MA Policy Problem in NY

[CaptiveBroke(r)]

I have a question for the medicare experts.

I have an FE client that told her health insurance agent at least 3 or 4 times who her primary care physician is at the time of enrollment in to an MA HOM plan, when asked, and then gets a UHC plan that does not have the doctor as a provider. What recourse does the client have?

She is 73 years old and did not switch during open enrollment. Her BC plan discontinued in Dec 2012 and she had to make a change.

The plan is called UHC Complete Mosaic...it has a limited number of doctors compared to the other UHC Complete plans, from what I see on their website.

This is an HMO plan where the doctor never was a provider, although he is one for their other HMO MA plans. Now she is getting bills from doctors office and is clueless on how to go further. She called up the agency that wrote the policy and all they tell her is that it’s an HMO and doctors can go in and out…not the case since doctor never belonged. They also told her she has to wait until open enrollment to change.

She’s been going to same doctor for over 25 years. Any suggestions for her to proceed to try to get someone to listen to her?

She lives in NY and has been a client for many years so I would like to at least give her some avenue to pursuit, if at all possible.

Any input is helpful. Thanks.

 

[BobbyMcGee]

What HMO Doc did she list as her PCP on the application? If she had the right one and ended up with a plan without him in it, she could file a grievance/appeal with UHC.

 

[Chazm]

Looks like the agent screwed her here if that was indeed the case, for a commission check. She might be SOL

 

[CaptiveBroke(r)]

She states that they asked her for her Dr.'s full name to check if he is a provider. And they never told her he was not.

I do some med sups but not familiar with MA plans. Wouldn't UHC just tell her that she has to contact Medicare?. She should have been in UHC Medicare Complete 2, Not the Medicare Complete Mosaic.

She called insurance "agency"...a big agency that does entire east coast (don't know name) and they switched her to a resolution specialist who only told her that she should opt for a PPO next time and that's the pitfalls of HMO's. They just told her to call Medicare if she feels there was a mistake.

Sounds like a lot of **** to me, though.

 

[Josh]

This wasn't that long ago, any reason to not request a copy of the app? On an HMO application (unless things have changed) a doctor has to be listed on the application. If a doc name is there and she signed it, I'm not so sure I'd throw the agent under the bus. That said, it's entirely possible the agent did mislead her (or even may have thought a doc with the same name was in the network?), so there is no reason she couldn't call 800 Medicare and explain that she was told the doctor was in the network and that he wasn't. This is a relatively recent enrollment so they may be able to do something for her.

The carriers get heat from CMS if their members call Medicare and complain, so UHC isn't going to want to tell her to do that.

 

[CaptiveBroke(r)]

This was a recorded phone application with a voice signature so I don't know how she would get a copy of that?
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Anyway, thanks for info...I will pass it along!

 

[Josh]

This was a recorded phone application with a voice signature so I don't know how she would get a copy of that?
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Anyway, thanks for info...I will pass it along!

Even better. Carrier has to keep those for 10 years. She should say the name of her doc on the app.

 

[Krocker360]

They also told her she has to wait until open enrollment to change.

I feel sad about it, after all seniors should not wait they always be the priority.

 

[bwade45]

She states that they asked her for her Dr.'s full name to check if he is a provider. And they never told her he was not.

I do some med sups but not familiar with MA plans. Wouldn't UHC just tell her that she has to contact Medicare?. She should have been in UHC Medicare Complete 2, Not the IMedicare Complete Mosaic.

She called insurance "agency"...a big agency that does entire east coast (don't know name) and they switched her to a resolution specialist who only told her that she should opt for a PPO next time and that's the pitfalls of HMO's. They just told her to call Medicare if she feels there was a mistake.

Sounds like a lot of **** to me, though.

I think she should file a complaint with the Centers for Medicare and Medicaid. That will get some attention.

 

[hassy99]

I feel sad about it, after all seniors should not wait they always be the priority.

My primary carrier is uhc. The best course is for her to call uhc (member service # on back of her card). File a complaint. Because she felt she was misled at time of sale
I have seen humana and uhc. Arrange a sep (special enrollment option) which will allow her the opportunity to make a change now.
After that then ask for an appeal of the claims that have gone unpaid. She can put the details in writing and submit

This all assuming that she is not in wrong.

Uhc would prefer not to go to Medicare with a complaint and solve it in house

Give this a shot. Appeals have worked for many of my clients. (Basically they went to a provider out of area and network).

Good luck with her
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My primary carrier is uhc. The best course is for her to call uhc (member service # on back of her card). File a complaint. Because she felt she was misled at time of sale
I have seen humana and uhc. Arrange a sep (special enrollment option) which will allow her the opportunity to make a change now.
After that then ask for an appeal of the claims that have gone unpaid. She can put the details in writing and submit

This all assuming that she is not in wrong.

Uhc would prefer not to go to Medicare with a complaint and solve it in house

Give this a shot. Appeals have worked for many of my clients. (Basically they went to a provider out of area and network).

Good luck with her

Also one additional item. If she left a Medicare supp last dec and this was the first time for Medicare advantage. There is a 12 month trial period in which. New members can dis enroll and get their med sup and rx plan reinstated. (Not retro though)
She can certainly go that route to get out of that plan