Adopting a medically fragile child - ins. question

My sister's two adopted children are on her private healthplan and have medi-cal as secondary. The way it works with them is medi-cal pays whatever the primary insurance won't pay. Medi-cal doesn't care why the primary insurance didn't pay, just that it didn't, so she can take them to doctors that she knows are outside her primary insurance's plan and Medi-Cal will still pay. She has done this a few times when she wanted them to see a specialist outside their regular plan.

when we adopted our son, he had an extensive list of medical "stuff" going on with him. we were going to a very well known children's hospital before he was adopted, and i was happy with the care, but i put him on our kaiser anyway. i was very happy! kaiser was awesome for him, even better than where we had been. they sent him to SO many specialists and quickly took care of most of his issues. my doctor did assure me if they could not handle something or the children's hospital was better at it than they were, they could send him there. but i will tell you, kaiser handled everything so well! i also loved having the medi-cal backup bc it meant i never had a co pay for all those specialist visits or hospital stays, surgeries, procedures, etc. it was the best of both worlds- good care, no co pay, AND it meant all of my children could have the same pediatrician....instead of carting 2 sets of kids to 2 sets of doctors on opposite ends of town. on occasion, i did have to travel to a different kaiser for a procedure. like for some of his procedures they wanted a specific pediatric anestheologist, and so we had to travel to the next city for the procedure, but it really wasn't a big deal...especially knowing that they were making sure our son had the best person for HIM, instead of whoever was available. i also liked them because they were GREAT about being extra thorough since we didn't have a family history and our son had lots of problems. if you want to pm me about any kaiser/medi-cal questions, i'd be happy to talk with you. :)

I think the number one deciding factor for me would be "Does Kaiser have the heart program/care that the Children's Hospital has?" If not, then I'd use his primary insurance for regular things and medical for his heart stuff.I have all my kids on both insurances and it's never been an issue at all. We don't have the health challenges though.You might pm Suzberg and ask her what she does for her dd E. I know she hasn't been on as much lately so she might not see your post.

If there is anyway you can keep him on MediCAL then I would do it. Private insurance often has lifetime limits. It might not matter to you now because most HMO's do not have the limits but the ability to get insurance and have that insurance have no lifetime limits because of my medically fragile bio DD is a huge controlling factor in our life. It controls where I can get a job. It makes it impossible for me to do anything other than work for a big company. Requires me to live in a city with big companies etc. . . I would do anything to have her on Medicaid. Alas, we will never qualify because of our income level (and of course, without the income level we have, we could never afford to pay for DD's care).

i'm fairly certain you can not use medi-cal this way. unless your primary kaiser doctor refers you back to the heart program in your current facility, kaiser will not pay at all and medi-cal will not foot the entire bill. the hospital will try to get kaiser to pay it, and kaiser won't if you didn't get a referral for that appt/procedure first. the hospital will try to get medi-cal to pay the entire bill, and they will not because kaiser is your primary. with neither medi-cal or kaiser wanting to accept responsibility for the bill, they will send it to YOU. this actually happend to me when i was new to all of this and didn't really get it all. it isn't fun.

Another happy Kaiser insured person here...I know my sw highly encourages you to have Medi-Cal as secondary....but I would list this as one of your questions (if your sw/cw is in the meeting) at your disclosure meeting coming up....since we received the wording that it is encouraged but not mandated, I'd see if there could be an exeption depending on what he needs. The main reason being if there are other children in the house on private insurance, they don't want a difference between the way a family treats their children (adopted/biological)....so I'd discuss this in full length with your cw. The second thing to do will be to take up mommytoeli's post to heart and pm her. I find that she is very knowledgable about Kaiser as I've asked her simple questions in the past.

We no longer live in Ca., but we did adopt 4 of our children there. During adoption assistance negotiations CFS wanted us to have them on our insurance but we told them we wanted them to have Medical (someone on the inside told us to request medical to continue) as it had better services and coverage. We also had Kaiser and though very happy with services there several of our children saw specialists at Children's Hospital and we wanted them to be able to continue to see there Doctor's. I am very glad we insisted as some of our kids have ended up with some rather significant medical problems and receive the best care and multiple therapist that might not have been covered otherwise.

Thanks for the information. MommytoEli - That's good to hear! I actually love Kaiser for us. No complaints at all. But we're all pretty healthy. But J will likely need a Fontan Procedure for his heart where one of his ventricles is bypassed. It's a delicate surgery and he is immune compromised besides. So I want him at a Children's Hospital because the syndrome has is rare and I would want him to have the most experienced doctors possible!! Kaiser told me that they didn't think it would be a problem to have him referred back to Children's. I just have to get a doctor to do it. And my SW told me that - contrary to what we had been told for our healthy son - we don't have to switch him. So we'll do one of those two things. Apparently, with a child as sick as J, the rules are a little different.

well, it sounds like you have 2 very good options. :) good luck!

The other thing is that private insurance often does not really cover private therapy (PT, OT, Physch, Speech). I would be very firm about keeping his MediCAL

Shannon if you don't have to switch him, I wouldn't. I have found medicaid to be SO much easier to work with. They approve things much more quickly without any problem. You are incredibly smart in wanting him to been at a Children's hospital. That is so very key with a heart baby. That continuity of care is vital. You need an experienced pedi CT surgeon and pedi cardiologist not to mention all the other specialities you'll need to see. Funny that you meniton the Fontan; that is supposed to be Cameron's 'final' stage open heart surgery when he's a little older.

Thank you, Nevada and DDW. I know you both have a lot of experience with this. I'll definitely keep that advice in mind. We'll have a few months before finalization to get acclimated to his medical needs and therapies. But we definitely don't want any changes in his care.DDW - Yes, he'll end up with the same surgery. I noticed that, too. Basically, J's heart is plumbed like it has two right ventricles. So somewhere between ages 2 and 4, (but usually closer to 2) they do a Fontan to bypass one of the ventricles. But they have to make sure those pressures are low enough. And there can be added complications because his other organs are not in the right places and he doesn't have a spleen. I'm basing this on what I've read about Heterotaxy and the info I have so far, but we'll know more on Wednesday.

What happens when he turns 18? His medical insurance will be very expensive; FD can get medical insurance until she is 21 because she was a foster child. I would definitely ask if he will allowed to be on for lifetime if he has major problems?

YUP... Crick is Right (as usual).... I didn't see this post. You probably already have your questions answered but I'll let you know what we do for E anway. We did put E on my husband's insurancefor her primary because it is REALLY good insurance (NO lifetime limit like Jen was referring to, E can stay on it until age 25-instead of 18 or even 21 like most insurance,really low premiums for our family of 6 etc). We kept medicaid for her Secondary. We could have just had her on Medicaid but I liked the idea of double coverage since we have the potential for some pretty outrageous medical bills. The state of Texas actually re-imburses us for the insurance premium we pay for the private insurance (my husband does have to fax them his check stub that shows the deduction every month), since we just use the Medicaid for secondary. I don't know much about Kaiser except kind of "scary" stories...so because that is my experience I would definatley just have Medicaid be his coverage! When you're talking about MAJOR heart surgery like the Fontan you want it done at Children's Hospital. And also those Surgeries are pretty expensive. E had a "Fontan Revision" (a special bonus surgery because my daughter is an overachiever)about 2 years after her Fontan. The bill was 300K. (I know DDW wins the contest on who has the highest med bills). I know here in Texas once we added her to the Private insurance it HAS to be the primary and Medicaid the Secondary. Medicaid does cover prescriptions (and E has had as many as 10 a month and the respitory rx are REALLY costly) with no copay (at least ours does). And it does cover PT, OT, ST better than most private insurance does. If you have any other questions please let me know!

I agree with several other posters. Keep him on Medicaid if at all possible. Neither of my adopted kids are on our insurance and only one is considered special needs currently.