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.

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