UHC Violates CMS Rules

[Packerland]

True… but I always read to them the Exclusions and Limitations found in the MedSupp Outline of Coverage. It's usually a very short list. The MA plans point of sale summaries lack these consumer disclosures.

Who do you suppose approved these sale summaries that you speak of. Let me give you a clue CMS. If you are indicating that MA plans are trying to hide something take it up with CMS.
As I am sure you are aware Med Supplements are are governed by state Insurance commissions and MAPD and PDP are under the guise of CMS.

 

[somarco]

True… but I always read to them the Exclusions and Limitations found in the MedSupp Outline of Coverage. It's usually a very short list. The MA plans point of sale summaries lack these consumer disclosures.

Then you and I are part of the very small group of agents who bother to read those, much less disclose the contents to prospects.

When I am asked to review coverage my first stop is the benefit summary for the highlights then on to the conditions & exclusions section. Folks buy insurance for what they expect it to cover. Sadly, they almost never read the conditions and exclusions until AFTER a claim is denied.

 

[MedSuppPro]

Who do you suppose approved these sale summaries that you speak of. Let me give you a clue CMS. If you are indicating that MA plans are trying to hide something take it up with CMS.
As I am sure you are aware Med Supplements are are governed by state Insurance commissions and MAPD and PDP are under the guise of CMS.

I don’t know what you are talking about: “Who approves… “. FACT: Packers sucked on Monday night against a very bad team.

 

[Packerland]

I don’t know what you are talking about: “Who approves… “. FACT: Packers sucked on Monday night against a very bad team.

Packers sucked...true...but not sure what that has to do with the price of eggs

 

[Todd King]

Well ...
As I told another poster, I would consider this to be a rare and unusual circumstance,
but I just checked my Medigap EOB history for last year on the carrier's website. I did not use the word denied in my discussion with the other person, but the specific verbiage the carrier uses in the online claims recap is "DENIED" (vs PAID).

I have 5 EOB lines that come up with a status of "denied".
Claim A was denied 3 times.
Claim B was denied 2 times.

These claims were processed by the CMS Part B contractor for Kansas and both contain Medicare approved services. On one claim not all services were approved by Medicare. The claims were not automatically transferred to the Medigap carrier by Medicare. The Part B provider seems to be unable or unwilling to submit the claims to the Medigap carrier in a manner that will lead to the Medigap carrier approving the claim.

You should be getting an EOB (that's what I still call it). All you have to do is submit it to the carrier. They will take if from you. First off though, I would call the carrier to see if they even got anything from Medicare on those particular claims. If so, they really don't have a choice but to pay it. If nothing else, call your agent!

 

[somarco]

First off though, I would call the carrier to see if they even got anything from Medicare on those particular claims. If so, they really don't have a choice but to pay it. If nothing else, call your agent!

I see very few denied claims from the Medigap carrier. Every one that is denied was first denied by Medicare . . . and Medicare does not use algorithms or AI to adjudicate and deny claims.

If Medicare denies the claim, the patient owes nothing UNLESS they signed an ABN and AGREED up front to pay the claim.

It's a very simple process . . . not complicated like MA plans where you are either fighting a carrier bean counter or giving in and paying the claim out of pocket.

 

[steve3752]

I just can't believe that mapd agents don't get these type of calls. I get 20 a year and they are not my clients.

In 14 years of selling both MA and Med Supp, I have never received one call relating to this topic.

 

[DonP]

I’ve written a few k mapd in 3 plus years . I’ve probably replaced 50-70 med sups . I’ve had many many people with cancer , severe heart, skilled nursing etc in those years . How come I’ve not had 1 person tell me “ United wouldn’t pay for my cancer treatment or Humana “ denied my heart operation “ ? Do you really think me as an agent would be writing this if I got calls daily filled with complaints? The stress would be to great . Those are facts not some article .

 

[Yagents]

I’ve written a few k mapd in 3 plus years . I’ve probably replaced 50-70 med sups . I’ve had many many people with cancer , severe heart, skilled nursing etc in those years . How come I’ve not had 1 person tell me “ United wouldn’t pay for my cancer treatment or Humana “ denied my heart operation “ ? Do you really think me as an agent would be writing this if I got calls daily filled with complaints? The stress would be to great . Those are facts not some article .

You're in AZ, when I get those dozen mapd calls a year looking for a supp, can I refer them to you? That way you can hear their story and maybe fix it with a better mapd?

 

[sshafran]

One thing I've been saying recently with my T65s is that with MAPD the insurance company gets "a seat at the table" in making decisions about which providers and which treatments are approved.

"You gave me three doctors - they're all three in network. Let's talk future for a minute. You don't see a cardiologist today. You might need one in 2025. If you go with this MAPD they'll be a part of the decision making process - they have a seat at the table. Now, it's $0/mo with better Rx and better blah blah blah but you need to be OK with knowing they'll be involved. You'll need to pick one of their cardiologists, and you'll also probably need their pre-authorization on some services as we discussed. The supps we also discussed - they don't get a seat at the table."

Maybe only 20% will remember this kid telling them this but if nothing else, I think it's quick and easy and does paint a pretty decent mental story of the downside of the plans.

My MA book is over 500. Medigap close to 900. I don't get many MA complaints but I think it's responsible to give some downsides.

Just like it's also responsible to tell medigap that their Plan G starts at $118/mo @ 65 and they need to be prepared for it to go up yearly.