Admitted Claimant Frequently Asked Questions

 

The following is intended only for general informational purposes and is not a guarantee of services or benefits. Please see the Program’s authorizing legislation and Guidelines for additional information.

Nursing & Caregiver

How many nursing hours per day are paid for by the Program?

The claimant’s primary care physician usually determines the appropriate number of nursing hours required and the appropriate level of care (i.e. C.N.A., L.P.N., R.N.). A written order of medical necessity from the physician must be on file with the Program and a new written order is required for any increase in hours. However, the Program reserves the right to review the medical necessity of the prescribed hours.

How many hours per day may a nurse care for a claimant?

Program guidelines stipulate that a nurse or caregiver should not work more than 16 hours per day (assuming the claimant has written orders for the nursing care). This is primarily due to safety concerns.

Additional hours per day in some circumstances may be allowed due to a medical emergency, however they should be pre-authorized by the Program if possible. For a medical emergency that occurs outside of normal working hours, please contact the Program as soon as possible afterwards to determine if the hours were payable/reimbursable.

Also please remember daily nursing hours may not exceed the physician prescribed daily hours.

What happens if a nurse or caregiver works more than the prescribed number of daily hours?

The Program can only pay for the prescribed number of hours per day.

Can family members be reimbursed for providing care?

Following legislation passed in 2008 family members may be reimbursed for care in accordance with the Program’s Guidelines. See the Guidelines or Handbook for details.

Are nursing agencies always utilized to provide services to a claimant?

Use of nursing agencies is the recommended method for obtaining services outside the family due to employment and tax issues and medical training, licensing and liability issues. In some cases, the Program will approve allowing families to hire their own nurses. However, it’s important to note that in such situations the nurse or caregiver must meet the medical requirements as prescribed by the physician and must be an employee of the family, not the Program. If approved, the Program will reimburse the family for the cost of nursing services as approved by the Program. The Program will not pay the nurse or caregiver directly.

All tax and employment issues are the responsibility of the claimant family in a reimbursement situation. We highly recommend families consulting with a tax professional, lawyer or other qualified individual to assure you are in compliance with all applicable laws and regulations.

Medical Services and Equipment

How do I purchase medical equipment for a claimant?

In order for the Program to pay for the equipment, the Program must be contacted prior to any purchase. The claimant’s health insurance must first be utilized for the equipment purchase. The Program also must receive a letter of medical necessity or a physician’s order along with what equipment is being recommended. Once the required documentation is obtained, the Program will place an order for the equipment and have it shipped to the family.

Do I have to use providers in my health insurer’s network?

The Birth-Injury Act states that the Program may not pay for any services that are contractually available to the claimant through a private or public health coverage policy. Therefore, if you utilize a non-network provider and your health insurer refuses to pay for the service, the Program is not allowed to pay for the service.

A provider in my health insurance company’s network says I must pay for charges the insurance company does not pay for; do I have to pay them?

As an “in-network” or contracted provider for your insurance carrier, the provider has a contract with the insurance company. The provider must abide by that contract. Any fees or co-payments not specifically allowed under your health insurance policy should not have to be paid. Similarly the Program also is not allowed to pay any co-payments or fees not allowed under your insurance policy.

Does the Program pay for diapers?

When medically necessary, the Program will pay for diapers once the claimant is three-years-old. As with all benefits, other health insurance benefits must first be utilized. If another source, such as your health insurance company is not paying for them, please contact the Program. In most cases we can arrange regular deliveries of appropriate diapers to save you time and effort.

Does equipment purchased by the Program need to be returned to the Program?

Equipment purchased entirely by the Program is generally required to be returned if no longer needed , although some exceptions apply. Returned equipment is sometimes utilized by other claimants or sold with all proceeds returned to the Birth-Injury Fund.

Vans/Transportation Questions

When is a claimant eligible for a van?

Generally, when a van becomes medically necessary for wheelchair transportation. A listing of van options is available from the Program.

When does the Program replace vans?

A van paid for by the Program will be replaced when it reaches 100,000 miles. However, other factors will be taken into consideration including the vehicles service history. Similar to a warranty situation, you should retain all service records to substantiate any concerns.

Do I have to return the old van to the Program?

Yes. The returned van must be in good running condition, with only reasonable and normal body wear and be able to pass a Virginia state inspection. Returned vans are sold with the proceeds returning to the Birth-Injury Fund, which pays for all claimant services.

Housing Questions

What housing related benefits does the Birth-Injury Program Provide?

The Birth-Injury authorizing legislation does not stipulate any housing benefit except when a claimant is placed in a residential facility. However, the Board of Directors of the Program provides a benefit as outlined in the Program Guidelines. Please see the current guidelines for details.

Will the Program make accessibility related modifications to my residence?

Generally yes, please contact the Program and review the Guidelines for details.

Does the Program have a housing benefit if I rent?

Yes. In April 2004 the Board of Directors approved such a benefit. Essentially, if a claimant moves into an ADA compliant rental unit of similar size and quality to the former rental unit, the Program will pay the difference. However, there is a lifetime benefit maximum of $175,000 and other restrictions and guidelines apply. Please see the Program Guidelines for details.

I understand the Birth-Injury Program once provided houses for claimants, is that still its policy?

In its early years, the Program provided “Trust Homes” for claimants. These homes are owned by the Program and provided for the claimantís use.

Additionally, for a short period, the Program provided “Cash Grants” for use in purchasing or building a suitable residence for the claimant.

Primarily due to financial considerations, both of these policies are no longer in effect. For the current policy, please see the Program Guidelines which are posted on this website.

How will I know if the Program changes its Program Guidelines?

The Guidelines change infrequently, however, if they are altered, generally all claimants are notified. Additionally, any proposed changes will be printed in the Virginia Register during a comment period. They also may be posted on this website.

How do I keep abreast with what’s going on with the Birth-Injury Program?

As needed, the Program sends out communications to all claimants, usually as a letter. Also, a lot of information is posted on this web site. All Virginia Birth-Injury Program board meetings are open to the public (however discussion of specific claimant issues is held in closed session). If you plan to attend a board meeting and speak with the board, while not required, we encourage you to let the Executive Director know in advance so that you may be placed on the agenda and to allow sufficient time.

General Questions

How much compensation is a claimant entitled to?

Entry into the Birth-Injury Program does not provide for any set amount of compensation. The Program operates much like an insurance policy in that it pays for actual medically necessary costs and other legislatively stipulated benefits. Additionally, the Program is the payer of last resort in all situations. There is no cap on the total eligible lifetime costs.

How can I obtain a copy of the Program Guidelines?

The Guidelines are available on this website or call us and we will send you a copy.

How often do the Program Guidelines change?

There is no set time or automatic updating every year. However, specifics of some of the Guidelines occasionally change to meet claimant needs. All of the changes are made available to claimants as they occur.

My child is newly admitted to the Birth-Injury Program, how do I learn more about the Program?

The Program’s case manager visits every newly admitted claimant soon after admission. Additionally, you may contact any of the staff members with questions. A list of families in the Program that are willing to help orient you also is available. For confidentiality reasons, we cannot publish this list on the web site.