MAPD as secondary to Employer insurance in NY?

Jul 2, 2019

  1. crs6633
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    crs6633 Expert

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    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?
     
    crs6633, Jul 2, 2019
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  2. TwoCents
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    Based on the info provided and time of year, I can't think of an available election for an MA enrollment.
     
  3. somarco
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    somarco GA Medicare Expert

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    Why is Anthem denying the claim?
     
    somarco, Jul 2, 2019
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  4. crs6633
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    crs6633 Expert

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    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.
     
    crs6633, Jul 3, 2019
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  5. LostDollar
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    LostDollar Guru

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    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?
     
  6. somarco
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    somarco GA Medicare Expert

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    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, Jul 3, 2019
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  7. somarco
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    somarco GA Medicare Expert

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    What does your E&O carrier say about that?
     
    somarco, Jul 5, 2019
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  8. crs6633
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    crs6633 Expert

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    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?
     
    crs6633, Jul 5, 2019
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  9. somarco
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    somarco GA Medicare Expert

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    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.
     
    somarco, Jul 5, 2019
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  10. vic120
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    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
     
    vic120, Jul 5, 2019
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