Posted on 02/06/2024 4:57:01 AM PST by tired&retired
How can Humana change the coverage after the patient is admitted?
I logged into the indiviual account and printed the "My Benefits" in November when a close friend was hospitalized for a severe stroke. I have full medical and legal POA.
The "Plan Benefits" showed FULL PAYMENT Coverage for skilled nursing through day 100.
While she was admitted, they changed her plan to only cover 80% through day 100. With a $203 per day co-pay, that is a lot of money she doesn't have.
How can they change the plan during continuous admission?
In addition, they keep denying any payment saying she is not benefitting from the treatment. She clearly is benefitting based upon a team of medical specialists who ordered rehabilitation treatment and are evaluating her on a regular basis.
Five times now they denied coverage five times I appealed and won. They are doing this to everyone. United Healthcare is doing the same.
This week, I won the appeal on Saturday and Monday they denied payment again.
I feel bad for all the senior citizens who have lived one's in treatment and must fight for coverage. Humana is ripping off many people and Medicaid by forcing people out of coverage.
In this case, she must give up her home for rehab, thus she has no place to live after she improves and no longer needs care.
If she were an illegal immigrant, all this would be paid by the government.
Any advice is welcome as my blood is boiling, I'm that angry at the Medicare Advantage rip-off plans.
Agree with the “Plan G”. But it will cost you. And if you have any serious pre-existing conditions you may not qualify for it.
“Advantage plans are just insurance. If you are tired of the insurance racket go Medicare and a supplement…”
Totally agree.
These plans were started by George W Bush.
Remember the Carlisle Group that was started by Frank Carlucci, Bush Sr’s Sec. Of Defense, as a defense contractor investment fund? Bush the father was their front person after leaving the presidency.
They own KEPRO, the agency responsible for reviewing appeals cases for Humana and United Healthcare. Effective the end of 2023 they purchased their only major competitor.
One of the Louisville news stations ran astory about the number of advantage plans that hospitals are now rejecting because of extremely delayed payment or non-payment by the underwriters. The article noted that with some of the underwriters 90% of claims were denied initially.
They listed about eight underwriters in the story I don’t remember which ones. And if you have one of those you’re not going to get a hospital to accept it
I just had both knees replaced and paid nothing.
About 9 months before that had a major shoulder repair - zero cost to me.
For us if we add up all the costs including the $255 deductible, drug plan, and a Cobra dental and vision we pay about $7000/year.
Having a fixed cost is comforting.
I don’t trust Humana; I have worked in some of their hospitals and the first thing they do when they come in is CUT STAFF TO SAVE MONEY. Makes working there not very pleasant; you get loaded down with patients.
That’s a question you need to ask them, and based on their answer, perhaps a lawyer, if feasible.
I failed in keeping up to date.🥴
From 1998☹️
“United HealthCare/Humana merger creates new managed care challenges for hospitals”
https://pubmed.ncbi.nlm.nih.gov/10182986/
United and Humana tried merging but it was blocked for antitrust reasons.
United Healthcare purchased the c9mpany that reviews and rejects patient care based upon AI software and algorithms. Humana contracted with United Healthcare to use their software to reject patient care.
The profits of both Humana and United Healthcare have skyrocketed.
Very good advice.
Thank You.
I’m interested in any thoughts on Medicare Advantage plans vs. straight Medicare Supplement plans. Currently in the sign up process.
Here is my simple take on Medicare Advantage vs Traditional Medicare with Supplemental plans and what I and my wife have done with our health insurance:
Medicare Part A: Basically Covers hospital care, skilled care, hospice and home care.
Medicare Part B: Pays for Doctors and ancillary care / outpatient care
Medicare Part D: Covers prescription costs to a certain extent
Medicare Part C: Medicare Advantage Plans - Insurers assume responsibility for providing reimbursement for Medicare expenses in exchange for a fixed payment from the government on a per member basis. For this payment the insurers assumes financial liability and risk. They “manage” the care and attempt to optimize health by offering services and programs that are preventative in nature. For instance they incentivize preventative care such as immunizations (flu shots, pneumonia shots, shingles vaccines, RSV shots), health club and exercise programs, social interactions etc. They profit if the members consume less dollars of health care than the government calculated and paid for the insurance companies to assume that risk.
Costs: Medicare Part A: No cost to the member
Medicare Part B: $174.70 (2024)
Medicare Part D: Variable depending on insurer and benefit. Avg. $48
There is a “IRMAA” (Income-related annual adjustment) for singles and couples that increases the above Part B and D premiums by up to a maximum of $594 for Part B and can add up to $81.00 to the baseline Part D plan.
Part C: Medicare Advantage: Many plans are at zero premiums but members must maintain Part B coverage so they still pay the Part B and any IRMAA as well as a Part D IRMAA if applicable based on income. They do not pay an extra premium (for most plans) for the Advantage plan.
Medicare Supplement Insurance: Medicare Part B pays 80% of “allowed charges” with Medicare determining the “allowed charge.” This leaves the patient responsible for the 20%, and if the provider does not accept assignment up to an additional amount as allowed by medicare. To cover this amount many purchase a supplement plan from insurance companies. Many different plans are available and provides different levels of coverage and are at variable prices. The most popular plan right now is called Plan G. Medicare dictates that there are basic coverages that each plan has to offer regardless of which Insurance company offers the product so one Plan G has to cover the basics as determined by Medicare but they can offer additional coverages above the minimum so there is variability in the coverages depending on which company you choose. The prices for these plans are set by the insurers and are generally competitive across the spectrum of offering companies. There is an annual Part B deductible that has to be met before medicare Part B kicks in ($240 in 2024).
Part A Medicare for hospital charges also has an annual deductible. For 2024 this amounts to $1632 for inpatient hospital costs. Should the hospital duration extent to days 61-90 there is a daily deductible of $408. If Skilled Nursing Care is needed beyond 20-100 days post hospital care the deductible for that is $204.00/day.
The Medicare Supplements may cover these deductible costs depending on which Supplement plan is purchased. Plan G for instance does cover the deductibles except the Plan B $240 deductible.
Plan C Medicare Advantage programs have variable benefits depending on the company and plans. They have HMO plans that are more “managed” and somewhat restrictive as to providers and pre-authorizations and PPO plans which allow members to seek care from a wider range of providers (although at a slightly higher co-pay amount) and less restrictive pre-authorization requirements.
Most Medicare Advantage programs have some coverage for things like eye care, exams, glasses, etc.; hearing aid coverage; dental coverages; health club memberships (silver-sneakers). Some provide a supplemental benefits to purchase over-the-counter health products (vitamins, toothpaste, mineral supplements, women’s health care products, and others); and incentivize by providing small payments to members who meet criteria for improving their health like exercising, getting immunizations, doing annual health assessments. Most Medicare Advantage plans offer better coverage for foreign travel emergent care needs (although travel insurance should still be highly considered)
There is a deductible (generally for the first few days of hospitalization for in-patient care and small co-pays for out-patient care {less for HMO than PPO plans}).
Given all the above, I think the bottom line depends on your individual needs and desires, but Medicare Advantage appears better suited for those wanting to save money over the costs of Medicare supplement plans, and those who live in an area where most providers are enrolled as providers (for HMO plans) or are accepting Medicare patients (PPO plans) and where the hospitals are participating (most are.)
Those who want some eyeglass care, hearing aid care, gym memberships etc benefit from Advantage plans.
Traditional medicare is likely preferred for those who anticipate considerable services with multiple hospitalizations as Medicare Advantage programs can have a high out-of-pocket limit especially if utilizing “out-of-network” providers.
My wife and I chose a Medicare Advantage Plan as Supplemental Medigap plans (G) and plan D plans) were costing us over $5000/yr. and do not anticipate multiple prolonged care needs and live in a region where most providers are either in-network or accept Medicare so we can use our PPO plan and pay a slight additional co-pay ($50 for specialist vs $35 in-network specialist). We also travel internationally every couple years and find emergent care coverage of the Advantage programs to be preferable.
Consult an independent health insurance consultant and do not rely on Joe Namath of JJ Walker to assist you in making the decision regarding you Medicare or Medicare Advantage plan.
BKMK
I have a friend that is an agent.
She told me that she could make 6 times the commission by putting me into an advantage plan.
She then said that she would not do that to me.
Medicare part G is what I have.
Everything is covered.
Anywhere I go.
2500 deductible.
You do pay for it, but it’s worth every penny.
>Consult an independent health insurance consultant and do not rely on Joe Namath of JJ Walker to assist you in making the decision regarding you Medicare or Medicare Advantage plan.
Thanks for the morning’s best LOL! And the overall post.
It's possible it's in the fine print.
If you still have time under a private insurance contract, if there is ANY medical care you have been considering, especially elective type treatments, do them BEFORE you go on Medicare.
Also, just before you switch over, get dental work done. Make sure you have your prescriptions all stocked up and refilled if possible, and if you have an optical plan, get new glasses and if you need cataract surgery get it done BEFORE you are forced onto Medicare.
These measures will not keep you going forever, but will buy you a couple years reprieve before getting taken to the cleaners by forced government “healthcare”.
We found out the hard way what a rip off Medicare is and their prescription plan with its *donut hole* in Rx coverage is an abomination, and yet you have NO choice.
Ooops, sounds like you’re already screwed over.
Sorry.
Still for anyone else, that advice about private ins still goes.
If you don’t sign up for the Rx plan right away, they penalize you and it isn’t a one time charge. It’s that your premium is higher for the rest of your life. EVERY month.
It’s a continual penalty.
We found the cheapest plan going just to technically have one and found that Good Rx was the best Rx plan for us.
You can't expect integrity from the government.
The medigap plan or Medicare Supplement plan generally does require that the applicant undergo medical underwriting that will determine issuance. However, there is a once in a lifetime window that lasts for 6 months after you get your part “B” Medicare (or your 65th birthday for most folks) in which you do not have to have underwriting. This is huge and most people miss it. You also can try a “C” plan (Medicare Advantage) for up to 12 months if you are dissatisfied with a supplement plan, then switch back with no underwriting one time.
Just one of the many reasons my wife and I stick with traditional Medicare.
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