Maybe You Guys Will Know

[Bob_The_Insurance_Guy]

I have a Medicare Beneficiary that is going to join the Humana Choice PPO for a January 1 effective date. Her meds and docs are on the plan. There is one question, though, and I wanted to see if anyone here can provide a clearer answer than Broker Support did.

She is needing a chemically-induced stress test, upon the insistance of her cardiologist. Due to pre-existing conditions, running on the treadmill is not an option. Looking through the Summary of Benefits, under 13 Outpatient Services/Surgery, I see where, if she stays in network - which she will, then it can be at the most $100.

Again, this is for the state of Georgia. Just wanted a second opinion before I went forward. Is this correct?

 

[sman]

I have a Medicare Beneficiary that is going to join the Humana Choice PPO for a January 1 effective date. Her meds and docs are on the plan. There is one question, though, and I wanted to see if anyone here can provide a clearer answer than Broker Support did.

She is needing a chemically-induced stress test, upon the insistance of her cardiologist. Due to pre-existing conditions, running on the treadmill is not an option. Looking through the Summary of Benefits, under 13 Outpatient Services/Surgery, I see where, if she stays in network - which she will, then it can be at the most $100.

Again, this is for the state of Georgia. Just wanted a second opinion before I went forward. Is this correct?

Would that fall under outpatient services or diagnostic procedures and tests?

Not sure which HumanaChoice PPO plan you are talking about, but under the Metro Atlanta plan (H5214-003) under diagnostic procedures and tests, your client would pay $10 to $75. The breakdown is as follows:

$10 if done in a PCP's office (not likely since it has to do with the heart)
$35 for a specialist or immediate care facility
$75 if done at hospital facility as an outpatient test

In reality, it will all come down to how it is billed.

 

[honestagent]

A bit late in the reply here but Sman is right.. it's all boils down to how it is billed and if it's billed accurately. Just fyi the client and plant the seed now if there's a boo boo (due to recent changes with plans and added networks) to 'rescue' when or if the need arises.

Would that fall under outpatient services or diagnostic procedures and tests?

Not sure which HumanaChoice PPO plan you are talking about, but under the Metro Atlanta plan (H5214-003) under diagnostic procedures and tests, your client would pay $10 to $75. The breakdown is as follows:

$10 if done in a PCP's office (not likely since it has to do with the heart)
$35 for a specialist or immediate care facility
$75 if done at hospital facility as an outpatient test

In reality, it will all come down to how it is billed.