I just received a notice that my local hospital will no longer be in my Humana Medicare plan network.

I live in a small rural community, 8500+/- when the college is in session, and we just finished building a brand new hospital a few years ago. This is the only healthcare facility within a 50 mile radius. Kicking Humana and several other providers out of the hospitals network is going to force some of us to find a new network insurance provider or travel longer distances to an in-network facility or pay the higher out of network fees.

What a crock!

Consider contacting Humana and requesting your typical provider... perhaps they are still in negotiations with the hospital and are unwilling to raise their fee schedule to meet the provider minimum.

I don’t believe any provider just casually drops in insurance company. It’s done with serious thought, because you are potentially giving up many patients, and in some cases, people you care about dearly. The hospital possibly had to look at the bottom line, and if they are the only hospital in 50 miles the insurance company should consider that (or take it into consideration) when they drop their new fee schedule.
Many providers are being “herded” into accepting plans that simply do not pay their expenses.

I’m not saying hospitals aren’t money makers. I am saying (from the other side of the coin) that some insurance companies are really stiffing private practice providers and forcing them to be the middleman between the patient and the insurance company. Often, the patient ends up angry with the provider, instead of the insurance company that underpaid for a service and either adjusted or shifted the rest of the responsibility back to the patient, who naturally feels they don’t have to pay because they paid their monthly premium and never read the fine print. Expecting someone else to do it for them and explain it to them (ie your provider/billing department) usually ends up in an unpleasant surprise.
Some providers are tired of it and just declining to mess with it anymore.

quote:

Originally posted by ggile:

I just received a notice that my local hospital will no longer be in my Humana Medicare plan network.

Is your Medicare plan the traditional Medicare Supplement? Or is it Medicare Advantage? If it is the Advantage type, you might want to look at switching to a traditional plan. The annual open enrollment period starts tomorrow.

We went through this as UHC and ORH went through price negotiations, went right up to the last minute and they of course came to an agreement.

UHC is one of the largest insurers, ORH one of the largest providers. During that I made appointments with a new provider at the other larger HC group in the area, so at least I have contact with a new doctor.

That is why I caution people about Advantage networks. I do not blame the hospital for going out of network. They are protecting their bottom line. The same happened here with Blue Cross and also the advantage plans. They finally came to terms. If you switch to traditional Medicare you will be subject to underwriting. In other words the supplemental Medicare plan can turn you down due to health reasons.

quote:

Consider contacting Humana and requesting your typical provider... perhaps they are still in negotiations with the hospital and are unwilling to raise their fee schedule to meet the provider minimum.

^^^^^^^^^^^^^^
Good luck. Doctors drop insurance plans for MANY reasons besides fees. Preauth requirements, slow payment,lack of cooperation from the insurer and in general failure to honor the contract. All of that bureaucracy increases overhead and causes headaches.
I see you live in South Dakota. Contact Gov. Noem.

quote:

Originally posted by V-Tail:

Is your Medicare plan the traditional Medicare Supplement? Or is it Medicare Advantage? If it is the Advantage type, you might want to look at switching to a traditional plan. The annual open enrollment period starts tomorrow.[/QUOTE]

Ya, I have a PPO Advantage plan. Looks like I am going to have to get busy and start checking out alternative plans.

It could be, Humana asked to reduce payments for services, and perhaps there were not enough people having that plan to offset the differences. Our area is in negotiations with anthem now. I’m sure they will be trying to keep anthem on, as that is a huge part of coverage here. Just depends on what the providers can afford and still keep on providing services. And prices will prob go up unfortunately.

quote:

Originally posted by ggile:

quote:

Originally posted by V-Tail:

Is your Medicare plan the traditional Medicare Supplement? Or is it Medicare Advantage? If it is the Advantage type, you might want to look at switching to a traditional plan. The annual open enrollment period starts tomorrow.

Ya, I have a PPO Advantage plan. Looks like I am going to have to get busy and start checking out alternative plans.

Medicare Advantage plans look like they're going to save you some money, but they are really DIS-Advantage plans. There are so many "gotcha's" in these plans.

We looked at them, I thought that I saw a bunch of loop-holes, I checked with my wife who is a (retired) Health Care Provider. She said that many of her patients were royally fucked by the Advantage type plans; we went with a standard, traditional, MediCare supplement plan. Much better. No worries about in-network, out-of-network, in state, traveling out of state, no need for referral, if I need a specialist I can just pick any one that takes medicare and make an appointment directly.

One of the guys who worked for me asked me what type plan to get, I advised him to stay away from Advantage plans. His wife decided that she was wiser, picked an Advantage plan strictly based on price, he has had nothing but grief, trying to get appointments with providers who take that plan.

With a traditional Medicare Supplement plan, you can go to any provider who takes Medicare -- most do -- no matter what company you buy the plan from, whether it's United, Blue Cross, etc. All offer identical coverage, prices may vary, with this type insurance (traditional Medicare Supplement) it's safe to shop by price. Just pick the coverage that you want. We went with Plan J, it was the most comprehensive. No longer being offered, but we are grandfathered in, and can keep it forever,

^^^^^^^^^^^^^^^^^
Exactly. Plus these advantage plans have to pay their shills for their annoying commericials that dominate the networks.

I just signed up with an Advantage plan (Brand New Day) because my existing doctors are in their network. So far, it's been great. Zero premium, little or no copays, lots of little perks. Just got my first shipment of pre-cooked frozen meals.

Only issue is getting my eczema shots covered, as I can't afford $3000 a month. But I think I can get it covered one way or another, maybe through Medi-cal.

Thanks V-Tail! I'll keep that in mind as I look for a new health care provider.

quote:

Originally posted by ggile:

Thanks V-Tail! I'll keep that in mind as I look for a new health care provider.

Just giving you a little more information:

2010: big bleeding (rectal). Went to ER, admitted, week in hospital trying to identify source of bleeding, finally found diagnosed and corrected.

2010: Prostate cancer. Eight weeks of daily radiation, along with all the associated tests and exams.

2013: Missed a step getting out of cargo area of my delivery truck. Ambulance to ER, surgery to implant metal support rods for hip / femur fracture, week in hospital, month and a half in live-in rehab center, many months of physical therapy, got a walker, shower chair, toilet chair.

2016: Guillain Barré. Week in hospital, spinal taps, IV steroids, IVIG transfusions.

2017: Cataract removal and IOL insertion, both eyes.

For all of the above, I had total freedom to choose the Health Care Providers that I wanted. No referrals required, just pick any specialist who accepts Medicare. Did not matter one iota whether the provider was in state or in another state.

My TOTAL out-of-pocket cost, for ALL of the above: $45.00. Yup, forty-five bucks. That was for post-surgery eye drops for the cataracts, and that was my choice -- pharmacy would have been covered by Medicare Part D Rx insurance, but that would have been three separate drops to track for two weeks after each eye; the eye clinic gave me the option of using their drops, which were all-in-one, but they did not take Medicare for Rx drugs; I opted to pay the $45 just for the convenience.

Medicare DIS-Advantage plans sound like a good deal, but they have many restrictions and can be VERY limiting in choice of providers, will assign providers with no choice given to you, will limit coverage when traveling out of state, the list of restrictions and loopholes just goes on and on, whereas traditional Medicare Supplement plans are straightforward and give the patient much more flexibility, more choice, fewer hassles. It is well worth paying the premiums unless you can absolutely not afford it. We (wife and I) chose the most comprehensive option for our Medicare Supplement, premiums are a bit less than $250 / month for each of us, $495 total. Neither of us has had to pay even one penny out of pocket for doctor visits (our choice of doctors), lab work, medical procedures, you name it. Our total cost for all of the above has been the monthly premium.

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הרחפת שלי מלאה בצלופחים

The Big Mistakes People Make in Medicare—And How to Avoid Them
Seniors choosing Medicare coverage often fall into hidden, costly traps that can leave them stranded—and unable to get the healthcare they want. But there are ways to avoid the pitfalls, if you know how.

Lothaire Bluteau, 66 years old, an actor who lives in West Hollywood, Calif., last year enrolled in one of the private plans known as Medicare Advantage. After he was diagnosed with prostate cancer last May, he discovered the specialists he wanted to see weren’t in his UnitedHealthcare HMO’s limited network. He faced delays getting tests and treatment.

He got a bigger shock when he tried to get access to more doctors by switching to traditional Medicare, run by the federal government. Bluteau worried about the steep out-of-pocket costs, so he tried to get a fill-in policy known as a Medigap plan that would cover many of those expenses. Yet health insurers said no because of his cancer diagnosis.

He didn’t realize he could be rejected. “I didn’t inform myself enough,” Bluteau said. “I was so stupid.”

Bluteau’s struggle to get a Medigap plan shows one of the risks seniors may miss when they are selecting coverage. Medicare beneficiaries generally don’t know that they have a right to get Medigap policies only at certain times, and if they don’t jump then, they might not be able to purchase them later.

Medicare’s open-enrollment period kicks off Sunday and goes until Dec. 7. During that time, beneficiaries can pick new plans for next year. The options include traditional Medicare from the government, or the wide array of Medicare Advantage plans, which are private-insurance products that wrap in the same benefits.

Advertisements for Medicare Advantage plans especially may promise rich bonus benefits such as dental and vision coverage, or even help paying for food, as well as generous financial terms. But consumer advocates said seniors should be mindful of the downsides. For those going through Medicare open enrollment this fall, here are five of the biggest pitfalls—and how to avoid them.


Bluteau, 66, discovered the specialists he wanted to see weren’t in his UnitedHealthcare HMO’s limited network.
Medigap Trap
One of the biggest traps is the one that claimed Bluteau. Patients with health issues may want to move to original Medicare, but they can’t buy Medigap policies. “This is where people get stuck,” said Kata Kertesz, a senior policy attorney at the Center for Medicare Advocacy. “They get really sick, and they can’t switch.”

Medigap, or Medicare supplement insurance, doesn’t have the same rules as most health insurance. For other types of coverage, insurers can’t reject you or charge you more based on your medical conditions. With Medigap, such guarantees are available only at certain times.

Medigap is vital for many people who enroll in traditional Medicare. The original government program can leave beneficiaries with big out-of-pocket bills for their care, and there is no cap on how high that tab can go. Medigap policies help cover those costs. They have standardized designs, listed here.

Your best chance to get Medigap is when you first join Medicare as a senior, after you turn 65. Then you have a six-month window when you can buy a Medigap policy, and insurers can’t turn you down or charge you more because of your health conditions.

There are a few other times when you have that federal “guaranteed issue” right, including if you opt out of Medicare Advantage during a limited initial “trial period.” You can find them here. When you aren’t in a protected window, however, you might not be able to get a Medigap plan.

States also have Medigap protections, and a few actually require the plans to always be available through “guaranteed issue.” You can check on your state’s rules here, but it is best to call your state department of insurance. Find the state insurance department information here.


After Bluteau was diagnosed with prostate cancer, he encountered delays getting tests and treatment.
Wrong Doctors
Another common trap that can ensnare people who sign up for Medicare Advantage plans: a lean menu of doctors and hospitals. The plans—particularly health maintenance organizations, or HMOs—can have limited networks that sometimes mean beneficiaries can’t go to the doctors or hospitals they want.

They may also have a hard time getting care if traveling outside their home region.

When Bluteau chose his HMO plan on the advice of an insurance agent, he said, he didn’t realize it lacked doctors he would want to see. He was ultimately able to switch to a different UnitedHealthcare Medicare Advantage plan, a preferred provider organization or PPO, that included them.

SHARE YOUR THOUGHTS
What questions or advice do you have about Medicare Advantage plans? Join the conversation below.

UnitedHealthcare said it has the largest national network and a range of plans and “supporting Medicare consumers in finding the right plan is a top priority for us.”

You can find directories of in-network doctors on the insurers’ websites, but be careful. “They can be wildly inaccurate,” said Julie Carter, senior federal policy associate at the Medicare Rights Center, a nonprofit. “It’s a mess, and we don’t really have a great solution other than doing a lot of legwork.”

Don’t just trust—be sure to verify. You should call the doctor offices and hospitals that matter to you, and consider looking up other providers you might need unexpectedly, such as nursing homes. You should call the insurer, and be specific about what plan you are researching and which doctors and hospitals you want.

And if you choose a limited network, know that your favored doctors can always leave it. Around the country, some hospital systems are abandoning Medicare Advantage plans.


Bluteau with a neighbor. He didn’t realize he could be rejected when seeking a Medigap policy.
Paperwork Problems
Medicare Advantage plans can sometimes delay or block access to care. A recent government investigation found some beneficiaries were denied services that should have been covered. You might need to get approval from the insurer before you get a surgery, or a referral from your primary-care doctor to see a specialist. You may also find that those nifty extra benefits touted in ads are extremely limited.

Seniors often don’t focus on these issues, particularly when they are healthy, said Tatiana Fassieux, education and training specialist for the nonprofit California Health Advocates. “Tomorrow you may end up having a stroke,” she said. “Once you start using the more costly care, that’s when the brakes come in.”

To understand the hurdles, you should look at plans in the Medicare.gov tool. As you scroll down each table, you will see small “limits apply” notices next to specific types of care, such as inpatient hospital use or radiology scans. Click on them, and you will find more details about what requirements you might face to get that kind of service, such as prior approval from the insurer.

For a more in-depth explanation, you should go to the insurer’s website and look at key documents, such as the summary of benefits and the full “evidence of coverage.” Here is an example, and here is another. They are difficult and complicated, but they include pretty much everything there is to know about the plan.

Drug Deficits
Your drug coverage can come through a stand-alone Part D plan—needed if you are in traditional Medicare—or wrapped into your Medicare Advantage. Either way, you can use Medicare.gov to see if your prescriptions are included. This is worth doing every year. You may also want to go to the insurer’s own website and look for restrictions on access as well as the “comprehensive formulary” document that lists all covered drugs. Here is an example, and here is another.


Bluteau says that when he chose his HMO plan, he didn’t realize it lacked doctors he would want to see.
Biased Advice
Be careful where you turn for advice. Ads peddling Medicare Advantage plans may flash pictures of government Medicare cards and include a toll-free hotline that looks official but isn’t the real federal number. Watch out for websites tied to particular insurers or online agencies that may have strong incentives to push certain plans.

A good bet is to favor sites ending in .gov or .org. To find real, impartial information, it is best to start with Medicare’s own website. The State Health Insurance Assistance Program has counselors in every state, and you can find them here—they are typically very knowledgeable. The Medicare Rights Center maintains a national helpline. KFF, a health research nonprofit, has helpful background, as does the Center for Medicare Advocacy. Local agents or consumer advocates with whom you have a relationship can also be helpful.


LINK; https://www.wsj.com/health/hea...3e7952?mod=wknd_pos1

As a now 70 year old, you couldn’t give me an Advantage plan.
Once you’re at Medicare age, it’s just a matter of time before you’ll be needing some sort of expensive medical treatment or at least testing.
Don’t think you can beat the system, get a real traditional Medicare plan and supplement and you can stop worrying, at least about the financial aspect of getting to be a geezer.

Open Enrollment Time. She’s BAAAAAACK!!!!!

quote:

Originally posted by ggile:
Thanks V-Tail! I'll keep that in mind as I look for a new health care provider.

Do it soon. If you’re still in your first year of Medicare, you can switch with relative ease. If it’s been a year, you have to go through underwriting that requires you to be approved by the plan and/or be subjected to higher premiums.

My local hospital stopped taking Humana PPO as part of negotiations. The hospital wants higher payments.

quote:

Originally posted by V-Tail:

quote:

Originally posted by ggile:

I just received a notice that my local hospital will no longer be in my Humana Medicare plan network.

Is your Medicare plan the traditional Medicare Supplement? Or is it Medicare Advantage? If it is the Advantage type, you might want to look at switching to a traditional plan. The annual open enrollment period starts tomorrow.

I will second what Mr. V-Tail says here. Mother was on a Medicare “Advantage” Plan and believe me…there was NOTHING advantageous about it. If you have ANYTHING that requires extended rehab and/or extended care, you’re gonna have to fight tooth and nail for EVERYTHING.

In our case, FORTUNATELY the doctors advocated on mother’s behalf long enough to give us time to shit-can that “Advantage” plan and get mother enrolled back to traditional Medicare/Medicaid with a Part D plan where she has been receiving EXCELLENT service and care. It’s been NOTHING but smoooooth sailing since.

** I have to give credit to the WONDERFUL young lady in admissions at the facility where mother now resides. She is the one that HIGHLY recommended we get mother off the DIS-Advantage plan ASAP with supporting and compelling reasons why. She received the biggest gift basket I could find at Harry & David…

quote:

Originally posted by Rey HRH:

My local hospital stopped taking Humana PPO

Humana PPO is a Medicare Advantage plan. ¡No bueno!

The vast majority of the members here are really against government intervention. I think that an exception could be made in this case. These Medicare DIS-Advantage plans prey on the elderly, with a lot of advertising that emphasizes low (or zero) cost, free this, free that, etc.

I would be highly in favor of a government mandate requiring all of these ads to state, in detail, all of the restrictions, and to require that the restrictions are given just as much emphasis in the ads, as the so-called positive points. I think we call that "Truth In Advertising."