Urgent help! MA plan member has no OON coverage

[EliseoRNCCM]

[EXTERNAL LINK] - Determinations, Grievances, and Appeals - Your South Florida Medicare Provider - HealthSun Health Plans

Next time you call Health Sun, have him on the phone with you so he can tell them it's ok to speak with you.

Your cousin has to tell the case manager that he would like to appeal the discharge.
The case manager will let their Utilization case manager know. UM RN will start the process and will speak with your cousin.
Your cousin can also call the Medicare 800 number to file. Medicare will call the MA and the UM. All together they will notify your cousin if the extended hospital stay will be covered or not. If denied, then your cousin has 24 hours before he is charged the HOSPITAL daily rate which can be $4500+ per day.
If you're going to be by your cousin's side, ask the case manager for an advance directive form to fill out so that you can be the designated POA if and when he is not able to speak. Do that now for future issues so that you, your cousin and the hospital staff won't have to guess what your cousin's wishes are.
I know you're scared of all the "what ifs" but if he can safely go to your house and create a plan then that would be a safer route than a rehab. Have the home care services go to your house if it is covered. If not covered, RN PT OT visits are about $300/ visit.

 

[myinsurebiz]

Sounds like he needs to move in with you and enroll in a local MAPD plan in your County.

 

[NolaChic]

He would be willing to do that however from what someone posted on this thread, looks like he would have to wait till April 1st to change that date which would put him at 3+ weeks with no services until the local MA plan covers.

 

[Chazm]

Whoever sold him that HMO should have stressed that you can’t go out of network if not an emergency.

I’ve explained your cousins exact situation many times when clients ask what happens in an emergency and out of the area if they choose am HMO? You must come home after the hospital if you want care.

 

[MichFlor]

It won't help him for the rest of the month. But, he can also use the Medicare Advantage Open Enrollment Period (OEP) to enroll in a different Florida MAPD PPO plan. It would be effective on 4/1/2024.

 

[somarco]

looks like he would have to wait till April 1st to change that date

Read post #6 again. That is NOT what @sman posted.

 

[goillini52]

You can always appeal and hope to get an exception. One alternative would be to put in a change of address and change him to a plan available in New Orleans. Or, just go straight Medicare and he'd pay 20% after the Part B deductible is met. Of course, the earliest either could go into effect would be April 1st so that leaves him with nearly 4 weeks of either no treatment or paying out of pocket.

He could also change during MA OEP.

 

[EliseoRNCCM]

He would be willing to do that however from what someone posted on this thread, looks like he would have to wait till April 1st to change that date which would put him at 3+ weeks with no services until the local MA

 

[EliseoRNCCM]

In reviewing what has been discussed regarding your cousin's options, we have to discuss what your cousin is willing to do about his situation.
How is he going to pay for his own care? I know we want to squeeze insurance as much as we can but we have to eventually take accountability and responsibility for our care.
Does he have emergency money stashed under his mattress? Does he have a military service that he can get additional resources? Does he have a home equity line of credit? Reverse Mortgage? Can he borrow money? Is he motivated to rehab quickly? If he were to go home, does he have 5 layers of friends or neighbors to check in on him? If he is taught exercises on how to get up and go, is he motivated to follow those daily exercises? There are physical therapy videos on YouTube that are free to rehab hips.

 

[Cenla Agent]

Whoever sold him that HMO should have stressed that you can’t go out of network if not an emergency.

I’ve explained your cousins exact situation many times when clients ask what happens in an emergency and out of the area if they choose am HMO? You must come home after the hospital if you want care.

Of course, most of us think that situation wont happen to us.