Clover Medicare PPO $0 in Network and Out

Discussion in 'Senior Insurance Forum' started by rhcbp, Sep 29, 2015.

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  1. rhcbp
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    rhcbp Expert

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    I was at a presentation last week for a new MAPD plan in New Jersey. The plan is a PPO, MAPD. $0 to see a pcp in network, $0 to see a pcp out of network, $0 to see a specialist in network and $0 to see a specialist out of network.

    My question to the presenter was that if a member went to a doctor out of network the office staff will say we do not accept Clover. His reply was that if a doctor accepts Medicare he has to accept the PPO. He even went as far to show everyone a picture of the back of the card which stated that it is unlawful for a doctor who accepts Medicare not to accept a PPO.

    Does anyone know if this is true? Everything I can find on the Medicare website states that if you use a PPO you may have to pay more out of network, nothing about if a doctor has to accept the plan or not.
     
  2. sman
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    Unless it's a NJ thing, it's news to me. Doctors who accept Medicare do not have to accept a Medicare Advantage plan.
     
  3. Chazm
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    Definitely not true. They still have to agree to the plans terms
     
  4. YouGotMyMoney
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    Common Sense would tell you the plan will be reprimanded by CMS in short order, lol. $0 copay PPO out of network, get da fu out of here.
     
  5. rhcbp
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    I agree with everyone that has posted so far. I do not know how CMS could allow this of a plan that has 2 1/2 Stars. Someone at our meeting asked the Sales Director how many stars the plan has and he said, "2 1/2 - 3, closer to 2 1/2". If they does not raise a red flag I do not know what will.
     
  6. Clover Service
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    Hi everyone!

    Here at Clover, we know how tough it can be sometimes to get the healthcare information you need. Thanks for having this dialogue so that we can have the opportunity to offer you more clarification.

    The Clover speaker was correct in saying Medicare doctors must accept Medicare PPOs, but a bit more context may help clarify. According to the Center for Medicare & Medicaid Services, if you’re a member enlisted in a Medicare PPO, Medicare doctors are obligated to offer you services unless the doctor is not accepting new patients and you are a new patient. So, the speaker was right in saying Medicare doctors must accept PPOs—so long as the plan is a Medicare PPO, like all Clover plans are, and the doctor is still accepting new patients, or you were an existing Medicare patient.

    We would also like to take this opportunity to confirm that Clover is a THREE STAR plan. This current rating is based on 2014 data when we were a small plan with few members. Since then, we have made fantastic strides with our technology platform around care management and provider alignment, and are happy to speak directly with anyone about it - as we are very proud of the work we are doing daily around quality care and service and know this is a very important aspect of our Medicare Advantage offerings.

    We hope this response helps to clarify some questions for you. If you have any more questions, or would like additional information about Clover plans, please reach out to us at (888) 657-1207, 8am – 8pm, EST.

    Sincerely,
    Your Friends at Clover
     
  7. somarco
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    But are not obligated to accept the PPO rate as "paid in full" for services rendered.
     
  8. j10
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    Yeah, I thought it was strange language when the doctor isn't contracted with the plan. The explanation from clover service makes sense and I feel like I learned something. So, in my experience, a lot of billing/offices in a provider facility are not familiar with who they're currently contracted with, to say nothing of their legal obligations. If a client ran into an unhelpful office/billing department that refused to charge clover and hands the client a bill, could the client then send the bill to clover or would they have to pay and get reimbursed?
     
  9. somarco
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  10. nymets365
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    nymets365 New Member

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    RHCBP...i'm curious if you had any other experiences with Clover as they have been super aggressive with mailings and advertising. If you can hit me up at [email protected] I would appreciate it.
     
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