Adopting a medically fragile child - ins. question
I have sooo many questions this morning! But I was wondering if anyone had advice on this one.

We just found out that we've been selected for a toddler with a heart defect and other health issues. He's being treated at our local Children's Hospital, which is quite good. Of course, as a foster child, he is covered by Medical. (California's version of Medicare.)

When we adopted our healthy son, we were told that we needed to immediately switch him to our insurance and Medical would be his secondary. Which wasn't a problem. But we have an HMO with their own hospitals and medical facilities, so I'm not sure he could keep going to the Children's Hospital. We don't want him to switch doctors when he's looking at major heart surgery within the next year. We also think he would probably get better treatment at a Children's Hospital.

For those of you who have adopted medically fragile children or children with ongoing health issues from foster care, have you been compelled to change their insurance immediately? Are there circumstances when you are able to keep Medicare if the child is very sick? Because of the budget issues, I'm guessing they'll push us to switch him over right away, and I'd like to know what is possible.
Our adopted son does not have any medical issues, but we kept him on Medicaid and we were NOT required to add him to our insurance at all (we are in Texas). We have not had a problem getting services with Medicaid, and it is nice because there is nothing out of our pocket at all.
In our state, once we adopt a child from Foster system you have to change him over to your insurance and then Medicaid would be secondary... so no copays... I find it interesting that if the HMO couldn't provide the service that he is currently getting they have to provide a waiver. Our insurance just decided this this year to add the local 3+ hours away children's hospital to our HMO list...
I have not adopted through foster care, but my dd is on the medicaid card, and my understanding is with the medical card if your insurance does not cover the hospital medicaid will. Whatever your insurance doesn't cover medicaid will cover. Please correct me if I'm wrong, but I am pretty sure that you can switch him to your insurance and still keep him at that hospital and medicaid will cover it.
momofMikhail said...
I have not adopted through foster care, but my dd is on the medicaid card, and my understanding is with the medical card if your insurance does not cover the hospital medicaid will. Whatever your insurance doesn't cover medicaid will cover. Please correct me if I'm wrong, but I am pretty sure that you can switch him to your insurance and still keep him at that hospital and medicaid will cover it.


I'm going to call my ins. company today and get the answer to that question. We have Kaiser, which works a little differently than other HMOs. You go to Kaiser hospitals and are treated at Kaiser medical centers. You get prescriptions at Kaiser pharmacies. Everything is self-contained. I actually like that because it's very efficient - doctors, specialists, labs, pharmacy, optometry etc. are all in one building. But in this case, it may limit who our child could see and what hospital he could be treated at. I do know that they partner with a local hospital with a large maternity ward and most moms give birth there. So they may partner in a similar way with the Children's Hospital. I just have to find that out. The only reason I would want to keep J on Medical is if that was the only way for him to keep getting his care at the Children's Hospital. We would try to fight the switch if that were the case.
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. Smile



OakShannon said...
I'm going to call my ins. company today and get the answer to that question. We have Kaiser, which works a little differently than other HMOs. You go to Kaiser hospitals and are treated at Kaiser medical centers. You get prescriptions at Kaiser pharmacies. Everything is self-contained. I actually like that because it's very efficient - doctors, specialists, labs, pharmacy, optometry etc. are all in one building. But in this case, it may limit who our child could see and what hospital he could be treated at. I do know that they partner with a local hospital with a large maternity ward and most moms give birth there. So they may partner in a similar way with the Children's Hospital. I just have to find that out. The only reason I would want to keep J on Medical is if that was the only way for him to keep getting his care at the Children's Hospital. We would try to fight the switch if that were the case.
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 Biological 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).
crick said...
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.


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.
OakShannon said...
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. Smile 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
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