Medical Resources

Daniel has more doctors than a typical child and you need to be more careful about Daniel's health insurance than you might otherwise be.

Physicians

Daniel's primary doctor is Mark Sherman of Sherman Family Practice at 1 Sears Drive in Paramus, New Jersey (201-261-6061). Dr. Louis Rutigliano is the lead physician in the practice, and knows Daniel, too. Neither Dr. Sherman nor Dr. Rutigliano is an expert in Down syndrome, so you could transfer Daniel to your primary physician if so inclined.

Dr. Mark Dombrowski of Paramus Family Practice at 599 Paramus Road in Paramus , New Jersey (201-670-6667) was Daniel's primary physician from July of 1997 until May of 1998. From March of 1993 until July of 1997, Dr. Patricia Ruppert (of the same practice) primarily treated Daniel.

Prior to the family moving to Dumont in March of 1993, Daniel was treated at Pine Street Pediatrics at 140 Pine Street in Kingston , New York . Dr. Roger Green and Dr. Roberta Goldberg were Daniel's primary physicians.

Daniel had his tonsils and adenoids removed in December of 2001 by Dr. Joel Levitt of 101 Short Hills Road in West Orange, New Jersey (973-731-5400). The surgery was completely successful and Daniel requires no further follow-up visits.

Dr. Manuela Almaguer of Wayne, New Jersey (973-450-9277) is Daniel's endocrinologist. Dr. Almaguer sees patients in her Wayne office or at St. Joseph's Hospital in Paterson, New Jersey. Her mailing address is PO Box 19493 in Newark, New Jersey. Dr. Almaguer should be consulted if Daniel's growth deviates dramatically from the standard growth chart for boys with Down syndrome. Dr. Almaguer specializes in pediatric endocrinology and has a lot of experience with Down syndrome, so she should continue to see Daniel if needed, rather than another endocrinologist.

Dr. Louis Moore, of 85 South Maple Avenue in Dumont, New Jersey (201-445-2830), is Daniel's orthopedist. Dr. Moore should be consulted if Daniel's fingers are observed to be triggering. If you prefer to use another orthopedist, you could do so.

Dr. Zvi Marans of 205 Robin Road in Paramus, New Jersey is a pediatric cardiologist who saw Daniel in February of 2003. If you prefer to use another pediatric cardiologist, you could do so.

Dr. Harry Mickey of 1111 Clifton Avenue in Clifton, New Jersey (973-778-1338), who is an expert in eye problems in handicapped children, cares for Daniel's eyes. Dr. Mickey should examine Daniel every eighteen months. Because of Dr. Mickey's expertise, he should continue to see Daniel, rather than another pediatric ophthalmologist.

Daniel's dentist is Dr. Eliot Frey of 11 Wyckoff Avenue in Wyckoff, New Jersey (201-445-4144). Dr. Frey should examine Daniel every six months. If you prefer to use another dentist, you could do so, although Dr. Frey has been very good with Daniel and has learned a lot about Down syndrome.

Insurance

Daniel is covered under my benefits through AT&T, which are very comprehensive.

Daniel is automatically covered under my AT&T health insurance until he reaches age 23. He can be covered on a year-to-year basis after he reaches 23 by submitting a form to AT&T indicating that he is still eligible (because he is unmarried, mentally disabled, unable to work, and dependent on us) at least 30 days before his birthday each year. This coverage is available as long as I am actively at work, on disability leave, or retired from AT&T with 30 years service (which I will reach on August 22, 2008 . If I die before I reach 30 years of service, benefits are available for one year after death and may be extended for an additional 18 months (these are known as COBRA benefits, named after the law that mandates them). If I leave AT&T before 30 years service, I can extend benefits for 18 months. If I die after 30 years service, Daniel can be covered for life (following the procedure to submit the form described above). Daniel's coverage can be managed through a guardianship or power of attorney after Sharon and I both die. AT&T has the legal right to modify this plan at any time, but it is unlikely that these provisions would be modified.

It is important that you keep AT&T benefits in place, because (while they are expensive) they offer very high quality of care for Daniel that he would not otherwise be eligible for. Down syndrome is a preexisting condition and may make coverage hard to get or impossible to afford if Daniel leaves the AT&T plan. Your only option might be Medicaid coverage that far fewer doctors accept (and that Daniel may not be eligible for until adulthood, when your income doesn't price him above the income ceiling). Keep in mind that the Lee Family Trust can pay for all of Daniel's medical coverage.

When Daniel turns 18, you'll want to investigate Medicaid. Depending on AT&T's Health Plan at the time, it may be important to have Medicaid coverage. It could be that Medicaid would be Daniel's primary coverage with AT&T supplementing what Medicaid does not cover. AT&T might even require that you exhaust Medicaid benefits for a procedure before using AT&T benefits. If Medicaid coverage is important, you should apply for Daniel when he turns 18.

Each fall, AT&T allows choices to be made for coverage for the next year (which have monthly premiums associated with each choice).

Medical Coverage

AT&T offers a variety of Health Maintenance Organizations, but we have not tried them due to our concern that Daniel's special treatments might be blocked by "gatekeeper" physicians trying to hold down costs.

AT&T offers a traditional fee-for-service medical plan, but it covers only 80% of hospitalizations up to a maximum annual outlay.

We've chosen the AT&T Network Select Plan, which is in between an HMO and a fee-for-service plan. It follows the normal HMO procedures of requiring consultations and referrals from the primary physicians (Dr. Sherman and Dr. Rutigliano of Sherman Family Practice), but it also covers 70% of any treatments you elect that are outside of the plan. Each fall, you can make a different selection for the health plan.

Here are the instructions for how to use the Network Select Plan (which is administered by Aetna US Healthcare):

Every service (medical, hospitalization, and prescription) uses the same patient card. (The cards are in my wallet and Sharon's purse—if you can't find them, call Aetna at 877-426-4426 for replacements.) When you use an "in-network" provider (including Sherman Family Practice), you have a "copay"—a payment that you make at the time of the visit. In the list below, the "copay" amounts are listed.

For prescriptions:

Call the number on the back of the patient card to locate an in-network pharmacy near you. (We use Franklyn's Pharmacy in Dumont , but you can use any one you want. We avoid Wayside Pharmacy because they once filled a prescription for us incorrectly.)

• Show the card for the patient.
• Pay the copay (calculated as a percentage of the total cost).
• You can get only 30 days worth of a prescription from the local pharmacy—longer-term prescriptions are available only by mail from Medco. Call 1-800-987-5254 for details.

For a regular checkup or when someone is sick (non-emergency):

Make an appointment with the current primary care physician, Sherman Family Practice (any of its doctors) at 201-261-6061, or find another in-network physician and call the number on the back of the patient card to change your primary care physician.

• At the visit, show the card for the patient.
• Pay $15 copay.
• If you need to see a specialist, get a written referral.

To see a specialist:

If visiting Sherman Family Practice, get a written referral. If no office visit is needed (for example, Daniel's annual hearing test, or Daniel's new orthotics), call Sherman Family Practice to have them provide a written referral.

• Make an appointment and see the specialist.
• At the visit, show the card for the patient.
• If the specialist is "in-network," pay $26 copay. If "out-of-network," pay the full charge and submit the medical claim. Call the number on the back of the card to get claim forms.

In an emergency:

• Seek proper care immediately. You don't have to see Sherman Family Practice first unless you think that's the right thing to do. Go straight to a specialist or the emergency room if you think that's right.
• At the visit, show the card for the patient.
• If you go to the emergency room, you'll be billed a $50 copay for the emergency room unless admitted (that's free). Pay the copay for any in-network office visit. Pay the total charge for an out-of-network visit and submit the medical claim. Call Sherman Family Practice within 48 hours of the visit.

For planned hospitalizations:

• For out-of-network, call the number on the back of the patient card to pre-certify.
• Show the card for the patient.
• Wait for the bill in mail. Pay it and file a claim form. (Call the number on the back of the card to get claim forms.) You will get 70% of the "usual and prevailing" cost reimbursed.

Dental Coverage

Daniel is also covered under AT&T's Dental Plan. We've elected the Metropolitan Preferred Dental Program (PDP) each year, because Dr. Frey participates and the fees are lower. It might make sense to elect AT&T's regular Dental Plan if Daniel requires extensive dental work or Dr. Frey leaves the MetLife PDP. These plan elections can be changed each fall for the following calendar year.

Vision Coverage

AT&T offers a Vision Plan as well, but we have not elected to make the co-payment required for Daniel to be eligible. The cost seemed higher than we'd expect to pay for glasses each year. Daniel can be added to the Vision Plan, if you think it's cost effective. We do have a Vision Card (which we keep in the Health Benefits file in the file cabinet in the closet of my office) that provides discounts on eyeglasses and contact lenses. These plan elections can be changed each fall for the following calendar year.

Special Coverage

In addition, physical, occupational, and speech therapies (as well as special devices) are also covered up to 80% under AT&T's Special Children Assistance Program, if they are prescribed by a doctor. (Therapies provided in the school setting are free; the Special Children Assistance Plan can cover 80% of additional therapies outside the school.) Daniel's home physical therapist, Louise Simmons (201-251-9359), was covered under this plan and she accepted the 80% as full payment during the period we used her services.

Daniel hasn't needed physical therapy since working with Louise, but we'd strongly recommend using her again if the need arises. Louise might be perfect for teaching Danny to ride a bicycle.