MAPD as secondary to Employer insurance in NY?

[crs6633]

I have a client who dropped his MA (with Aetna) after getting a job that offered Employer insurance (with Anthem.) . He only dropped the MA after each of the insurance companies claimed to be the primary. He has since regretted the decision as his current Anthem plan will not pay for the very expensive knee injections he receives every 6 months. Aetna was paying for these.

Is it possible to add back the MA as a secondary to his employer plan?

 

[TwoCents]

I have a client who dropped his MA (with Aetna) after getting a job that offered Employer insurance (with Anthem.) . He only dropped the MA after each of the insurance companies claimed to be the primary. He has since regretted the decision as his current Anthem plan will not pay for the very expensive knee injections he receives every 6 months. Aetna was paying for these.

Is it possible to add back the MA as a secondary to his employer plan?

Based on the info provided and time of year, I can't think of an available election for an MA enrollment.

 

[somarco]

Anthem plan will not pay for the very expensive knee injections he receives every 6 months.

Why is Anthem denying the claim?

 

[crs6633]

Why is Anthem denying the claim?

Anthem says the treatment is not necessary and that they would cover knee replacement but not the shots. Client claims the shots are a $2000 precedure. My instinct is to recommend he drop the ER plan all together to opt back into his MAPD but I'm not sure he will be willing to do that.

 

[LostDollar]

Once a person has enrolled in an employer plan, is it even possible for the active employee to then drop the coverage unless it is during the employer's annual enrollment period?

 

[somarco]

Anthem says the treatment is not necessary and that they would cover knee replacement but not the shots. Client claims the shots are a $2000 precedure. My instinct is to recommend he drop the ER plan all together to opt back into his MAPD but I'm not sure he will be willing to do that.

Medical necessity is a criteria for any health insurance. Makes no sense for a carrier to deny a $2k treatment but willing to pay for a $50k knee. Something isn't adding up.

My gut says if Anthem denies the shots the MAPD will do likewise.

 

[somarco]

My instinct is to recommend he drop the ER plan all together to opt back into his MAPD

What does your E&O carrier say about that?

 

[crs6633]

What does your E&O carrier say about that?

Gotta admit, that question is over my head. I thought the E&O coverage was only for errors. Would they take issue with my writing business with a client as dual coverage?

 

[somarco]

Gotta admit, that question is over my head. I thought the E&O coverage was only for errors. Would they take issue with my writing business with a client as dual coverage?

It is for a lot of stupid things agents do.

Suggesting a client drop group coverage on the HOPE the MA plan will cover a claim denied by the group plan comes to mind.

 

[vic120]

Seems Like there is more to the story if insurance is denying Knee Injections

MA's don't usually cover that stuff well anyway 20% on average, MedSupp GI would be a better choice as far as coverage

Either way, I don't want to be the guy responsible if things don't work out well for the guy, He already had 2 insurance in place at the same time, I would walk away from that one, Or at least tell him there is no guarantee injections would be covered