A week ago, I posted about my 90 & 92 yo parents [forums.macresource.com] and their medical insurance issues, and here's an update:
The plan that they have is indeed a Medicare Advantage plan which I was told by hospital billing is a replacement plan [as in, in lieu of Medicare??] and not, as I had stated, a supplemental plan. They pay $270 a month for this plan AND they pay another $200~ for Medicare out of their [less than $2K] social security check each month. Recently, they have been getting lots of bills for my father's health issue which this replacement plan doesn't cover fully and yet, the hospital say, it doesn't bill Medicare for.

I just got off the phone w/ the insurance company and I really feel as if I need to speak to someone who is knowledgeable yet impartial on the whole topic of senior health options. They live in PA and I in Indiana - of course the web is everywhere...I'm just feeling a little overwhelmed. Any suggestions?



Edited 1 time(s). Last edit at 06/04/2012 01:05PM by abevilac.

no advice, just my sympathies.

Many hospitals have staff or dept's to help you navigate the insurance/medicare waters... (not all hospitals... but at least two around here do).

I would see if the hospital where he was treated might at least have some suggestions for a local-to-them expert that can help you out.

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Paul F.
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A sword never kills anybody; it is a tool in the killer's hand. - Lucius Annaeus Seneca c. 5 BC - 65 AD
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Good is the enemy of Excellent. Talent is not necessary for Excellence.
Persistence is necessary for Excellence. And Persistence is a Decision.
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Eureka, CA

I know and met these folks:

[seniorlawcenter.org]

If you don't have authority to talk for your parents, they may need something from them directly (like permission to talk to you). they may know of resources in PA.

Nationally, these are the experts on Medicare. they have info and self help packets. I am not aware of any other national medicare advocacy group.

[www.medicareadvocacy.org]

I don't deal with Medicare Managed Care, a "Medicare Advantage Plan", (also referred to as a "Part C" plan), but generally that will operate with the same basic coverage rules as regular medicare (Part A, B and D). So to get any sense of what is going wrong, I would need to know what is not being covered (you can PM me if you want). You may be able to "demand bill" medicare, which is officially request that the hospital must submit the bill to the plan. They are giving you the run around which makes me suspicious.



Edited 1 time(s). Last edit at 06/04/2012 01:57PM by michaelb.

It's a damn maze of mirrors. I had to deal with my mother in law and then my father in law and all the medical billing. Hospitals, even highly rated institutions like the Cleveland Clinic, conduct billing in such a confusing fashion that I defy anyone to find fraud unless it's easy (like the Mammogram they billed for my father in law).

Good luck. I found putting it all in a single spreadsheet and then comparing dates of service with actual issues and times helped me negotiate with them. And it's a negotiation, no doubt about it. The insurance companies are in on the joke as well.

Just a clarification about Medicare Advantage. MA by design does not bill Medicare. With MA, the insurance company (BCBS, Humana or whatever company) contracts with Medicare to completely take over everything. The insurance company designs the plan--which must be "actuarially equivalent" to original Medicare*--negotiates with provider networks and handles all claims. That is why when you go to the doctor or hospital you only need your insurance card, not your Medicare card.

* means the plan must be OVERALL at least as good as Medicare but that does not mean copays for some things cannot be higher than original Medicare.

I specialize in Part D, but have some familiarity with the medical side of Part C plans. The below is provided on the basis of general info, does not constitute specific advice, should not be taken as recruitment to sign up for a plan offered by the company I work for, blah blah blah.

In 2012 the standard Part B premium is $99.90. Some individuals may be subject to an income-related monthly adjustment amount causing a higher premium, though based on your OP I doubt your parents are subject to IRMAA. If your parents used standard Part B (aka Original Medicare) they would pay only the standard premium. They would also be subject to standard Part B pricing including the normal Part B deductible and coinsurance rates. Enrollment in a Medicare Advantage plan (aka Part C) carries a premium in additional to the regular Part B premium (for most plans, some plans do not charge an additional fee on top of Part B). The MA plans then provide a different benefit structure which can include a lower/no deductible, different copay structure, a maximum out of pocket, coverage of extra benefits like vision, dental, etc.

The plan I think your parents are enrolled in (based on info you provided in this thread and your prior one) does carry a premium that is in addition to the standard Part B premium, and this is very normal for a MA plan. If they are indeed enrolled in the one I think they are, then the price they are paying for the coverage itself is correct. It is also correct that the hospital would not bill Medicare directly - instead it would bill the health plan which would process all claims.

Three suggestions for your parents:
First, for the short-term to help sort out whether their hospital/medical bills are being properly submitted to their plan or not, and to help you and them better understand their plan/coverage, consider requesting help from the state State Health Insurance Assistance Program. For PA the SHIP is called APPRISE. Their phone is 800-783-7067.

Second, as you mentioned your parents' resources are limited, it would be worthwhile to check if they are eligible for any assistance to reduce the cost of their coverage. A SHIP counselor at Apprise can review that with your parents, but you can also look at basic eligibility info here. Even if you think your parents may be slightly over the limits, an application is still worth it as they may qualify.

Third, if their current plans are not working, they will have an opportunity to change plans during open enrollment. Open enrollment for Medicare Advantage is 10/15-12/7 and takes effect 1/1. There is an additional opportunity to disenroll from a MA plan 1/1-2/14 in order to enroll in Original Medicare (plus Part D if selected). Your parents don't have to be in the same plan, so if the current plan works for one but not both, one parent could make a change. Your parents may also qualify for a Special Enrollment Period to make a plan change outside Open Enrollment. This would be analogous to qualifying life events for plan changes that those of us in the working insured world deal with, just with slightly different criteria.

If you want to PM me directly regarding any of this, I'm happy to try to provide any more specific help possible.

Thanks everyone for all this info. I will be picking up a book at my local library that purports to explain everything medicare and I will follow-up w/ kind forum members too.

^^^Three cheers for TL!!!^^^

Check with your state or local advocacy program and see if they have one on one personal help.

My state has this...

[www.cahealthadvocates.org]