Medicare Advantage Plan denied basic DME supplies

[MagsterMile]

Many health providers are unsure of Medicare Advantage Plans and what they do and don't do. I'm still not clear on what the 'advantage' is of having such a plan. I pay $59 month premium to Humana plus I pay my medicare premium every month. Since Medicare Supplement plans seem to run in the $100's for monthly premiums in addition to your regular medicare monthly premium and most of the claims are paid, a person who signed on when first eligible is probably getting very good coverage. My friend, who has multiple medical issues, carries a medicare supplement plan which is very beneficial to her. I think that if a person has a lot of medical issues, you are better off getting a medicare supplement as opposed to a medicare advantage plan where you end up paying through the nose a lot of the time. But premiums being so high for the supplemental plans, getting the advantage plan may be your only alternative.

My overall experience with Humana Advantage is a Fair +. First I was told I owned my machine, then I was told 'no' I don't own it but the rental cost is $1,000 per month. Why would the DME bill for $1,000 per month which is idiotic IMO. Somewhere along the line, someone's pockets are being lined IMO. Call 'Humana' any day of the week and answers will never be the same to the same question. Humana wasn't even able to provide a list of 'opticians' that I could access for RX glasses. I have what is referred to as a 'discount' plan for vision but I ended up paying for the complete pair since Costco was 'out-of-network' (as usual) and would not be able to file a claim. No surprise there.

[hyperlexis]

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.

Um it says they need a referral from your MD saying the stuff is needed. Send them the referral and they should pay it.

M.A. is a set up started years ago under Ronald Reagan as Medicare Part C and amended later under the Bush Admin to be called Med. Advant. It allows private insurance companies a crack at servicing Medicare beneficiaries for a flat fee (remember the plan to privatize Soc. Security too...). The goal was for the private insurers to do so for less than actual Medicare. The private insurers, however, have generally not been able to do so without added federal subsidies. (Those are what the ACA is finally cutting). Plus, another downside is the private insurers don't legally have to offer plans in all locales in the U.S. They insure some areas, but can choose to ignore less profitable ones.... M.A. plans do sometimes offers more benefits than standard Medicare, plus drugs. It can basically save people from having to buy a more expensive MediGap plan plus an added drug plan.

But in exchange for the out of pocket savings, you have to know how to use the plan and navigate it properly to get all the benefits you need.

If you want simplicity and ease, stay with standard Medicare and get an expensive MediGap plan. But if you want to save money and don't mind working with claims issues and/or making phone calls, an M.A. plan can save you some cash. You just need to learn how to work it to your advantage.