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.
Three things about the Medicare Supplemental Plans are:
(1) they are not paid for merely by your Medicare premium, you pay additionally (mine $2k plus a year), and \
(2) while they do not have some “free benefits” that some Medicare Advantage plans have (dental, eye care, ect>), they essentially pay certain levels (depending on the insurer, the health care item & the specific plan) above the Medicare 80% amount, and
(3) they usually have no “network” or PPO; and usuually your Medicare Supplemental Plan is good anywhere in the U.S. with any provider that also takes Medicare.
Nursing home care
Medicare doesn’t cover custodial care, if it’s the only care you need. Most nursing home care is custodial care, which helps you with activities of daily living (like bathing, dressing, using the bathroom, and eating) or personal needs that could be done safely and reasonably without professional skills or training.
Medicare Part A (Hospital Insurance) may cover care in a certified skilled nursing facility (SNF). It must be medically necessary for you to have skilled nursing care (like changing sterile dressings).
Custodial care
Non-skilled personal care, like help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving around, and using the bathroom. It may also include the kind of health-related care that most people do themselves, like using eye drops. In most cases, Medicare doesn’t pay for custodial care.
https://www.medicare.gov/coverage/nursing-home-care
Skilled Nursing Facility (SNF) Care
Medicare pays 100% of the first 20 days of a covered SNF stay. A copayment of $204 per day (in 2024) is required for days 21-100 if Medicare approves your stay.
via Google
This is going on with a lot of plans. Cigna is a major perpetrator, exposed recently as having routinely denied claims by the thousands without even being medically reviewed. Think clearly about “health insurance.” They couldn’t care less about your health. They are not healthcare organizations. They are insurance companies, and they make money by taking your premiums and denying your claims. States have insurance commissions who are supposed to oversee this stuff but they are unreliable. The only recourse is persistence.
“The “Plan Benefits” showed FULL PAYMENT Coverage for skilled nursing through day 100.”
I would make an appeal and include a photocopy front cover and actual page of the document that says that.
Be aware that 2024 plan benefits may not be the same as 2023 plan benefits.
Make sure you have the 2024 plan benefit book.
Thanks.
Thank you. I have seen them, I just didn’t know what the abbreviantion EOB stood for.
Interesting thread considering what’s going on with us.
They are banking on you dying soon.
It is not that Humana is changing the basic terms of the policy, but that the published benefits vary upon care setting under the policy terms and conditions.
My advice is to always work with the insurance and the facility's utilization review department. The lay person does not have the expertise to navigate the system alone.
While I haven’t posted on FR in so long that I forgot my old login, I have been following some of the dialog with interest for many years, and this one really hit me close to the heart. I am in the mid-point of my seventies and make a good living during my retirement by not only selling Medicare health plans but teaching my clients about the pit falls of the various choices they can make, many of them exactly what have been mentioned in your post.
I do not like the Medicare Advantage plans in general. Not because they are intrinsically bad, but because most people coming onto Medicare have no knowledge of how it works or how the plans themselves work. The absolute best plan for those that can afford the premium is a supplement (medigap) plan “G” that really is a Cadillac plan regardless of the company selling it, and possibly the worst would be a Medicare Advantage HMO plan. The difference being the upfront cost of the supplement plan that pays everything and is network free nationwide, and the MA plan that is a nearly free option with ancillary benefits, but that is loaded with co-pays and also binds the client to a narrow network of providers in a specific location.
While we have to take courses annually on ethics and fraud among other things, there are agents that intentionally commit violations of both to sell unsuspecting prospects something that they cannot afford in the long term.
I would suggest everyone spend some time on Medicare.gov to educate themselves about Medicare, and don’t agree to purchase any plan presented by someone you don’t know.
From what I can tell (and it’s complicated), Advantage plans are better if you’re on a tight budget and relatively healthy. But who knows what one’s health will be like a year from now?
So I went with straight Medicare, and bought a supplement.
Advantage plans are just insurance. If you are tired of the insurance racket go Medicare and a supplement…
No, you are wrong.
I would not purchase an Advantage Plan. I would purchase a supplemental along with keeping Medicare.
The only way to know for sure which is best is to have a crystal ball. Affordability is a factor, as is current and foreseeable healthcare needs.
They give lots of trinkets when you are healthy and dump you when you get sick.
...other than the post babyboomer's gen. message of...
Just DIE already!
There is already a class action lawsuit against Humana.
Nursing homes now ask if you have Humana. If you do, you are rejected.
Many hospitals are suing them for non payment.
They will ask you to bend over when uou really need them.
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