Most of us have been covered by managed care plans since the 1980’s. These plans differ from original Medicare in several ways.

 

• Provider networks, mostly PPO or HMO
• Pre-authorization is often required
• Penalties for out of network charges
• Balance billing from non-par providers
• Health care decisions made by bean counters

 

Here’s a big one that most folks don’t know about . . . and it comes direct from Medicare.

 

Providers can join or leave a plan’s provider network anytime during the year. Your plan can also change the providers in the network anytime during the year. If this happens, you may need to choose a new provider.

https://www.medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/things-to-know-about-medicare-advantage-plans

 

Original Medicare does not have networks. Neither the government nor insurance carriers come between you and your doctor.

This dispute also involves employer group health insurance plans and individual ACA (Obamacare) plans  . . .  but NOT Medigap insurance.

 

So, at least for the moment, hundreds of thousands of Georgia patients with Anthem insurance will remain in network if they go to Northside providers

 

https://www.georgiahealthnews.com/2022/01/covid-hospitalizations-soar-atlanta-northside-wins-court-victory-anthem

 

Doctors said she had a case of appendicitis. But she also tested positive at the hospital in Marietta, Georgia, for Covid-19. Physicians decided not to do surgery and treated her with antibiotics and painkillers. Azzopardi, 47, went home after a couple of days in the hospital, feeling better.

 

But in October, the appendix pain again flared. Her husband took her to the same hospital, where surgery was performed successfully. This time, though, she ran into a snag with her insurance.

 

Azzopardi has UnitedHealthcare coverage, and as of Oct. 3, Wellstar Health System was no longer in the giant insurer’s network, after the two sides did not agree on a new contract.

https://www.georgiahealthnews.com/2021/11/patients-stranded-network-contract-talks-collapse/

 

https://www.medicare.gov/care-compare/

 

Search by location, type of provider or by keyword. Discover which are accepting new patients. Search by gender, which are board certified, which providers only bill the Medicare approved amount. Look for providers by hospital affiliation.

 

Illness or injury doesn’t just affect the person with the health issue, it also impacts the spouse. Sometimes the spouse must assume the role of caregiver. This impacts the dynamics of the relationship.

 

This shared responsibility for care can create a wedge, or strengthen the bonds of the relationship. During these difficult times, relationships are tested. The role of a caregiver is enough to challenge any relationship.

 

For more information and resources, follow this link to Next Avenue.

https://www.nextavenue.org/how-a-spouses-disability-impacts-a-relationship

 

I have been involved in the health insurance and health care arena since 1975 and during that time I saw how healthcare changed . . . but not always for the good. Recently, an agent I know pointed me to a movie about a real life incident where an insurance carrier denied access to care, resulting in the death of the policyholder.

 

"As a physician working for Humana, I denied a young man a heart transplant that would have saved his life, and thus caused his death," testified Dr. Peeno. "No person or group has held me accountable for this, because, in fact, what I did was I saved a company a half a million dollars."

 

"Humana's only concern was costs," says Dr. Peeno. "The young man fit all the criteria, a donor had been found, his doctor was ready to do the operation. Meanwhile, behind the scenes Humana employees scrambled to find a loophole in the patient's contract. When they did, I was the one who had to tell the surgeon that the operation would not be covered."

http://www.pnhp.org/news/2002/may/damaged_care_premi.php

 

Many of us have enjoyed relatively good health throughout our life. If you had an HMO or PPO there were provider restrictions but, if you didn’t know anything different, you just assumed that was the way it always was and always would be.

 

When the HMO and PPO concept was introduced we were also introduced to another 3 letter entity . . . the PCP. With the advent of managed care your PCP, in conjunction with your insurance carrier, assumed a gatekeeper role.

 

The gatekeeper may, at their discretion, allow you to have a higher level of care or not. If you were denied services you have the right to appeal. The question is, how many appeals will you have to file before you are allowed to advance to the next level?

 

Original Medicare does not have networks or gatekeepers. Your level of care is between you and your doctor. No one, including Medicare, will intervene and deny your care.

 

Some of you will recognize these names . . .

 

MD Anderson

Sloan Kettering

Mayo

Cleveland Clinic

Johns Hopkins

 

Each one listed has something in common.

 

First and foremost, they are considered the best in the country when you need cancer care.

 

Second, every one of them accepts original Medicare . . . they may or may not participate in your particular Advantage plan. Each hospital has similar wording on their website . . .

 

If you are enrolled in a managed care plan (HMO, PPO or POS), your treatment at (this hospital) may or may not be covered by your insurance. Before scheduling an initial appointment, please call your health plan/insurance company and ask if you have access to health care services at (this hospital).

 

I have clients that have been treated at the listed hospitals. Some have incurred bills in excess of $100,000 yet their out of pocket costs were less than $300.

 

This article can be used as a resource to top hospitals in the US, segregated by specialty.

https://health.usnews.com/best-hospitals/rankings/cancer

You may never need a high level of care for cancer, cardio-pulmonary conditions, neurology, diabetes or other medical conditions. But isn’t it nice to know you have access to care and don’t have to question if your treatment is a covered expense?

This is another long newsletter but hopefully you have found it to be informative.

 

Never take your health, or your access to healthcare, for granted.

 

Please pass this along to your friends.

 

Call or email if you have questions.

 

Bob