Medicare Advantage Plan denied basic DME supplies

[MagsterMile]

A word of caution regarding DME coverage if you have a Medicare Advantage Plan. I was just denied coverage of my DME supplies - mask cushion,tubing, headgear - I just switched over to Humana Medicare Advantage Plan as of 1/1/13 and they have denied my claim for typical DME equipment supplies. The reason code: 08Z read as following 'Payment has been denied because these services were not urgent/emergent, nor have we received a referral approving services in advance from the Primary Care physician'.

I'm waiting breathlessly to see if they will or will not deny coverage for rental of my Vpap Adapt machine for the same reason.

This whole thing is scary since the booklet I received from them shows that I have DME coverage. Are they picking and choosing what they will cover?

It seems that perhaps Humana Medicare Advantage Plan that I have is willing to accept my monthly premium but not so quick to accept my claims.

[DannyPh]

Hmmmmm, That's sounds Mighty Strange. I have Humana Advantage Plan also and I just received a New S9 autoset cpap machine and it was covered 100 %. But I also Have Medicare along with BC/BS But I doubt seriously that either one paid 100 % for the machine. It was a combined Deal.

[TiredAlot]

A word of caution regarding DME coverage if you have a Medicare Advantage Plan. I was just denied coverage of my DME supplies - mask cushion,tubing, headgear - I just switched over to Humana Medicare Advantage Plan as of 1/1/13 and they have denied my claim for typical DME equipment supplies. The reason code: 08Z read as following 'Payment has been denied because these services were not urgent/emergent, nor have we received a referral approving services in advance from the Primary Care physician'.

MagsterMile,
It appears that if you get a referral from your primary care physician for your machine and supplies they will cover the cost for you. You may need a referral for seeing your sleep doctor as well. Just make sure you get referrals from your primary care physician before ordering any more supplies. This will include seeing specialists as well.
Good luck.

[StuUnderPressure]

Hmmmmm, That's sounds Mighty Strange. I have Humana Advantage Plan also and I just received a New S9 autoset cpap machine and it was covered 100 %. But I also Have Medicare along with BC/BS But I doubt seriously that either one paid 100 % for the machine. It was a combined Deal.

Medicare together with BC/BS will pay 100%.
BC/BS pays 100% of the Medicare deductible plus 100% of the 20% Medicare co-pay.

Under that scenario, you would pay nothing.

[Pugsy]

Medicare Advantage plans are a whole different animal. They don't have to play by the typical usual Medicare guidelines if they don't want to.
Sounds like Humana wants proof of medical need. They don't have your original "proof" because you just switched to them and they don't have your old information and they are doing what insurance companies do when they can...come up with a reason to deny payment.
Unsure what the requirements for proof are but you should be able to get with them and your doctor and get the proof they require.

[chunkyfrog]

This is why I opted for Part B and D supplements. "Advantage" sometimes means theirs--just saying.
Consulting with SHIIP and similar free services under your state's department of insurance is not only a good idea;
it can be your only protection against the wolves.
Another good idea: run the situation past your state department of insurance.
If something is not on the up & up, you can get action, information, or whatever is appropriate.

[LSAT]

I have the AARP Medicare Advantage Plan and I have no problem getting any supplies. This is thru United Healthcare and they follow Medicare guidelines.

[chunkyfrog]

MM probably just had a duck slip out of line.

[RogerSC]

This is why I opted for Part B and D supplements. "Advantage" sometimes means theirs--just saying.
Consulting with SHIIP and similar free services under your state's department of insurance is not only a good idea;
it can be your only protection against the wolves.
Another good idea: run the situation past your state department of insurance.
If something is not on the up & up, you can get action, information, or whatever is appropriate.

Wee bit off-topic, but I started with a Medicare Advantage Plan when I went on Medicare back in October of last year. It was $200/month, and included pharmacy, dental, and some vision coverage. My main reason for going that way was because the plan was mentioned by name in the clinic's online information where my PCP practices. Looked into the dental care, and found that they had one participating dentist for the entire county that I'm in, which is just useless (but cheap and easy for them). I started asking around, and found that my clinic also "works with Medicare Supplement plans", so looked into that. Got similar coverage for less than $100/month with a Medicare Supplement plan and a separate pharmacy plan (both with AARP/UHC) that my clinic and doctor are happy with. For dental, I got lucky and am on my wife's plan work plan for the moment. So things are just fine at half the cost. No problems with cpap supply coverage as well. Even if I had to get a separate dental plan, it would still cost way less than the $200/month, with my choice of dentist.

My point is that you need to be careful with those Medicare Advantage plans, they look okay going in, but you may find that you're paying a lot for very thin services. At least the one that I was on was that way. And it also sounds like they have enough freedom in their operation that they can deny coverage rather than ask for specific verification from your medical providers so that they can help you. Don't like that approach to health coverage.

[chunkyfrog]

With the supplements, it's all ala-carte.
The dental college is in town, and those rates are likely better than any insurance or discount plan.

[MagsterMile]

Thanks everyone for your responses. I'm getting ready now to call Dr's office and Humana and to figure this mess out. A call to Medicare may also be in order. I'm ready for them and have all my paperwork on hand!!!!

[NateS]

Thanks everyone for your responses. I'm getting ready now to call Dr's office and Humana and to figure this mess out. A call to Medicare may also be in order. I'm ready for them and have all my paperwork on hand!!!!

When the annual switch opportunity arises, I would highly recommend that you take the opportunity to switch from what I call Medicare (Dis)Advantage to true Medicare plus a Medicare Supplement also known as Medigap.

I have an extensive background in insurance and the private insurance industry, and when I first turned 65 I did an extensive study and investigation of Medicare Advantage. It may be lovely to have all the alleged "extras" while they work but in the long run sooner or later you will get ripped off by the health insurance company you buy your "Advantage" Plan from. When a private insurance company sells you a Medigap policy, they have to go by the government's uniform rules. When they sell you Medicare (Dis)Advantage, they can go by their own rules when they feel like it and they can get away with it. Everytime an insurance sales person signs you up for the Advantage Plan, they get a quick commission of $500 or more - that money plus their need for profits adds up to big bucks that have to be squeezed out of someone or somewhere at claims time.

Genuine government Medicare plus a Medicare Supplement aka Medigap from a group plan or a private insurance plan is always the better, more uniform coverage in the long run. Not Medicare Advantage, IMHO.

Regards, Nate

[chunkyfrog]

This was the information I gleaned from our free consultation with SHIIP.
The insurance market is indeed an abbatoir. Abandon hope, or go in fully armed.

[Janknitz]

Chunky is mentioning SHIP and I want to be sure everyone understands what it is. If you are on Medicare you receive a booklet every year called "Medicare and You" and on the back of that booklet is a phone number for SHIP or HICAP (California). This is FREE Medicare counseling by certified and dedicated volunteers who know their stuff. They can definitely help in situations like this.

Also, if you are new to Medicare or if you are thinking about switching plans, it always pays to check in with your local SHIP/HICAP people because they can help you understand and break down the terms of each supplemental policy.

Medicare Advantage still has to follow Medicare guidelines. They can't deny coverage for things that are covered by "traditional" Medicare. So the refusal to provide the supplies because it's not an emergency is just bunk. But they can make you jump through that particular plan's hoops BEFORE they have to supply anything. Unfortunately, that may mean a new sleep study with a plan-approved sleep clinic and physician, and your equipment and supplies MUST come from their own approved providers, NO chance of coverage for a provider that's not part of their plan. So if you have a capped rental ASV from a provider that's not approved by your new Advantage plan, you may have to switch machines and providers. And in my experience, Advantage plans often DO specify the make and models of machines they cover in their formularies, rather than going by HCPCS codes.

It is a cautionary tale that if you already have OSA or more complex apnea, you need to check things out VERY carefully before switching to an Advantage plan or an HMO if you're not on Medicare.

[chunkyfrog]

Another point: SHIIP and (I think) the HICAP programs are for seniors on or entering Medicare.
For younger folks facing the insurance exchanges in 2014, similar programs are being developed to offer the same advice.
Check with your own state's department of insurance. Do not rush yourself-
-the insurance companies are poised to strike in favor of their own interests only!