MOOP's

somarco said:
Not being a smart a$$, but what is the point?

Hitting the OOP only matters if it is you.

Also, the max OOP in most MA plans is an illusion. On a large claim you will undoubtedly slip out of network on more than one occasion.
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My mamma has an ma plan... She was on life support for a month. She never hit her opkt.... No out of network claims either... She paid 500 bucks... Next rebuttal you use?
 
anonymous1 said:
One thing to look out for or educate your clients is that hospitals are keeping clients in outpatient observation They receive the same care but are not admitted. I have had clients with pacemakers put in had three day stay all outpatient. My father is a director of nursing for a nursing home. Told me they had three potential stroke clients turned down because they were outpatient at the hospital and did not qualify for skilled. The patient went home instead of paying the cash. As we move forward in the coming years I see this as a big deal. Clients can request to be impatient but if they are out patient gtl will not pay either on the advantage plus If they are outpatient more than likely they will hit the moop. Pacemaker in outpatient will hit the 5000 moop
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Original Medicare three day hospital stay rule prior to SNF typically is not required in an MA. No way a pacemaker will put anyone remotely close to $5K OOP.

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We have the bill it did 24 hour observation for 3 days the cost of the pacemaker the surgery to put it in. The Medicare approved amount was 25k. The charge was I believe with going back and finding it was 85k And yes you are correct the three day stay does not disqualify a client from skilled on an ma but does so on a med sup
 
She never hit her opkt.... No out of network claims either... She paid 500 bucks..
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Sorry to hear about your mom.

One situation does not diminish the argument about OOP. You have written enough major med to know about hidden provider claims.

Same thing happens in MA but can happen with more frequency, especially HMO plans.
 
G.Gordon said:
I've had one carrier say that less than 1% of enrollees hit the moop.
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That's my experience with my book of business and I would guestimate from my experience talking to my clients that about 80% of them spend less than 800.00 on medical copays in their typical year and that about 50% of that 80% spend less than 300.00 in in their typical year.

Given that in Florida my clients that opt for Med Supps spend on average about 3000.00 on premiums including part D that's not too bad .

I wish my major medical policy would give me a pay as you go option up to a reasonable MOOP. - for that matter I wish my auto and home owners did too!
 
I also do the MAPD along with GTL hospital plan and sometimes the lump sum cancer. GTL will pay for observation as long as it is more than 24 hours of observation. I have sent claims in for this and they have been paid. I have a lot of people on MA's and can only think of 2 that have maxed it out. Could be others that didn't tell me but in most cases they will let you know one way or the other.
 
Some MA's use 20% coinsurance for outpatient services (i.e. UCH/AARP in my area). While better carriers like Coventry and Humana use a flat copay such as $200 to $300. That is how some people can see a MOOP hit with outpatient versus plans that use a true copay. I would never sell an MA plan with 20% coinsurance for outpatient services. Too much risk. It is like chemo with all plans being 20% insurance. That is why I sell the GTL Advantage Plus hospital with the cancer rider. I love to run across folks with a 20% coinsurance outpatient benefit. I point it out and make plans to talk to them in AEP for a better plan option.
 
Here Coventry has a co insurance for out patients. But the moop is the lowest and most of the other copays are lower with no premium Every area is going to be different on ma
 
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