickly took longer than usual or was rejected/denied?

It’s all about numbers and codes. The right ones make the paperwork get processed quickly which means you get your reimbursement faster, your doctor gets paid for services he/she has already rendered, and all of us spend less time on the phone trying to expedite payment.

So what are these numbers? And why should YOU – the consumer – be more familiar with them?

Things to Know

1. The doctor is legally responsible for the codes selected and submitted to your insurance company whether it is public or private insurance.
2. There are two categories of numbers: CPT codes and ICD-9 codes.

• CPT (Current Procedural Terminology) is a standardized mechanism for reporting medical services (usually physician services) using numerical codes.
  • CPT details the average amount of time physicians spend on various levels of office visits, inpatient consultations, home services, etc.
  • A large number of procedure coding errors and claim denials for professional services occur because of inaccurate application of the codes found in the CPT book.
  • There are some CPT codes which are not reimbursed by some insurance companies, although they describe the services your doctor provides.
    
    
• ICD-9 (International Classification of Diseases) consists of three volumes. The first two contain a tabular listing of diseases organized alphabetically and by body system.
  • The three-digit code represents the diagnostic category.
  • The fourth digit identifies complications associated with the health issue.
  • The fifth digit describes the type of health issue and its level of control which justifies the tests that are ordered on outpatients

REMEMBER:

1. CPT CODES - WHAT THE DOCTOR DOES
   • time spent with patient, tests, counseling, etc.
     
2. ICD-9 CODES - YOUR HEALTH ISSUES/DIAGNOSES

YOU CAN:
If your bills are not getting paid quickly make sure that the Doctor’s office is using the correct Codes. Ask for the person who is in charge of billing, how your paperwork was coded.

CALL YOUR INSURANCE COMPANY TO TRACK THE PAYMENT
Ask the insurance company if this is the right Code that they will reimburse for services and why reimbursement is taking longer than usual. Let the Doctor’s office know what you have learned.

COMPARE CODES FROM PREVIOUS BILLS – WHAT GOT PAID BEFORE.
Look at past bills (from your Doctor) and past reimbursement statements (EOB-Explanation of Benefit) from your health insurance company to see what they have paid for in the past.

What ICD-9 Code is Your Health Issue?

Look at your last medical bill for the CODES. Use these web site databases to learn what those numbers mean. If you do not have the CODE, then type in your medical issue to learn what the CODE is.

STANFORD UNIVERSITY SCHOOL OF MEDICINE
ICD9 Database
neuro3.stanford.edu/CodeWorrier/
Database it designed to input Diagnosis and/or partial ICD-9 code. Search provides you with not only ICD-9 listing but also brief narrative about each code extension after the three-digit category.

AAFP- ICD-9 Coding Tools From Family Practice Management
www.aafp.org/x20096.xml
ICD-9 coding, Family Practice Management offers three tools

CPT Codes Tools & Info

AMERICAN ACADEMY OF PEDIATRICS
Medical Home Curriculum - Underutilized CPT Codes
www.medicalhomeinfo.org
Medical Home Training Facilitator Manual – appendix has a section called Underutilized CPT Codes which lists reimbursement codes starting with “99”. List is adapted from the AMA’s 1998 CPT Coding, p 35-39.

• CPT - Coding and Documentation References
• Coding frequency comparison spreadsheet
• Guidelines for time-based coding
• House calls
• Office Visits: Level 1
• Office Visits: Level IV

AAFP-Time Is of the Essence: Coding on the Basis of Time for Physician Services
www.aafp.org/fpm/20030600/27time.html
Times are listed for each service in the CPT manual only as a guideline. On the other hand, CPT lists a variety of codes that are strictly time dependent and even has codes for prolonged services. As a result, there is much confusion around the importance of time, especially when coding unusually long office and inpatient visits. With a correct understanding of time and how it relates to coding, physicians can know when a higher code may be justified even though the history, exam and medical decision-making elements are lacking.

AAFP-A Quick-Reference Card for Identifying Level-4 Visits 99214 in a nutshell
www.aafp.org/fpm/990700fm/32.html
According to CPT, 99214 is indicated for an “office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history, a detailed examination and medical decision making of moderate complexity.”

AAFP-Level 4 Reference Card
www.aafp.org/fpm/990700fm/refcard.html
Fact sheet and pdf file you can download for a mini pocket guide.

UNIVERSITY OF SOUTHERN CALIFORNIA
Introduction to the Coding Systems
www.usc.edu/health/uscp/compliance/tm5.html
The USC Care Compliance Office has developed a comprehensive reference manual for faculty physicians and staff on CPT coding, Medicare's Teaching Physician Regulations and other related coding and billing issues. This document is meant to offer general guidance on common coding and documentation issues.

ICD-9 Codes Tools & Info

AMERICAN ACADEMY OF FAMILY PHYSICIANS (AAFP)

AAFP- ICD-9 Coding Tools From Family Practice Management
www.aafp.org/x20096.xml
ICD-9 coding, Family Practice Management offers three tools

AAFP - ICD-9 Changes for 2002-2003
In Microsoft Word - a convenient list of all the new and changed ICD-9 codes for this year.

AAFP - The FPM Short List of ICD-9 Codes
This list of about 600 codes has been a popular FPM resource over the past few years. It replaces ICD-9 descriptors with problem-oriented descriptors of conditions common in family practice. At two pages in print, it's hard to beat for convenience. PDF, ASCII text and new Palm-compatible hand-held computers (MAC and PC)

AAFP - The FPM Long List of ICD-9 Codes
This list of about 1,500 codes common in family practice expands on the short list to include a wider range of four-digit and five-digit codes. It also includes more codes useful for hospital care. PDF, ASCII text and new Palm-compatible hand-held computers (MAC and PC)

ASK DR WALKER.COM
Family Practice 2000-2001: Online with AskDrWalker.com
www.askdrwalker.com/index/icd-9%20fp%20codes.htm
ICD-9 Major Categories

ASK DR WALKER.COM
Connection to e-ICD Online Code Finder
www.askdrwalker.com/index/e-icd9.htm
Type in the Disease or Condition or classes.

• Tax Deduction- Medical & Dental Expenses

• What is it?
• Who qualifies?
• What it covers
• What it costs
• Impact for YOUTH
• How to Apply
• Resources

What is it: IRS allows a tax deduction for medical expenses that exceed 7.5 % of your annual gross income. You must file form 1040 when claiming any medical tax deductions. The total expenses are entered on line 36, Schedule A.

Who qualifies: People who have out-of-pocket expenses that exceed 7.5% of their gross incomes AND who file their income tax on the “long form” 1040.

What it covers: Expenses that have not been paid by your health care, dental or vision benefits nor has been reimbursed by a flexible spending account. You can also deduct related expenses such as lodging and mileage that occurred while you were getting medical treatment.

• Amounts paid for the diagnosis, cure, mitigation, treatment, or prevention of disease, and for treatments affecting any part or function of the body, including dental.
• Health insurance premiums you pay, if you are self-employed
• Limited amounts paid for any qualified long-term care insurance contract.
• Transportation to get medical treatment
• COBRA premiums

** You may not deduct bills for which you were reimbursed

TIPS

Create a medical expense log for your medical expenses such as mileage to and from doctors’ offices and out-of pocket expenses that were not covered. Save ALL bills and medical receipts, checks and insurance payment EOB statements (Explanation of Benefits) for the year. You may be surprised how much you have paid out!

Create a call /correspondence log to document phone calls, claims, and other health insurance matters: Include dates when you submitted a claim to the insurance company and who you talked to about payment or reimbursement from your insurance or with your physician offices.

What it costs: Just the time and materials to log your activities. Keep receipts and good notes for mileage, hotel and meals.

Impact for YOUTH: There may be some years when medically related expenses are high. Getting a tax break will give you a rebate on some of those expenses.

IF YOU ARE a DEPENDENT ON YOUR FAMILY’s IRS FORM: Your family can declare this tax deduction for your medical expenses ONLY if they also declare you as a tax dependent.

IF YOU PAY FOR your own EXPENSES - If you have your own health care plan and file your own income tax – YOU must be the person who paid for these bills. Keep in mind family members are legally allowed to give you up to $10,000 a year as a gift. You then can use this gift to pay for expensive medical costs (examples: co-pay for wheelchair expense not covered by health insurance – or – crowns for your teeth that are only partially covered by your dental plan.)

Can be helpful if you have expensive COBRA payments

For tax years that you have a lot of medical expenses and/or travel to obtain recommended treatments in you may incur enough expenses in that tax year to generate a tax deduction.

How to Apply: Save receipts and make sure to include mileage and hotel stays, meals and related expenses that were incurred while obtaining treatments. At the end of the year total the amount and if it the amount exceeds 7.5 % of your annual gross income, then the expenses can be claimed on your IRS form.

Resources:

INTERNAL REVENUE SERVICE
Medical and Dental Expenses, Publication 502, Cat. No. 15002Q
www.irs.gov/pub/irs-pdf/p502.pdf
Easy to read and understand publication from IRS that explains what is and what is not a medical tax deduction.

TAXES IN DEPTH
Medical Expenses Tax Deduction
www.taxesindepth.com/medical-expenses-tax-deduction.html
Information on this site is easy to understand. Medical expenses over a certain amount become tax deductible items, saving you money when you need it most. This site briefly describes medical tax deductions; Lists criteria for claiming these itemized tax deductions and explains how to claim medical tax deductions. Scroll past the H&R Block ads to links to IRS publications and approved and not-approved items are also included.

Tax Deductions For Dental Expenses
wwww.drdorfman.com/textbook/tb34
An individual is entitled to an itemized deduction for medical and dental expenses paid during the tax year, to the extent the expenses exceed 7.5% of adjusted gross income. If your medical and dental expenses do exceed 7.5% of adjusted gross income, only the portion of the expenses that exceed the threshold will be deductible. Proper planning and timing can help to increase your potential deduction.

FEDERAL - Treasury Department and the IRS
Health Flexible Savings Account and Over the Counter Drugs
www.treas.gov/press/releases/js695.htm
Effective September 3, 2003, the Treasury Department and the IRS announced over-the-counter drugs can be paid for with pre-tax dollars through health care flexible spending accounts. Treasury and IRS issued guidance clarifying that reimbursements for nonprescription drugs by an employer health plan are excluded from income. Thus, reimbursements by health flexible spending arrangements (FSAs) and other employer health plans for the cost of over-the-counter drugs available without prescription are not subject to tax if properly substantiated by the employee.

PACER Center - Health Information and Advocacy Center
Billing for Health Services in IEPs and IFSPs
www.pacer.org/health/healthbilling.htm
Health Information and Advocacy Center Fact Sheet: Billing for health services included in your child's individualized educational program or individualized family service plan.

• What is it?
• Who qualifies?
• What it covers
• What it costs
• Impact for YOUTH
• How to Apply
• Resources

What it is: You may be able to deduct 100% of the amount paid in a year for medical insurance and qualified long-term care insurance for you, your spouse, and your dependents.

Who qualifies:

A self-employed individual with a net profit reported on Schedule C, C-EZ, or F.

A partner with net earnings from self-employment reported on line 15a of Schedule K-1 (Form 1065).

A shareholder owning more than 2% of the outstanding stock of an S corporation with wages from the corporation reported on Form W-2.

What it covers: Cost of premiums.

Impact for YOUTH: For families or youth who own their own business this is way to off-set the expenses for paying non-group health care insurance premiums (which are usually higher than a group plan.)

Resources:

INTERNAL REVENUE SERVICE
Self-Employed Health Insurance Deduction
IRS Pub 535 www.irs.gov/pub/irs-pdf/p535.pdf
Publication that explains deductions for self-employed.

TURBOTAX
Self-Employed Health Insurance Deduction
www.turbotax.com/articles/DeductingSelfEmployedHealthInsuranceCosts.html
Fact sheet with links to forms and related sites.

• Resolving Disputes

It is frustrating when your health insurance plan does not pay for a medical treatment that has been deemed necessary by you and your treating physician. Sometimes you can provide better, more complete documentation to justify the treatment. Talk with a person who has more knowledge. Sometimes these problems need to be called to the attention of the department or person who handles the health benefits – as they are the ones who purchase what services the health plan will provide.

1. CORRECTIONS - Along with the original required paperwork, did the claim include correct CPT and ICD-9 coding? Check previous bills which have been paid. Also look on the “EOB” (Explanation of Benefits) sheet that details which expenses have been paid, which ones are not being paid – there is usually a coding by these amounts explaining why the charges are being refused.
2. ADDITIONAL INFO - Did you attach medical documentation and evidence to justify unusual expenses? It helps to include a medical summary, rationale how this device/treatment will improve or maintain health status to avoid costly future hospital admissions. Pictures of x-rays, copies of test results may also substantiate issues.
3. LINGO - Are you speaking their lingo? Look for specific language in the medical benefit book, refer to select key phrases and, when available, coding numbers in your attached documentation.
4. NEGOTIATE - Get smart about negotiation techniques. Learn through books and audio-tapes how to improve your skills when verbally presenting your issues and how to write a better letter to get what you want.
5. SUPPORT FROM OTHERS – Ask other consumers how they are able to get health care reimbursed – they may have the documentation or coding you need. Also ask the person who is in charge of billing at your doctor’s office for their advice.
6. CHAIN OF COMMAND - Have you spoken with a supervisor? If your health issues/claims are unique, ask to speak to someone in authority who may have more experience and knowledge. Also ask them for help in exploring better ways to expedite payment or approval of this claim. Have your insurance card and the paperwork in front of you when you call – look for file or account numbers at the top.

   DO NOT GET ANGRY – the person you are talking to did not make the rules. Ask for the person’s name early in your conversation and add it to the “log” you are keeping that contains notes of phone calls and copies of correspondence.

   THE PROBLEM - The problem is usually either a coding error from the doctor’s office (this can be corrected and resubmitted) - or – the treatment is not covered by your health care benefit package (this can be appealed.) Ask the person for guidance in seeking how to resolve this decision or even how to appeal the decision. This polite discussion may help you further in understanding how their system works.

   If the problem is still unresolved, call your health care benefits director.

7. APPEAL - You have the right to appeal all health care claim decisions in a designated time frame (refer to the health benefit booklet.) Make sure that you have reviewed the original claim for any errors or omissions, try to gather additional documentation/medical justification. Reread the rules on how to file an appeal including time limitations. Ask for help from the health care benefits director.
8. DENIED AFTER APPEAL – Sometimes even with the best medical evidence and other documentation your claim for reimbursement or approval of treatment may be denied. Your options: (1) request an additional medical review, (2) pay for treatment and consider a tax deduction, (3) notify your health care benefits director at your employment to voice your concerns and needs or (4) litigation (lawsuits are costly and take time).

Guides:

NE SERVE – Paying the Bills: Tips for Families on Financing Health Care for CSHCN
www.neserve.org/publications/index.html
(Second Edition, 1999 – 69 pages), was developed by parents who have children with special health needs. The parent authors have tapped their own experiences, as well as those of other families and professionals, in order to share information and strategies for getting payment for children’s health care. Paying the Bills encourages families to ask questions, learn about the health financing system, and be persistent.

BAZELON CENTER
Possibilities: A Financial Resource Book for Parents of Children with Disabilities
A simple, straightforward guide to money management and financial resources targeted to parents of a child, under the age of 18, who has a disability" published by the PACER Center. It includes a discussion about how to maintain financial eligibility for programs like Medicaid and SSI. For a copy, send $3 to cover postage and handling to Publications Desk, Bazelon Center, 1101 15th Street NW, #1212, Washington DC 20005; request the PACER Center Resource Book.

Resources:

CENTER FOR HEALTH CARE RIGHTS
Sample Letters for Health Care Consumers
www.healthcarerights.org/letters/lettersindex.html
Site provides sample letters as guidance for billing problems, denials based on medical necessity, denials based on not a covered benefit, quality of care and other related issues consumers may face. The Center for Health Care Rights is a California-based, nonprofit organization dedicated to assuring consumer access to quality health care through information, education, counseling, advocacy and research programs. The Center informs its efforts to represent consumers in public and private policy forums by the direct service it provides to individual consumers.

KAISER FAMILY FOUNDATION/CONSUMERS UNION
The Consumer Guide to Handling Disputes with
Your Employer or Private Health Plan, 2003 Update
www.kaisernetwork.org/daily_reports/rep_index.cfm?hint=3&DR_ID=15686
The guide offers consumers information on how to resolve disputes they have with their health plans, providing information to help them understand their health plans’ rules and coverage, internal and external review processes and government health plan regulations (Kaiser Family Foundation release, 1/23/03).

WRIGHTSLAW
Learning to Negotiate is Part of the Advocacy Process
www.wrightslaw.com/advoc/tips/SIte ppalmer_negotiation_process.htm
Negotiating solutions to disputes and/or claims saves time and money. Most of our experience is in the civil area, but the techniques and skills in special education cases are the same. By using these techniques, we rarely are forced to take a special ed case all the way to a hearing.

NEGOTIATION TIPS - Addressing Interpersonal Conflict
www.mapnp.org/library/intrpsnl/conflict.htm
Orient yourself towards a win-win approach: many studies support the view that how you approach a negotiation will play a key role in how the negotiation proceeds.

• Debt/Credit Help

NATIONAL FOUNDATION FOR CREDIT COUNSELING (NFCC)™, INC.
When Paying The Bills Becomes A Problem Seek Help
From Non-Profit You Can Negotiate Lower Interest Rates
www.nfcc.org
Founded in 1951, NFCC, sets the national standard for quality credit counseling, debt reduction services and education for financial wellness. NFCC is the nation’s largest and longest serving national nonprofit credit counseling network. With more than 1,300 community-based agency offices across the country, NFCC Members help over 1.5 million households annually. NFCC Members, often known as Consumer Credit Counseling Service (CCCS) or other names, can be identified by the NFCC Member seal. To locate a NFCC Member offices in your community call, 1-800-388-2227.

• Medical Necessity

JOHNS HOPKINS SCHOOL OF PUBLIC HEALTH
Defining Medical Necessity- Strategies for Promoting Access to Quality Care for Persons with Developmental Disabilities, Mental Retardation, and Other Special Health Care Needs
www.jhsph.edu/WCHPC/Publications/cshcn-MedicalNecessity.pdf
In managed care plans, access to services depends in part on whether a service is found to be “medically necessary.” Many existing definitions of medical necessity may lead to the denial of services required by special populations, including children, youth, and adults with developmental disabilities, mental retardation, serious emotional disorders, or other special health care needs. Most definitions lack critical components that will promote appropriate care for this population.