Inadequate health insurance coverage for disability

March 26, 2023 11:43 PM

TW: Insurance bureaucracy hell. I got a job at Columbia Med School. I have a physical/mobility disability that requires a lot of physical therapy, but their health insurance (United Healthcare) only covers 60 sessions/year, cumulative. Not enough for me -- I need at least twice that. I can't pay an extra $10k+ for out of pocket costs. I have to choose between an awesome job I want and getting my health needs met. Any specific or general recommendations to try to come up with funds and/or better insurance?

I am trying to navigate an unfamiliar system to try to find out how I can find solutions, including: 1) additional insurance through NY healthcare marketplace 2) additional funding from elsewhere in the university 3) renegotiating the university's insurance contract to increase the phys therapy coverage (not a short-term solution, but I have talked to the union).

I've been passed like a hot potato between various DEI offices, Leave Management, HR and Benefits, Office of [My Position] Affairs, Office of Equal Opportunity and Affirmative Action, etc.

Any tips about navigating the Columbia bureaucracy, insurance plans, contacts, other solutions, or amazing NYC massage and physical therapy recommendations would be really helpful!

posted by anonymous to Health & Fitness (9 answers total)

Do you think you might be eligible for Medicare? It sounds like you would need to pay for it and it would probably take quite a while to go through the process but could be worth looking into, from what I could tell it had no limit to the amount of physical therapy you could have.

https://medicareadvocacy.org/medicare-info/medicare-coverage-for-people-with-disabilities/#exceptions
posted by pairofshades at 4:21 AM on March 27, 2023

Many PT practices have sliding scales for self-pay and discounts for multi-session purchases. Since you're already getting 60 sessions a year through insurance, it's in your PT practice's interests to make additional sessions affordable for you.
posted by headnsouth at 4:56 AM on March 27, 2023

I don't know if any commerical insurance plan that offers more than 60 sessions a year (that's 3 sessions a week for 20 weeks or 2 sessions a week for 40 weeks). From what I've seen that seems pretty standard per plan year for plans that are considered "good". If you've had an insurance plan in the past that has offered you more, then I would like to know what it is.

If access to specific equipment is a primary concern, you might be able to go through the department of rehabilitation for funding for items that help you live independently as possible. It may be considered a bit of out of scope, but you might be able to argue it as it helps you so much.
posted by AlexiaSky at 5:55 AM on March 27, 2023 [5 favorites]

It sounds like it's too late to negotiate for higher pay based on this, yes?
Assuming yes, It looks like a couple of options might be available:

https://www.vagelos.columbia.edu/education/student-resources/office-student-affairs/vp-s-club/clubs-and-organizations/student-run-clinics/columbia-student-medical-outreach-cosmo

https://www.vagelos.columbia.edu/education/student-resources/office-student-affairs/vp-s-club/clubs-and-organizations/student-run-clinics/columbia-harlem-health-and-medical-partnership-chhmp
posted by chesty_a_arthur at 6:27 AM on March 27, 2023

Are you eligible for Medicaid? If you can get Medicaid secondary, it may pick up what your commercial plan does not cover.
posted by ThePinkSuperhero at 7:24 AM on March 27, 2023

To follow up on some comments, medicaid coverage for PT really varies between states, so you would have to look up what is required for it to be a covered services. Original Medicare doesn't have a hard limit, but can require medical necessity after particular spending limits. Medicare advantage plans are their own thing, so you would need tread very carefully to understand what is covered by those plans. From my experience some of the advantage plans are pretty terrible about authorizing PT/OT services.

Your PT provider billing office likely has a inside on all of this stuff, if you haven't asked them yet it may be the most helpful thing to do at this stage.

So switching plans may not be as beneficial as people are saying. Adding a secondary may help but some plans will deny if the primary denies, so if there is a limit with the primary you will need to insure the secondary will continue to cover after you meet maximum with united or another health plan
posted by AlexiaSky at 9:16 AM on March 27, 2023 [1 favorite]

The solution may be outside of your employer.

You may be able to buy Secondary Insurance on the private market. Not sure if the nys health insurance market sells secondary insurance, but its worth calling.

Can you divide your pt treatment among different providers? Use the 60 sessions with the most expensive providers, other sessions with sliding scale, student or lower cost services. You mentioned pt and massage. Massage might be cheaper to source than pt and could be a candidate for cash pay.

If you itemize your taxes medical expenses above 7.5% of your agi should be tax deductible (not sure if this rule is changing)

This is a complex question and your employer might have an EAP (?) or health advocate program, aka someone to research questions like this i.e. secondary insurance, and state resources for people with your disability
posted by jello at 9:17 AM on March 27, 2023 [1 favorite]

Supplemental insurance that will cover aspects that you will use in excess?
posted by kschang at 9:45 AM on March 27, 2023

The IRS deduction referenced above. A friend used a 0%-interest-for-18-months credit card for qualifying med expenses, and paid that with their tax refund.
posted by Iris Gambol at 1:07 PM on March 27, 2023 [1 favorite]