DO$ES EVERYONE ACCEPT MEDICARE ADVANTAGE?

The answer may surprise you. Read on . . .

 

 

You may never need, or want, the best care available from any of the top specialty care hospitals and clinics . . . and I hope you don’t. But don’t fool yourself into believing you are better off with something other than original Medicare.

 

There really are places where Medicare PPO plans are not welcome . . .

https://www.beckershospitalreview.com/oncology/us-news-10-top-hospitals-for-cancer-care.html

 

Your benefit coverage for care provided by Mayo Clinic is determined solely by your insurance company and is based on the provisions of your specific medical benefit plan.

 

Mayo Clinic may not be at the highest benefit level or participate in every product offering from the health plans listed below. Please contact the customer service department on the back of your member identification card to confirm that you have in-network access to Mayo Clinic.

https://www.mayoclinic.org/patient-visitor-guide/billing-insurance/insurance/accepted-insurance/contracted-health-plans

 

Mayo Clinic does not participate with all health maintenance organizations (HMOs). In addition, an HMO will not typically pay for Mayo Clinic services without prior authorization from your insurance company. Your physician's referral alone does not necessarily constitute an authorization from your HMO.

https://www.mayoclinic.org/patient-visitor-guide/billing-insurance/insurance/accepted-insurance/hmo

 

For example, services that may require pre-certification include outpatient and inpatient hospital services, observation services, invasive procedures, CT, MRI and PET scans, and colonoscopies.

 

Patients are responsible for knowing the pre-certification requirements of their health plans. 

 

Managed care plans such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs) may deny or reduce benefits if care is obtained outside of the established network or authorization of the plan.

 

Patients' plans that require prior authorization or pre-certification may provide only a reduced insurance payment if not previously authorized. In such cases, the patient will be financially responsible for more — possibly all — of the provided services.

 

A pre-service deposit may be required for nonauthorized visits.

To avoid paying a pre-service deposit or experiencing either denial of payment or a reduction of benefits, Mayo Clinic highly recommends you contact your insurance carrier prior to services to determine plan requirements or limitations to receiving care at the Mayo Clinic site at which you will receive services.

https://www.mayoclinic.org/patient-visitor-guide/billing-insurance/insurance/insurance-approvals

 

I have south Georgia clients who never have a problem being accepted by Mayo . . . everyone has original Medicare and a Medigap plan. Treatment is never a problem for them.

Medicare Parts A and B  are both accepted at MD Anderson.  

 

Medicare Part C, also known as the Medicare Advantage Plan, replaces traditional Medicare. Kelsey-Care Medicare Advantage is the only Medicare Advantage plan with which MD Anderson is contracted

https://www.mdanderson.org/patients-family/becoming-our-patient/planning-for-care/insurance-billing-financial-support/medicare-medicaid.html

 

Some places, such as MD Anderson, only participate in a SINGLE Advantage plan.

 

Others seeking care may be out of luck.

Medicare Advantage (Part C)

Memorial Sloan Kettering is in network with:

 

Most Emblem Medicare Advantage Plans, including the below:

Medicare Choice PPO Network

VIP Prime Network

VIP Premier (HMO) Group

VIP Rx Carve-out (HMO) Group

Memorial Sloan Kettering is not an in-network provider with all other Emblem Medicare Advantage networks.

Empire BCBS Medicare Advantage plans except Empire MediBlue HealthPlus Select (HMO) product

At Ralph Lauren Center for Cancer Care and Prevention ONLY:

HealthFirst Medicare Advantage and Medicare Advantage Plus

Fidelis Medicare Advantage

Horizon Medicare Advantage Plan is in-network for Memorial Sloan also in-network in New York.

 

If you are enrolled in any other Medicare Advantage plan, please contact your insurance carrier to determine your benefits and coverage at Memorial Sloan Kettering since your access may be limited.

https://www.mskcc.org/insurance-assistance/insurance-information/medicare-medicaid

 

Most, if not all of the Advantage plans listed above are regional plans, not available in other parts of the country.

Johns Hopkins Community Physicians is participating with Medicare A and B, but has limited participation with Medicare Advantage plans. 

 

Currently, we are participating only with the following Medicare Advantage plans: Johns Hopkins Advantage MD HMO, Johns Hopkins Advantage MD PPO (also includes Plus and Group), Geisinger Gold Medicare Advantage, and Kaiser Medicare Advantage HMO (Specialty care with referral only). (Note:  selected Johns Hopkins Community Physicians cardiologists have limited participation in Aetna Medicare Advantage plans). If you participate with another Medicare Advantage PPO plan that has out of network benefits, you may be seen at Johns Hopkins but may incur higher out-of-pocket costs.

https://www.hopkinsmedicine.org/community_physicians/patient_information/insuranceplans.html

 

Johns Hopkins participates with original Medicare (and supplement plans) but once again we see regional Advantage, not offered outside of the Baltimore area

Dana-Farber and our affiliated physicians are contracted with an extensive list of local and national health plans and participate as in-network of providers. Even if your plan is listed below, it is important to learn how your benefits will apply at Dana-Farber. Many health plans require primary care physician (PCP) referrals and/or health plan authorizations for coverage of health care services. Most health plans require patients to pay for a portion of their health care services.

 

If your health plan requires a PCP referral, we recommend that you reach out to your PCP to initiate the process of obtaining a PCP referral and approval for services at Dana-Farber.

 

Accepted Insurance Plans

Dana-Farber may not be in-network for all products offered by these health plans. This list is not specific to individual product offerings and is subject to change.

 

Medicare A&B, Managed Medicare or Medicaid***

 

*These payers have products such as HPHC Elevate and Tufts Direct that limit access to in-network hospitals, and Dana-Farber is not in-network. Please check with your health plan to verify that Dana-Farber is in-network for your specific health plan product and if referrals are required from your PCP.

 

**Dana-Farber is in-network with the following MassHealth plans. Most plans require a PCP referral to come to Dana-Farber. If you have questions about your MassHealth plan, including if you are interested in changing your health plan product, you can refer to their website, masshealth.ehs.state.ma.us/StateForms/, or call 800-841-2900.

 

Allways Health Partners My Care Family First ACO

Boston Medical Center HealthNet Plan MCO

Boston Medical Center HealthNet Plan Community Alliance ACO

Boston Medical Center HealthNet Plan Mercy Alliance ACO

Boston Medical Center HealthNet Plan Signature Alliance ACO

Boston Medical Center HealthNet Plan Southcoast Alliance ACO

Tufts Health Public Plan MCO

Tufts Health Public Plan Atrius ACO

Tufts Health Public Plan BIDCO ACO

Tufts Health Public Plan CHA ACO

Tufts Health Public Plan Boston Children's ACO

MassHealth PCC

MassHealth PCC with Comm Care Coop (C3)

MassHealth PCC with Partners ACO

MassHealth PCC with Steward ACO

 

***If you have Medicare Part A only, you will need to enroll in Medicare Part B to be covered for outpatient services at Dana-Farber. If your health plan is a Managed Medicare or Medicaid product, please check with your health plan to confirm that Dana-Farber is in-network.

 

If your product is not listed or if you are unsure whether your health plan will cover services at Dana-Farber, please contact your health plan using the number located on the back of your health plan insurance card.

 

https://www.dana-farber.org/for-patients-and-families/becoming-a-patient/insurance-and-financial-information/

 

Original Medicare and Medigap? No problem. Advantage plan? Could be an issue.

If your insurance company is not accepted by Cleveland Clinic: This means your insurance plan is considered out-of-network which can lead to greater out-of-pocket expenses for your care. Please contact your insurance company for more information about what your financial responsibility may be if you choose to receive care at Cleveland Clinic. Find more information about Cleveland Clinic’s out-of-network insurance process.

 

Medicare Advantage Plans

The federal government’s health insurance program for people ages 65 and older, and certain younger people with disabilities or kidney failure.

 

(Plans below include a link to the carrier so YOU can determine coverage)

Aetna Medicare Plan (Golden Choice)

Aetna Medicare Plan (Golden Medicare Plan)

Anthem BCBS Medicare Preferred

Anthem BCBS Medicare Select

Anthem BCBS Senior Advantage

AARP Medicare Advantage (Through UnitedHealthcare)

AARP Medicare Advantage Choice (Through UnitedHealthcare)

AARP Medicare Advantage Walgreens (Through UnitedHealthcare)

CareSource Medicare Advantage

Cigna Preferred Medicare (HMO)

Cigna True Choice Medicare (PPO)

CommuniCare Advantage I-SNP/C-SNP

Devoted Health

Fida North Shore-LIJ Medicare – Cleveland Clinic main campus only

Humana Choice Medicare Advantage

Humana Cleveland Clinic Preferred

Humana Gold Choice

Humana Gold Plus

Medical Mutual of Ohio Medicare Advantage

Medicare A, B, C, and D

Medigold – Union Hospital Only

Molina Healthcare Medicare Advantage – Mercy Hospital Only

Paramount Elite

Perennial Advantage I-SNP/C-SNP

PrimeTime Health Plan

Provider Partners Health Plan (PPHP) I-SNP

SummaCare Medicare

The Health Plan SecureCare MDCR HMO

The Health Plan Secure Choice

United Healthcare Dual Complete SNP

United Healthcare Medicare Advantage

United Healthcare Medicare Complete

United Healthcare Medicare Complete Essential

United Healthcare Medicare Complete Choice

UPMC for Life

Valor Health Plan I-SNP

https://my.clevelandclinic.org/patients/accepted-insurance

 

Cleveland Clinic participation in Medicare Advantage plans is quite extensive but not all inclusive. Original Medicare and a supplement plan is not a problem.

Cedars-Sinai participates in the following Medicare Advantage plans:

 

Alignment Health Plan

AVA (PPO) 007

Anthem Blue Cross of California

Anthem MediBlue Connect Plus (HMO)

Anthem MediBlue Diabetes Care (HMO C-SNP)

Anthem MediBlue ESRD Care (HMO C-SNP)

Anthem MediBlue Heart Care (HMO C-SNP)

Anthem MediBlue Lung Care (HMO C-SNP)

Anthem MediBlue StartSmart Plus (HMO)

Blue Shield of California (HMO)

Blue Shield 65 Plus (HMO)

Blue Shield 65 Plus Plan 2 (HMO)

Blue Shield AdvantageOptimum Plan (HMO)

Blue Shield Balance Plan (HMO)

Blue Shield Coordinated Choice Plan (HMO)

Blue Shield Inspire (HMO)

Blue Shield TotalDual Plan (HMO-DSNP)

Blue Shield Vital (HMO)

UnitedHealthcare

AARP Medicare Advantage Patriot (HMO)

AARP Medicare Advantage SecureHorizons Assure (HMO)

AARP Medicare Advantage SecureHorizons Focus (HMO)

AARP Medicare Advantage SecureHorizons Plan 1 (HMO)

AARP Medicare Advantage SecureHorizons Premier (HMO)

If you enroll in an HMO plan, you must choose a primary care doctor in either the Cedars-Sinai Medical Group or Cedars-Sinai Health Associates HMO provider networks and be referred to specialists within these groups.

 

https://www.cedars-sinai.org/billing-insurance/insurance/medicare.html

 

Cedars-Sinai has an unusual approach to accepting Medicare Advantage plans. You must have an HMO plan (in most cases) and your PCP must be part of the Cedars-Sinai medical group of doctors.

There is nothing humorous about denial of access to health care. I know some agents who either never bring the subject up, minimize the issue or simply say “There has never been a problem with any of my clients”.

 

I have always cared about the welfare of my clients, and never want to hear they have been denied service due to having a plan that is not accepted by a provider.

 

Reminder . . . when you see or hear news stories about a provider (usually a hospital) that is “out of network” with a particular insurance carrier, understand they are ALWAYS talking about Advantage plans.

 

If you ever have any questions about your coverage, please call or email.

 

If you want to enroll in a Medicare Advantage plan, I will not try to talk you out of it. My approach, as always, is this is YOUR plan and YOUR money. Choose the plan you believe is right for you, now and in the future.

 

Take care,

Bob