Urgent help! MA plan member has no OON coverage

[NolaChic]

My 77 year old cousin lives alone in Florida. While visiting here in New Orleans, he fell and broke his him and had surgery a week ago.

He has a Medicare advantage plan in Florida with no out of network benefits. His care so far has been covered due to it being an emergency.

The hospital is now calling me saying his plan says he has to go back to Florida to get physical therapy or any other services. Problem is he lives alone and would not be able to care for himself.

Is there anything the hospital should be doing to get extended care? They are expecting to discharge him to my home but I am also 78 and cannot care for him (bath, restroom, etc.) Ideally, they should move him to an inpatient rehabilitation facility here.

What is done in these situations where a person needs care but they are in another state?? This is insane . They are saying he would have zero care in this state.

 

[somarco]

HMO???

 

[EliseoRNCCM]

My 77 year old cousin lives alone in Florida. While visiting here in New Orleans, he fell and broke his him and had surgery a week ago.

He has a Medicare advantage plan in Florida with no out of network benefits. His care so far has been covered due to it being an emergency.

The hospital is now calling me saying his plan says he has to go back to Florida to get physical therapy or any other services. Problem is he lives alone and would not be able to care for himself.

Is there anything the hospital should be doing to get extended care? They are expecting to discharge him to my home but I am also 78 and cannot care for him (bath, restroom, etc.) Ideally, they should move him to an inpatient rehabilitation facility here.

What is done in these situations where a person needs care but they are in another state?? This is insane . They are saying he would have zero care in this state.

I'm sorry you're going through this.
I'm a hospital discharge planner and nurse for 30 years.

You'll have to immediately find a way to coordinate care for your cousin.
Insurance does not cover recovery care beyond rehab. Even follow up home RN PT OT is sporadic, limited and pulled back quickly.
The hospital cannot help after your cousin leaves to go to rehab. Going to rehab is a safe discharge. The rehab can only keep him until he is
Medically stable to go home. For Medicare advantage plans, that may be 3-5 days then home. For original Medicare, they may stay for up to 20 days.
If you are not able to help, then your cousin will have to pay out of pocket for aides to help him recover at home. Asking friends, family, neighbors and favors is another option.
This should be a wake up call for longevity planning if he is going to live alone. He now knows what happens with his insurance coverage if he travels out of network. He should look into short term recovery policies. Again, they're for short term. What will it look like if it is a forever issue?
Sending positive vibes for a safe solution.

 

[NolaChic]

Yes I guess. It’s HealthSun health plans .

Even if they cover only emergency care when out of network, there should be some type of protocol for this type of situation.

 

[EliseoRNCCM]

Yes I guess. It’s HealthSun health plans .

Even if they cover only emergency care when out of network, there should be some type of protocol for this type of situation.

Yes. All insurance cover emergencies. The protocol is to return to the network where he signed up so they control the cost.
I have seen some patients insist on staying and paying out of pocket for continued care in the area.

 

[sman]

Yes I guess. It’s HealthSun health plans .

Even if they cover only emergency care when out of network, there should be some type of protocol for this type of situation.

You can always appeal and hope to get an exception. One alternative would be to put in a change of address and change him to a plan available in New Orleans. Or, just go straight Medicare and he'd pay 20% after the Part B deductible is met. Of course, the earliest either could go into effect would be April 1st so that leaves him with nearly 4 weeks of either no treatment or paying out of pocket.

 

[NolaChic]

thanks for the information. So how do I go about appealing? Right now, the case manager at the hospital is saying that Health Sun is saying he has no coverage. Would he have to call HealthSun and appeal it? Does the hospital appeal it? I tried to call Health Sun and they won’t speak to me because of HIPAA but they told me to have the case manager call provider services. When I call the case manager and tell her that, she says that her team already spoke to the insurance company who says he has no out of network coverage. It’s like everybody is pushing it off on each other and really not doing anything about it. I can feel from my conversation with the case manager that they want me to take care of him even when I explain I am not in a position to do that.

 

[EliseoRNCCM]

You can always appeal and hope to get an exception. One alternative would be to put in a change of address and change him to a plan available in New Orleans. Or, just go straight Medicare and he'd pay 20% after the Part B deductible is met. Of course, the earliest either could go into effect would be April 1st so that leaves him with nearly 4 weeks of either no treatment or paying out of pocket.

Yes appeal but it is usually declined with uncomplicated hip fractures. This may get him one or 2 days extra.
If he is relocating to another State, he may get a guaranteed issue Medsupp but like you said, may be the first of next month.
The issue still is, if he is now needing assistance to get up, is his cousin ready to provide that help because insurance will not pay for that help.

 

[sman]

thanks for the information. So how do I go about appealing? Right now, the case manager at the hospital is saying that Health Sun is saying he has no coverage. Would he have to call HealthSun and appeal it? Does the hospital appeal it? I tried to call Health Sun and they won’t speak to me because of HIPAA but they told me to have the case manager call provider services. When I call the case manager and tell her that, she says that her team already spoke to the insurance company who says he has no out of network coverage. It’s like everybody is pushing it off on each other and really not doing anything about it. I can feel from my conversation with the case manager that they want me to take care of him even when I explain I am not in a position to do that.

[EXTERNAL LINK] - Determinations, Grievances, and Appeals - Your South Florida Medicare Provider - HealthSun Health Plans

Next time you call Health Sun, have him on the phone with you so he can tell them it's ok to speak with you.

 

[NolaChic]

Yes I need to be go to the hospital and call while he is next to me..