UnitedHealth pushed employes to follow algorithm to cut off Medicare patients' rehab care; STAT News Nov. 14, 2023

[Mary]

Another reason to avoid Medicare "advantage" plans if possible!

https://www.statnews.com/2023/11/14/unitedhealth-algorithm-medicare-advantage-investigation/

Unfortunately, you can't read the entire article without a subscription but this is the gist of it.

Medicare Advantage plans are HMOs which give control of your Medicare benefits to insurance companies, which will do whatever they can to maximize profits. Their concern is not your health. I've had straight Medicare for many years and have never had treatment or benefits denied. No insurance company is involved with straight Medicare.

 

[Mary]

@Rufous McKinney - I couldn't help but think of you when I saw the above . . .

 

[Cipher]

Unfortunately, you can't read the entire article without a subscription but this is the gist of it.

You can read the whole article here.

 

[Rufous McKinney]

wonder if anybody is going to Sue them over this.

I was informed my husband would receive 14 days of rehab: two days into the process.

It concludes, before its undertaken.


BTW: I ended up not changing plans, @Mary Because I get my plans through my employer. (I can change annually)

They were going to charge my employer EVEN MORE money per month: 100s more. I just cannot bring myself to transfer MORE funds to an insurance company who provides me with so much grief.

Two Medicare Supplements were offered. Both are run by insurance companies. When I looked at what they would cover since I am now "traveling" (ie. hiding out I'm a foreign place)....they had a more complicated process for reimbursing a travel emergency.

United HC: actually has approved $1400 of the $1800 emergency we already had. I was surprised we got that to happen.

Also, they cover UrgentCare and the Medicare Supplement, didn't not. Of course, what do they mean by Urgent Care.

______

Anyway, these algorithms were used to limit my husbands coverage and its shocking, because how can you know before you get rehab, how much rehab you will need.

 

[Rufous McKinney]

There is a class action lawsuit in prep. I am going to contact the law firm, and see if we can join in.

 

[Rufous McKinney]

I wasn't able to search for this thread because I typed United Health Care and its not written that way in the title.

Maybe if I typed Medicare I might have found it? I tried several versions of spelling UHC.

 

[Rufous McKinney]

You can read the whole article here.

I strongly suspect most of these insurers are using algorithms (ie, just ask a computer) (using our assumptions)...and certainly aren't allowing Employee Judgement or any other forms of flexibility.

Everybody should be warned.

 

[Mary]

Two Medicare Supplements were offered. Both are run by insurance companies.

I think you are trying to compare Medicare Advantage plans with Medicare Supplement plans, and they can't be compared. They're entirely different animals.

Also, they cover UrgentCare and the Medicare Supplement, didn't not.

Medicare supplement plans basically only pay the 20% copay owed if you have straight Medicare. Yes, the supplement plans are run by insurance companies but they don't have any discretion - they can't refuse to pay the 20% or require pre-authorization etc. The only thing the supplement plans do is pay that 20%.

You can only purchase a supplement plan IF you have straight Medicare. So you shouldn't be looking at the supplement plans as though they are comparable to Medicare advantage plans.

If you research straight Medicare, you'll see that it does pay for urgent care visits. And then the supplement plan, if you purchased one, would pick up the 20% copay.

So what you need to compare are straight Medicare vs. Medicare Advantage plans. Straight Medicare does not require all the pre-approvals or deny coverage like the Medicare Advantage plans do. Straight Medicare does have some limits but it's not controlled by insurance companies and I don't believe it uses algorithms to deny coverage.

I really think you should talk to an independent insurance agent about this so that you know exactly what's what. And I know your employer is involved with your insurance but you can still talk to an insurance agent - someone who can explain all this to you.

 

[Rufous McKinney]

I think you are trying to compare Medicare Advantage plans with Medicare Supplement plans

The plans I access aren;'t available to the public, they are from My Employer. There are pages of comparison charts.

I don't use private insurers, they would not know anything about the plans I have access to.

Straight Medicare does have some limits but it's not controlled by insurance companies and I don't believe it uses algorithms to deny coverage.

I'm convinced they will find a way to limit your access to daily skilled nursing/ the 100 days.

Sure, they will probably pay the copay.

I'm curious Mary: would your plan cover use of a laser for cataract surgery? They refused to cover that, even tho my husband had a stroke, is on many blood thinner, and you will have longer recovery and more bleeding and potential for scar tissue.

so I paid $5000 for that.

 

[Rufous McKinney]

A huge problem with medical services is: residing.

The moment you move to a new zip code: all your medical stuff is changed.

Medicare is run through the COUNTY you live in.

I don't live I a county, any longer.

so you tell people your' traveling. It's not legal to be A Traveler. You must always be Residing.

 

[Mary]

would your plan cover use of a laser for cataract surgery?

I don't know. My plan is straight Medicare. I also have a supplement plan which covers the 20% copay I owe for Medicare services. It also covers a few other things - e.g., I was hospitalized for 2 weeks last spring and would have owed some $1800 for that alone, but my supplemental plan paid for it.

My sister gets regular laser treatments for macular degeneration. She has straight Medicare, and her copay would be quite high for each treatment - I forget how much - but her supplement plan pays for that copay. She does have to pay around $200 a month for the supplement plan. My supplement plan costs $100 a month. It all depends on where you live etc.

Also - who is the "they" who refused to pay for a laser for cataract surgery? I'm assuming it was United Health, a Medicare Advantage plan. What you need to look up is whether STRAIGHT Medicare would have paid for the laser. And you would owe a 20% copay for whatever you have done through straight Medicare (except for lab work which is covered at 100%), unless you have Medicare supplement plan.

I don't know anything about how Medicare would or would not pay for care in Mexico, and again, I'd talk to an independent agent about that. You are able to buy the same Medicare plans as anyone who is eligible for Medicare and an agent could help you understand about that. No, the agent wouldn't have access to all the plans your employer does, but and agent would have access to and are experts in Medicare plans, and that's what you have right now - a Medicare Advantage plan, which is using algorithms and denying coverage etc. And I have a feeling there's no monthly fee for that plan or maybe there is.

 

[Mary]

I just found out my sister would have a roughly $520 copay for each laser treatment, and she gets them four times a year. But her supplement plan pays for this copay. She pays roughly $200 a month for the supplement plan.

 

[Rufous McKinney]

$200 a month for the supplement plan.

over $800 a month to cover myself and my husband (which my employer would pay)....for the supplement offered.

I really wonder how these costs can vary that much. Also, the pool I am in is considered a group of healthier than normal people. Yet we are charged that kinda money.

 

[Mary]

over $800 a month to cover myself and my husband (which my employer would pay)....for the supplement offered.

That's a lot! I'd still urge you to talk an independent agent. They don't work for insurance companies. The prices can vary a lot from company to company and the agent will tell you about all of them. You might not be able to do better than this, but you might. If your employer would pay for it, why not get it? You might get better care - e.g., laser surgery when you or your hustand need it, though this is something you would have to look into.

I'll stop bugging you now!

 

[Rufous McKinney]

I don't know.

Unable to determine this from my Medicare Book for this year.

If I query online, it says neither medicare nor private commercial insurance cover using the laser. I've debated trying to file an claim to attempt to get them to cover it due to the stroke.

 

[Rufous McKinney]

If your employer would pay for it, why not get it?

My employer is Taxpayers. To make them pay even more, when I cannot readily access any of it currently, feels wrong.

But maybe next year. maybe over the course of a year, I can actually figure this out better.

I have a small challenge called: lymphoma diagnosis, Watch and Wait. Well, I'm waiting.