Question About Windsor MAPD, MOOP Policy..

[kennethbroyles]

I met a prospect yesterday who has Windsor Gold MAPD here in TN, he has had for the past 3 yr. He gets no extra help, with only about $1800 per mo. income. Late in 2008 he started Cancer treatments and they continued till early this year. The co insurance for chemotherapy is 20% or about $6k per year in 2009 and 2010. I talked to a supervisor at Windsor who told me the MOOP of $3400 would not take place until the member actually has paid the treatment center the full amount of $3400, and the member is on a payment plan with the center of $50/mo. That isn't the way I had understood MOOP to work. I thought when your co insurance amount reached the $3400 MOOP, the plan would "kick -in" to pay all other expenses.

( I don't contract with Windsor.) Its pretty early, so please forgive the poor statement of the problem my me.

That is the basics of the story. Does anyone have a comment or suggestion on how to advise this member or help me better understand how MOOP works on a MAPD?

 

[Bob_The_Insurance_Guy]

Kenneth,

If he is paying $50 per month, then he is NOT out of pocket $3400.

Once his "true out of pocket" expenses reaches $3400, then Windsor will pick up the rest of the tab. Just because someone is billed more than the MOOP, doesn't mean they are out of pocket that amount.

Paying $50 a month for $6K worth of treatment is a good payment plan, and he should be happy. Since he is really paying $600 per year for the treatment, he will never meet the MOOP of $3400.

Is the care he is receiving to his liking? Is he getting the quality of treatment he feels he should? Has Windsor not paid any other cost sharing as they have promised?

Now, if he were to stroke a check for $3400, then he would be "out of pocket" $3400.

It's time to hear from all the Medicare Supplement guys about how he should be on plan F, and his costs would be nothing (except of course for the monthly premium + PDP monthly premium).

 

[kennethbroyles]

Kenneth,

If he is paying $50 per month, then he is NOT out of pocket $3400.

Once his "true out of pocket" expenses reaches $3400, then Windsor will pick up the rest of the tab. Just because someone is billed more than the MOOP, doesn't mean they are out of pocket that amount.

Paying $50 a month for $6K worth of treatment is a good payment plan, and he should be happy. Since he is really paying $600 per year for the treatment, he will never meet the MOOP of $3400.

Is the care he is receiving to his liking? Is he getting the quality of treatment he feels he should? Has Windsor not paid any other cost sharing as they have promised?

Now, if he were to stroke a check for $3400, then he would be "out of pocket" $3400.

It's time to hear from all the Medicare Supplement guys about how he should be on plan F, and his costs would be nothing (except of course for the monthly premium + PDP monthly premium).

Thanks... with his expenses.. he doesn't think he can afford a Sup.
But a great story to help others understand the benefits of Medigap for sure...
Thank you for your kind reply!

 

[tins]

I'd like to hear some other experts thoughts because it is my understanding the MA company cannot bill anything over the MOOP regardless of whether the member has paid or not. Once they hit the MOOP the MA company must cover all medical costs for the remainder of the year (and chemo is a Medicare part B expense).

 

[senior-advisor-indiana]

Tins that is my understanding too. Maybe Bob was hitting the bottle early this morning.

 

[ksigmtsu]

They cannot bill over the max oop, regardless of what the member paid.

That case needs to be appealed to medicare for non-payment.

 

[Millwood]

Something doesn't sound right. How would a company ever know if the client had paid the MOOP to the provider? There's no way a company could track various accounts to see if MOOP had been paid.

On the other hand I was at a Universal Healthcare meeting and the representative said some companies had excluded chemo, radiation, dialysis, and excess charges from their MOOP.
That would seem to make more sense.

The last time this came up on the board I was told those things could not legally be excluded from the MOOP. I don't sell advantage plans and haven't been able to nail down a definitive answer .

Ok any experts able to quote CMS on this ?

 

[ksigmtsu]

I've never seen a schedule of benefits from any carrier in my state that allowed them to exempt anything other than out of network POS benefit and medications from the calculation for max oop.

 

[policy doctor]

My understanding is that medicare advantage plans have to be equally as good as original medicare benefits or better, which is why they get extra money per beneficiary per month from CMS. Original medicare pays for all those services you listed. Hence ma's.

 

[sman]

Kenneth,

If he is paying $50 per month, then he is NOT out of pocket $3400.

Once his "true out of pocket" expenses reaches $3400, then Windsor will pick up the rest of the tab. Just because someone is billed more than the MOOP, doesn't mean they are out of pocket that amount.

Paying $50 a month for $6K worth of treatment is a good payment plan, and he should be happy. Since he is really paying $600 per year for the treatment, he will never meet the MOOP of $3400.

Is the care he is receiving to his liking? Is he getting the quality of treatment he feels he should? Has Windsor not paid any other cost sharing as they have promised?

Now, if he were to stroke a check for $3400, then he would be "out of pocket" $3400.

It's time to hear from all the Medicare Supplement guys about how he should be on plan F, and his costs would be nothing (except of course for the monthly premium + PDP monthly premium).

Bob,

You usually give good advice and seem fairly knowledgeable. However, I believe you are wrong on this. There is no way an insurance company could possibly know what a patient has paid to a doctor, hospital, etc. The coinsurance amounts are between the patient and person/facility providing the services. It has absolutely nothing to do with the insurance company.

In the case outlined (MOOP of $3,400), if the insurance company has been billed $30k and the coinsurance for said services is 20%, then once the charges reached $17,000 the insurance should cover the rest at 100%.