UHC Violates CMS Rules

[Newby]

I think some of the people that have gone from a supplement to an Advantage and if they don’t like the Advantage it’s because when they heard that it covers the same as original Medicare A&B they ASSUMED that it covered the same as original Medicare A&B and their supplement.
I had one this week and that’s definitely what I was gathering from her. I have no idea where she got that idea. I wasn’t her agent. But people hear what they want to hear sometimes.

 

[somarco]

I think some of the people that have gone from a supplement to an Advantage and if they don’t like the Advantage it’s because when they heard that it covers the same as original Medicare A&B they ASSUMED that it covered the same as original Medicare A&B and their supplement.
I had one this week and that’s definitely what I was gathering from her. I have no idea where she got that idea. I wasn’t her agent. But people hear what they want to hear sometimes.

I hear the same thing quite often. Why pay a premium when I can get the same coverage for less?

 

[LostDollar]

Well ...
As I told another poster, I would consider this to be a rare and unusual circumstance,
but I just checked my Medigap EOB history for last year on the carrier's website. I did not use the word denied in my discussion with the other person, but the specific verbiage the carrier uses in the online claims recap is "DENIED" (vs PAID).

I have 5 EOB lines that come up with a status of "denied".
Claim A was denied 3 times.
Claim B was denied 2 times.

These claims were processed by the CMS Part B contractor for Kansas and both contain Medicare approved services. On one claim not all services were approved by Medicare.

The claims were not automatically transferred to the Medigap carrier by Medicare.

The Part B provider seems to be unable or unwilling to submit the claims to the Medigap carrier in a manner that will lead to the Medigap carrier approving the claim.

You should be getting an EOB (that's what I still call it). All you have to do is submit it to the carrier. They will take if from you. First off though, I would call the carrier to see if they even got anything from Medicare on those particular claims. If so, they really don't have a choice but to pay it. If nothing else, call your agent!

I have made the original posts I've made just to note that there seem to be circumstances that can generate exceptions to the general rule of thumb about Medigap carriers denying Medicare approved claims; not, to be asking agents for claims help.

In my opinion the most likely explanation of the situation is a pi$$ing match between two large companies about the proper way paperwork can be created to support a Medigap claim.

I broke up the text in my original post and put the sentences in different colors. I think those comments addressed the issues you raise.

I do have MEOB's and Medigap carrier EOB's for all the claims in question showing Medicare approval and Medigap denial.

I did speak to both the provider and the Medigap carrier. I am watching the situation. It is not in my best interests to actively pursue it further at this time.

 

[LostDollar]

One thing I've been saying recently with my T65s is that with MAPD the insurance company gets "a seat at the table" in making decisions about which providers and which treatments are approved.

"You gave me three doctors - they're all three in network. Let's talk future for a minute. You don't see a cardiologist today. You might need one in 2025. If you go with this MAPD they'll be a part of the decision making process - they have a seat at the table. Now, it's $0/mo with better Rx and better blah blah blah but you need to be OK with knowing they'll be involved. You'll need to pick one of their cardiologists, and you'll also probably need their pre-authorization on some services as we discussed. The supps we also discussed - they don't get a seat at the table."

Maybe only 20% will remember this kid telling them this but if nothing else, I think it's quick and easy and does paint a pretty decent mental story of the downside of the plans.

My MA book is over 500. Medigap close to 900. I don't get many MA complaints but I think it's responsible to give some downsides.

Just like it's also responsible to tell medigap that their Plan G starts at $118/mo @ 65 and they need to be prepared for it to go up yearly.

You forgot to mention HDG!

Although I would have to say there could be a collision coming between HDG and MAPD if MAPD max OoP's continue to drop and the HDG deductible continues to rise.

 

[sshafran]

I hear the same thing quite often. Why pay a premium when I can get the same coverage for less?

You'd be shocked.

People sit across the table from me glassy eyed. I explain Plan G. "Sure, sounds nice but my friend gets a card to use at CVS."

Ok, here is that MAPD. You'll pay $325 per day at the hospital. 275 for an MRI. $203 per day for SNF. But you'll get $50 per quarter for toothpaste at CVS.

"I want that one with the card."

Ok, sign here. Collect my $600+ and move on...

 

[Bevo]

You'd be shocked.

People sit across the table from me glassy eyed. I explain Plan G. "Sure, sounds nice but my friend gets a card to use at CVS."

Ok, here is that MAPD. You'll pay $325 per day at the hospital. 275 for an MRI. $203 per day for SNF. But you'll get $50 per quarter for toothpaste at CVS.

"I want that one with the card."

Ok, sign here. Collect my $600+ and move on...

This is a great point, Scott. Let's not assume that most people in this world are smart. They're most certainly not. The last 3 years should have taught everyone that if there were any doubts.

 

[somarco]

Although I would have to say there could be a collision coming between HDG and MAPD if MAPD max OoP's continue to drop and the HDG deductible continues to rise.

And yet . . . OM + HDG has a much greater access to care than MAPD can even dream about. Even if the numbers were dead even, HDG would still beat MADP almost every time.

 

[sshafran]

What’s not smart about choosing MAPD over a supplement??? Cause there is a 6% chance their pre authorization could be denied? Because they could potentially be liable for $1000 in copays? How much are they paying annually in premiums??? That’s real money too.

I think the point is that people sometimes can't see past tomorrow.

Talk to them about frequent specialist visits, or diagnostics, or even the need to a SNF and they act like they're 21 years old.

Not unlike a lot of other things in life so I don't worry about it more than they do for them. Tell a 40 yr old that he/she should be putting $$$ away for their 60s and you'll get a blank stare. But they need the $73,000 suburban on their $67,000 salary because they have 2 kids...

Then they hit 68 and wonder why it's difficult to afford their Rx's.

 

[Bevo]

What’s not smart about choosing MAPD over a supplement??? Cause there is a 6% chance their pre authorization could be denied? Because they could potentially be liable for $1000 in copays? How much are they paying annually in premiums??? That’s real money too.

Geez, not enough question marks. Please try again.

 

[somarco]

Talk to them about frequent specialist visits, or diagnostics, or even the need to a SNF and they act like they're 21 years old.

Almost no one mentions LTC until they or their spouse starts the downhill slide. Of course by then they can't qualify and the premium is unaffordable. So that's a no sale.

But talk to them (seniors) about CANCER and they will listen. Almost everyone knows someone who has dealt with cancer. The "C" word resonates with them. If they don't bring it up then you should.

Cancer runs through my wife's family like there is no tomorrow . . . aunts, uncles, cousins . . . I have never seen anything like it before. Her father, mother and brother died from cancer.

So far she has dodged the bullet but is keenly aware of what could happen.

When she was ready to retire she wanted a Medigap plan . . . I did not have to explain the difference in that vs what she had (EGH PPO). She wanted the regular G, not the HDG and that is what she has.

This is pretty much the way almost all of my first conversations go with prospects. Not all have concerns about cancer but they do know they have no interest in MAPD . . . so I kindly take their order.