IBM Medicare Advantage Brochure Assessment & another sad story

 The brochure arrived yesterday.  I have two comments on it.  

They say you can "go back" to Original Medicare with a Medicare Supplement plan if you decide you don't like the United HealthCare plan. There is a footnote to that statement that refers you to www.medicare.gov to look at "guarantee issue".  First off, going back to Original Medicare isn't at your whim. That is usually possible to do once a year, during Medicare Fall Open Enrollment (Oct 15- Dec 7th), or if you move to a new state.  The bigger issue is rebuying the Medicare Supplement plan. Depending on what state you live in, you might not be able to rebuy the Medicare Supplement plan. That's what "guarantee issue" means.  Some states allow you to reenroll in a Medicare Supplement plan without underwriting or age rated adjustments.  Most states leave it up to the insurance company to decide if they even want to sell you a policy and, if they do, at whatever price they want. There is no cap on out of pocket cost if you use Original Medicare without a Medicare Supplement plan so, unless you also have Medicaid, you need a Medicare Supplement plan.  

My second comment is there is nothing in the brochure about how often United HealthCare denies claims if you have already received treatment, or requires pre-approval before you can be treated.  That information is available from Kaiser foundation and it is not good.  I have written over and over again about the nightmare of pre-procedure and post-treatment denials.  They say wonderful things in the brochure like they will provide unlimited "Skilled Nursing Facility" days for rehabilitation. What they don't say is the probability of receiving unlimited SNF days is slim to none.  They typically deny more SNF coverage after about 10 days (that's the pattern I have seen) and say it's because more treatment is not medically necessary. Then you are in the cycle of needing to appeal.

Another sad story from this past week about a Medicare Advantage plan. A man, in his nineties, went to the ER because he was having significant heart problems.  The ER doctor immediately admitted him to the hospital.  The staff cardiologist monitored him for several days and stabilized him.  When he got the first denial of payment for treatment from his Medicare Advantage plan, they not only denied the hospital treatment as not being medically necessary, they said the provider was out of network. The man was looking at a bill of about $11,000. He didn't focus on the denial of treatment, he focused on the out of network statement.  He called the Medicare Advantage plan and they said they had made a mistake and the hospital treatment was in-network.  They adjusted the claim amount to $6,000 and then denied the claim, again, saying it was not medically necessary. When treatment is denied, the policy holder is responsible for the full amount of the treatment and it does not count toward the MA plan deductible.  The man now has 60 days to appeal.  It must be a written appeal. He needs to get a letter from his provider to attest to the fact that the treatment was medically necessary.  Needless to say, he was totally overwhelmed with what he has to do to fight to get the MA plan to pay the claim while struggling with his medical problems.  Having to battle with a behemoth  insurance organization is the last thing in the world he needs to worry about. This reporting by Axios is about Medicare Advantage denials.

  https://www.axios.com/2022/04/29/medicare-advantage-debate-rekindled-by-report-on-coverage-denials