On a sunny, 75-degree day Melinda rolled her sister Juanita out of the house in Southwest Austin. The sun hits their smiling faces as they make their way toward a shiny, white van parked next to the driveway.
As the automatic door slides open, a black metal ramp begins to unfold and comes to a rest on the pavement. Juanita’s special wheelchair rolls easily into the back of the van, and Melinda locks the wheels in place and then buckles the seat belt to the floorboard.
Juanita and her family are ready to head to lunch at one of her favorite restaurants: The Cheesecake Factory at Barton Creek Square Mall. It’s a Saturday afternoon outing her family does not take for granted.
For years, Juanita was confined to the house because it was too difficult to leave. When her parents were caring for her in her hometown of Del Rio, Texas, her dad cut a piece of plywood to use as a makeshift ramp to get her in and out of their old van that was not even equipped to transport a wheelchair.
When Juanita moved in with her sister in south Austin and got a new, larger wheelchair that does not fold down, Melinda said something had to change.
“I’m like, ‘This is not gonna fly,’ said Melinda. “For one, it’s not safe. Two, I threw out my back trying to lift her in this new wheelchair.”
Melinda and her husband started shopping around to see what adding a ramp to a van would cost. A local mobility vendor said the basic model would be about $24,000.
UnitedHealthcare told Melinda her sister’s STAR+PLUS Medicaid program would only cover $10,000 of it — the allotted annual amount for something like a van modification. Melinda was also told the family could not gift Juanita the rest because that would put her Medicaid eligibility in jeopardy.
As a solution, the vendor told Melinda other customers have been able to split up the cost, by putting $10,000 down at the end of the year, and another $10,000 to cover the majority of the rest when next year’s benefits kicked in.
But Juanita’s claim was denied.
UnitedHealthcare told Melinda it was against their policy to split up the cost. Melinda tried again, and received a second denial. She was not giving up.
Melinda started the appeal process and was scheduled to continue fighting for her sister at what’s called a fair hearing. She also sent letters to the Texas governor, the Texas insurance commissioner and Texas Health and Human Services.
The best advice came from someone who used to work for an insurance company.
“If you want to get their attention, I’ll tell you what works,” she told Melinda. “You’ve got to get a hold of the CEO.”
Melinda got to work typing out an eight page letter detailing her sister’s story, and included color photos of Juanita showing how much she could benefit from being able to get out of the house.
“I was trying to get the message across that it’s impacting us significantly,” said Melinda. “She’s missing out on a lot of things and it’s not fair to her.”
One week later, Melinda got a call from a UnitedHealthcare manager telling her the claim was authorized, and then a couple of hours later a CEO called to tell her she was moved by Juanita’s story.
“I started crying and I said ‘Thank you’ and I just said, ‘It’s overwhelming,’ you know it’s been a long fight,” said Melinda as she started to cry.
Melinda said she was also filled with anger because she had to take such extreme measures to get results.
“[United Healthcare] prides themselves on wanting family members to take care of their own, but here they are offering a benefit that isn’t a benefit.”
KXAN reached out to UnitedHealthcare for comment on Juanita’s case. A regional communications director sent the following statement:
“Ms. Rodriguez and her designated case manager have worked within UnitedHealthcare’s internal appeals process to resolve her claim for vehicle modifications. Working within internal and external appeals processes ensures that state Medicaid dollars are managed effectively and that fraud, waste and abuse of the Medicaid system is avoided at all costs.”