MA, what Am I Missing

SouthernComfort

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Friday I met with a prospect who had lived in the county I was working all of his adult life. He had a Blue Cross/Blue Shield Wellpoint MA(PPO). The thing is the county that he lives in is not listed as a service area for this MA. Now, he is LIS not full dual and he told me that he only paid the co-pays listed when he went to PCP.

How did he enroll in this plan out of the listed service area? Is it normal that out of network physicians accept the listed co-pays?

The plan has good benefits and he was happy but I did tell him about in and out of network costs and how his was not living in a service area.

What am I missing and if this plan can be written here why am I not offering it?
 
Friday I met with a prospect who had lived in the county I was working all of his adult life. He had a Blue Cross/Blue Shield Wellpoint MA(PPO). The thing is the county that he lives in is not listed as a service area for this MA. Now, he is LIS not full dual and he told me that he only paid the co-pays listed when he went to PCP.

How did he enroll in this plan out of the listed service area? Is it normal that out of network physicians accept the listed co-pays?

The plan has good benefits and he was happy but I did tell him about in and out of network costs and how his was not living in a service area.

What am I missing and if this plan can be written here why am I not offering it?

He can't enroll in a plan if it's not offered in his county. With that said, I have people who live on the border of counties. While their zip code would indicate a city which is in another county, they actually live in a different county. For example, zip code 30238 is a Jonesboro zip code which is Clayton County. I have clients who have this zip code, but actually live in Fayette County. Since they live on the border, the powers that be have decided the Jonesboro post office will deliver their mail and thus they have a Jonesboro zip code. Without knowing this persons situation, I can only guess that this could be a possibility.

As for the out of network doctors, it is entirely up to the doctor to enforce the copay amount. I haven't seen the BCBS I.D. card, but it may only list in-network copays. And since some doctors offices are clueless, they may be charging the copay listed on the card since they think they are part of the BCBS network all while not realizing the Medicare PPO network is different from other BCBS networks.

Just a guess though.
 
This comes down to one of two things:
1) what sman describes with insured living close to county line; having zip code that is common to one county and they actually live in another county. I have a number of insureds who are in this same situation since we are quite rural.

2) the writing agent may have fudged the zip or county since the covg was better. This may have happened more a few years back since CMS was less of an all-encompassing net in those days, it seems.
 
Did they (BCBS) drop the MA plan in that area?


No, to my knowledge it has never been available in this area(rural). The benefits are good and according to the Wellpoint agent sheet it is available in surrounding counties and according to the Blue Cross agent website almost 100% of the PCP's, specialists, and Hospitals in the area accept the plan.

If it is available to be sold I want to be able to offer the plan.

The counties are spread out 2 here then 60-120 then 2 more....
 
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Friday I met with a prospect who had lived in the county I was working all of his adult life. He had a Blue Cross/Blue Shield Wellpoint MA(PPO). The thing is the county that he lives in is not listed as a service area for this MA. Now, he is LIS not full dual and he told me that he only paid the co-pays listed when he went to PCP.

How did he enroll in this plan out of the listed service area? Is it normal that out of network physicians accept the listed co-pays?

The plan has good benefits and he was happy but I did tell him about in and out of network costs and how his was not living in a service area.

What am I missing and if this plan can be written here why am I not offering it?

Is it possible that they have another zip code listed with Social Security/Medicare? I have a couple who physically lives in another county, but since their mail comes to a neighborhood convenience store that is in the service area, they are "in like flynn."
 
I can think of several differnent ways to "trick" a carrier into allowing you to enroll when your zip code doesn't.

So are you going to keep all this 'trickeration' to yourself, or share with the rest of us tricksters...? :twitchy:
 
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