Medical Insurance Coverage
We now have an ‚application help pack‘ for insurance coverage in Germany.
A big thank you goes out to the supporter who made the info pack.
t2 prosthetics
is not in communication with any insurance companies. I am happy to assist you where I can, but I
don't have the resources to communicate directly with your insurance company.
Please Note
1. I am paid by you, and not by the insurance company. The insurance company pays you, and you pay me. It’s your name on the invoice, not that of the insurance company.
2. Should your insurance company cover the costs, the order process will remain the same - You will still need to pay the deposit at time of order, I receive the payment in full 2 weeks before mailing your prosthesis.
If you wish to
receive a Cost Quote for a t2
prosthesis, please send me your name and address and request a Cost Quote.
The Cost Quote includes a short description of the prosthesis, certification and registration, a few points on the production process, and the cost.
If you are in Germany, I will also send you a commented exerpt from the ‘medical
device listing for the German statutory health insurance association’. („GKV-Hilfsmittelverzeichnis 35.27.01.0001
Angang Kostenvoranschlag") As well as „the application help pack’ (‚Antragshilfepaket’ is in German and includes: document checklist, templates/examples, and a list of organisations that can help).
If you are not in Germany, the Cost Quote I send you will be in English, German, or French and the wording a bit different (more universal). Feel free to give me country specific information that I may be able to ad to your Cost Quote.
Useful information (in German, for reimbursement in Germany):
Seite 55, ‘Penis-Hoden-Epithesen’
Seite 38, ‘Versorgung mit technischen Produkten / Hilfsmitteln’
Links to information about cost coverage in
general (in German, for within Germany)
The following is a compilation from a few years back. The information is still relevant:
Common
explanations for denial with corresponding counter-arguments
(Quotes
are in German because you will be corresponding with them in German, and I
prefer to give you the original texts)
1.
Reason
‘The
prosthesis is not in the medical device directory (Hilfsmittelvezeichnis)*.’
Counter-argument
About the medical device directory
„Alle von der Leistungspflicht umfassten
medizinischen Hilfsmittel sind im Hilfsmittelverzeichnis der gesetzlichen
Krankenversicherung gelistet (§ 139 SGB V). Dabei ist das
Hilfsmittelverzeichnis keine Positivliste, sondern eine unverbindliche
Empfehlungshilfe. In der Praxis heißt das, dass auch Hilfs- mittel, die (noch)
nicht im Hilfsmittelverzeichnis gelistet sind, durch die GKV erstattungsfähig
sind (vgl. BSG-Urteil vom 29.09.97, AZ.: 8 RKn 27/96 und BSG-Urteil vom 31.08.2000,
AZ.: B 3 KR 21/99).“
Quoted
from
2.
Reason
‘It’s
an epithesis not a prosthesis.’ OR ‘It’s a prosthesis not an epithesis.’
Counter-argument
(Exactly
which term best fits is unclear, but either way) it’s a "substitute body
part" (Körperersatzstück).
Law on coverage of medical devices
„(1) Versicherte haben Anspruch auf Versorgung
mit Hörhilfen, Körperersatzstücken, orthopädischen und anderen Hilfsmitteln,
die im Einzelfall erforderlich sind, um den Erfolg der Krankenbehandlung zu
sichern, einer drohenden Behinderung vorzubeugen oder eine Behinderung
auszugleichen, soweit die Hilfsmittel nicht als allgemeine Gebrauchsgegenstände
des täglichen Lebens anzusehen oder nach § 34 Abs. 4 ausgeschlossen sind.“
Quoted
from
http://www.gesetze-im-internet.de/sgb_5/__33.html
3. Reason
‘Cost
coverage is excluded according to SGB 5 § 34 Abs. 4 with reference to:
"Ausgeschlossen
sind insbesondere Arzneimittel, die überwiegend zur Behandlung der erektilen
Dysfunktion, der Anreizung sowie Steigerung der sexuellen Potenz"’
Quoted
from
http://www.gesetze-im-internet.de/sgb_5/__34.html
Counter-argument
The prosthesis is not an „Arzneimittel“. Arzneimittel means pharmaceutical (= medicine, drug). The section refers to „Arzneimittel“ and not to „Hilfsmittel“. The prosthesis is a „Hilfsmittel“(Körperzusatzstück/ Prothese oder Epithese).
Thanks to everyone who shared their ideas, discussions, letters of denial and acceptance from their health insurance companies so far.
If you want to help increase cost coverage from insurance companies, please share your ideas or information with me info@tyron2.net