I was recently talking to a woman who is 62 years old and “uninsurable”.  You’d never know it to look at her, but she cannot get health individual insurance, no matter how much she is willing to pay.  Paula M wanted to leave her job after her husband retired and she figured she’d quit her job and buy individual health insurance until she turns 65 and gets Medicare.  Before leaving her job, Paula figured she’d get the most out of her employer health insurance by getting a full physical and tests she might have to pay for once she retired.  As part of her physical, Paula got a chest x-ray, and here is where her troubles started.

The chest x-ray showed a small spot on Paula’s lung and her doctor said this is probably nothing. A month or so later, when Paula applied for individual health insurance through Blue Cross Blue Shield, this x-ray was in her record and the insurance company thought the spot was something.  BCBS told Paula they would not insure her because of the spot on her lung x-ray. Paula’s doctor sent her analysis to BCBS, which was that the spot could have been left over from Valley Fever, but was probably not cancer.  BCBS said the spot could be cancer and, therefore, Paula was a bad risk.

Paula told me her story and I contacted UnitedHealth to see if they might consider her case.  I was quickly told that, if a person is turned down by one insurance company it is in her record, and no insurance company will touch her.  Paula was……uninsurable.

Because Paula has had employer coverage (without a gap of 63 days) she can get expensive insurance because she can use COBRA for 18 months. This means she can continue to use her company health insurance, but she pays the full cost that is normally shared between the employer and the employee.  When the 18 months is up, she will be able to get even more expensive insurance, but she will pay twice as much as anyone would pay for the policy.  There is a federal law that requires insurance companies to offer at least two plans (usually the lousiest ones they have) to someone like Paula. The policy will have a big deductible and a big price tag – but at least she will be able to get insurance.

Eighteen months from now, when Paula’s COBRA insurance runs out, she is hoping the spot on her lung will not have changed and an insurance company will determine it is no risk – and will agree that Paula is no risk for insurance coverage.  Otherwise, Paula’s only choice will be to let an  insurance company rob her with their overpriced, high-eductible ”guaranteed issue” coverage.

Paula is also hoping there will be some healthcare reform this year or next.  If (and that’s a big if) legislation is passed, it looks like insurance companies will not be able to deny coverage to people like Paula.  And insurance companies will not be able to charge people like Paula a higher premium.

There has been so much negative talk about healthcare reform legislation – which is actually “health insurance reform”, that people seem to have overlooked some important changes that will affect millions of people like Paula.

Medicare Advantage plans are run by insurance companies and they are complex. Rules must be followed and enrollees must stay in network, or they will face complicated billing problems.  Sometimes, when you call the insurance company, they don’t seem too clear on the rules themselves.

I was talking to a couple who have homes in Tucson and Missouri, so they signed up with Evercare, which is a PPO Medicare Advantage plan here in Tucson. A PPO (Preferred Provider Organization) allows people to go out- of-network for a higher co-pay, so people who travel think this serves them better than an HMO.  These folks did not really understand how their Advantage plan would work out-of-state, so I called the company to ask a few questions.

I asked the customer service rep what these folks would have to pay if they saw a doctor in Missouri and was told they would be charged 30% of the actual doctor bill.  That’s not too bad.  Then I asked about hospital charges.  The answer was that they would pay 33% of hospital charges.

I then asked about emergencies. The representative, who sounded like he was in his twenties, said emergency room visits have just a $50 co-pay, but if they are admitted to the hospital, the co-pay would be 33%.  I knew this was wrong, but he insisted he was right. So I told him to go talk to a supervisor and get me the right answer.  He came back on the line to say he was mistaken and that emergency hospitalizations out-of-network are covered at the in-network co-pay.  However, a doctor will determine when the emergency is over, and then the patient has to leave the hospital or start paying 33% of the charges. 

Emergency hospitalizations out-of-network are tricky, and I have another client (enrolled with another company) who ran into billing trouble when some of the bills related to his out-of-network emergency hospital stay were not paid.  The insurance company sent him a notice saying certain tests were not part of the emergency.  Apparently he was supposed to call and ask the insurance company to approve certain tests – while he was lying in a hospital bed in agonizing pain.

This man was so mad at the insurance company he only made one attempt to get them to pay the bills.  The rules say he must file an appeal with the insurance company, and fill out specific forms, and send them to a specific department in order for the company to review his case.

These problems must arise often enough that all the Medicare Advantage companies have told insurance agents to be sure to review the appeals process with their clients.  Talking about how to appeal billing issues is supposed to be part of every discussion with clients.

I haven’t had many clients who have reported problems to me, but the ones that did have problems were very frustrated and, come to think of it, they never did get the problems resolved to their satisfaction.

Sorry I haven’t written all week, but I’ve been very busy talking to seniors about their Medicare Advantage plans and their Medicare options.  With big changes to certain plans, people are confused and unsure about what they should do.  Should they stay put?  Should they change plans? Should they go back to Medicare and get a Medicare Supplement?

Here are some examples of people I’ve met with this week.

I met with several veterans who use the VA for their medications and even some of their health care, but they are also enrolled in Medicare Advantage plans.  All of them had forgotten how to use their Medicare Advantage plan, and in some cases they would have saved money if they had used their Advantage plan rather than the VA.  The VA has deductibles and co-pays for services which, in some cases, are higher than what they would have paid using their Medicare Advantage plan.

Several seniors had run into problems with their Advantage plans because they went out of network for lab services, or showed their Medicare card when they went to the emergency room.  They ran into lots of hassles trying to get their plan to pay the bills because of their mistakes.

One plan’s application form says, “I will read the Evidence of Coverage from ____ when I get it to know which rules I must follow in order to get coverage with this Medicare Advantage Plan”.  The Evidence of Coverage is over 100 pages of details about what is covered and rules that must be followed in order to get medical bills paid.  This book arrives after a person has enrolled in a Medicare Advantage plan.  I ask people, “Do you promise to read the Evidence of Coverage?”

I met a woman who had just quit her job to take care of her elderly parents, and she seemed very, very stressed.  I don’t know if she can afford to go without a paycheck, but both her parents are frail and need a lot of attention.  This woman asked me if Medicare pays for respite care for a caregiver like herself.  I had to tell her that I have never heard of that as a Medicare-covered service.  This woman, in her fifties, seemed overwhelmed by the responsibility of taking care of her parents and figuring out their medical bills, their prescriptions, and what might lay ahead in the coming months. 

So I’ve been very, very busy this week, and I’ve met lots of interesting people.  There are many more people to see over the next five weeks.