Denied rehab stay by Medicare advantage insurance, post hip replacement surgery. Others have this experience? What did you do?

Sooooo much advertising right now for Advantage Plans during the Open Enrollment period!!!!
Please, everyone know what you are buying. There are so many stories here on the forum of how Advantage Plans fall short when it comes to providing benefits.

Don't be tempted by retired athletes making excited promises on TV. These plans are a great revenue source for the companies that sell them, but they Take Advantage of the consumer.

To Dizzerth:
Wow! I did not know one could not move from and Advantage Plan to a regular Medigap Plan. Ever? Did your agent maybe just mean you could not change plans between enrollment periods? I thought you could make a new choice of any kind during Open Enrollment.

To newbiewife:
Not sure if you have been able to make headway on your appeal, but you are presenting an example to all of one of the downsides of Advantage Plans. Regular Medicare/Medigap typically pays for 30 days of rehab. At least that was my own experience. Medicare/Medigap then continued to pay for in home PT and OT visits until I was permitted to drive myself to outpatient Rehab which was also paid for by Medicare/Medigap.
Good Luck!

You all make me feel better about staying with our supplimental which is not a MA. Yes, we don't have all the advantages of a MA but I rather pay what we do than go thru the MA mess.

Apeal, apeal, and apeal. The third apeal is the only one that is reviewed by doctors in my plan!

Will they cover the expense of in-home care? PT coming? I'd rather be safe in my own home any day compared to these places...

Our local Home Health P.T. services are swamped, as Medicare has recently disallowed Rehab admissions, if P.T. and no other medical requirements are required. The Therapist that told me this, did not mention if it was just for Medicare Advantage plans.

I ran three years of premiums and copays paid for each of us, compared yearly average, and it was about the same yearly cost for original Medicare plus supplement for two seniors. So we are now happily on original Medicare with supplement plan.

The delays and outright withholding of medical care under the Medicare Humana Dvantage Plan in south FL nearly cost both of us our lives, several times. Things like delaying my spouse’s fully blocked carotid artery repair surgery a full five months, trying to not pay for his surgery, waiting for him toile first. Then there was their refusal to order and pay for the pulmonary function tests and overnight oximetry testing for my lung disease, knowing they would have to pay for oxygen for me if they allowed the routine testing that all persons with interstitial lung disease routinely are monitored with. It took almost a year fighting, complaints, appeals, sending copies of the American Respiratory Society recommendations to the HMO PCP, to document I was not receiving industry standard care for persons with lung disease. Then there was my skin cancer, Humana tried to not approve MOHS skin cancer surgery on my face, even though it is industry standard. The HMO doctor kept refusing to make the referral, insisting since I wasn’t a model or movie star, any skin doctor could carve on my face, and to heck with having a cosmetically acceptable surgery on my face. Then there was the years of Humana not performing the yearly low dose CT chest scans on my husband, recommended for high risk persons with history of heavy smoking. It had been their recommended screening for nearly a decade, yet Humana was skipping the screening. When we got here, moved to GA a year and a half ago, moved us back to original Medicare. He got the low dose CT scan of his chest, and sure enough he had lung cancer.

Bottom line is this. If you are willing to be under-treated, have high risk medical conditions and screenings ignored, willing to risk death, by all means, sign up for an Advantage Plan. Don’t say you weren’t warned. For me and mine, even if the company paid for their choice of a Medicare plan, I’d be paying out of my own pocket and pay for the original Medicare plan B, plus a supplement, to prevent careless decisions compromising life, via an HMO or PPO.

Ask for a review of the benefits with your plan. It may be that it was inadvertently denied (these are people we are dealing with) or that your plan doesn't have these benefits - which would be really strange! So glad you have something that is working for now. You may want to consider looking into other plans as the open season of enrollment approaches.

Igloo, check out plan G. When I was researching for my dad I found that plan F was more expensive and didn't really cover anymore than G.

I used a broker that was able to give me a booklet that showed me exactly how the coverage compared from one plan to the next. It was still complicated but it was massively simplified.

I tell everyone to find a Medicare specialist insurance broker.

Not that I could tell you anything, the clever lady you are, but I wanted to share my experience.

Is this Kaiser? Same thing happened to my dad after a fall and hospitalization. They also denied our appeal. They wanted me to put him in a nursing home because they said due to his dementia rehab wouldn’t help him. I took him home with me and Kaiser did finally agree to home health and we got some PT and OT that way. I will not be choosing them for my plan when I qualify for Medicare.

Here is one of the obvious problems with "Advantage Plans." They may sound tempting b/c of lower premiums, but there are way too many limitations on benefits.

During this Open Enrollment period, consider moving his coverage to a standard Medicare Supplement Plan. It will cost you more in premiums but it will give you much more in choices and services.

Since this is open enrollment time I wanted to let people know to avoid Humana at all costs. So difficult to work with and they send you in circles when you call them on the phone. Their online pharmacy is ridiculous and you can wait a long me to have Prescriptions filled.
My dad is now with blue shield and we have not had problems with them. I think one reason for this is because the doctor at the memory care facility where he lives is also the doctor on his hmo plan that he is on so super convenient to have him come to my dad. If this were not the case I would not have my dad on an advantage plan.

Medicare advantage is a “in service” hmo or ppo only

frankly, it is super cheap premiums because it delivers very little actual service. Medicare is pushing this hard this year...but...avoid advantage. Their goal is to pay for little to nothing. The internet is rife with the huge number of people denied health service because they have advantage.

you can change to any of the medigap plans anytime...but, you will have to go through underwriting to join a different plan. Check it out.

meanwhile, see if you can find a rehab that is in the PPO for you Medicare advantage plan.

Have the hospital recheck the code numbers they used. You won't believe how often a refusal is caused by the wrong code numbers.

I learned this the hard way - now I make them recheck anytime a charge is refused.

Everyone on Medicare makes their own choices of what doctor to see. Medicare is a very generous payor. The days of fee-for-service are gone and never going to come back unless you can afford to pay out of pocket. Ask anyone on Medicare whether they want to give it up and you will get a resounding "hell no!" The amount of misinformation about Medicare is staggering.

Happy update! Our appeal of the denial was successful, so Aetna Medicare Advantage (ppo plan) will pay retroactive to admission to the facility.

To address a few of the questions raised by helpful posters: (1) This was not a planned or elective hip replacement surgery. It was necessitated by a fall that resulted in broken femur, near the head. Surgeon said it was a displaced fracture. Not a total hip replacement, "just" the head of the femur. (2) My husband was admitted to the hospital from emergency room and had to wait a day before surgery because he was on a blood thinner. He was in the hospital over the 3 days required by Medicare to be eligible for rehab. In fact, he was in there several extra days because of the Aetna denial. He has other complicating medical factors that already affect his balance and walking, so we were sure he ought to be elgible for rehab. stay medically as well. (3) We had no choice in having this advantage plan as my husband's employer has contracted to put all their retirees on it. The employer heavily subsidizes the employee's monthly premium, and dependents have a very reasonable monthly premium. Between two of us, we are paying only slighty more than half of what our brother in law pays for just himself on a Medicare supplement plan (United Healthcare). Annual deductible is $300 each, and there's a decent cap on annual out of pocket payments. Prescription (Part D) benefits are included.

I've learned a lot in reading the responses, which I think may be helpful for others as well. Thanks all.

Shane1124,
You clearly believe a lot of political scare-talk about Single Payer.
I do not. Nor does most of the rest of the First World, where no one navigates for-profit obstacles or suffers bankruptcy because of medical situations.
Please note where the problems are coming from when the for-profits (Medicare Advantage) are permitted into the government-run nonprofit arena (Medicare),

Wow. I came SO close to changing over to an Advantage policy instead of the supliment one I have now. I pay a very small co-pay at the beginning of the year and from that point on no deductions. And you guys are right, even my doctor's office is trying to get us to with advantage....

First off, keep appealing. I used to write appeals for a Blue Cross HMO before changing career path.

Second-without knowing if he satisfied Medicare’s three day hospital inpatient requirement, we can’t know if he qualified for rehab facility.

Third-Medicare is moving toward outpatient joint replacements, same day discharge, or next day. They are doing this partly to prevent joint replacement patients from qualifying for rehab care post-hospital discharge. Virtually nobody with hip surgery qualifies for rehab now. Just because the model patient without comorbidities May do well with outpatient joint surgery, we all are now expected to recover just as quickly.

Fourth-As others have said, if a person is on a Medicare Advantage Plan, if one can get through underwriting, and if the premiums are affordable, Original Medicare with a supplement, Plan G, is best option, for getting needed care, with all the Advantage Plan restrictions.

You say Medicare PPO, not HMO, correct? You will probably find, as your husband ages, most seniors tend to get sicker and need more care, not less. Insurance companies are in the business of making profit, whether HMO or PPO, and its a powerful incentive to deny as many services as they can get away with. We said good riddance to the south FL Medicare Advantage Plan HMO Humana, when we moved to another state. Both back on original Medicare. We don’t have all the games with insurer denying care now. We are receiving proper medical care, and the screening tests for our various medical needs, plus the accepted medical treatments we weren’t receiving on the Advantage Plan. Strongly urge changing to Original Medicare if you can.

ProPublica has an article out today on RN who was billed $880,000 for her 3 mo early preemie & it’s the hospital group she works for!!!

Its the structure of “Advantage” plans that are the inherent problems.
The whole premise of Advantage is to limit you to a narrow network with an even narrower group of providers. So if the care you need doesn’t fall within basically a subset of a set, just too bad. You pay out of network or you get wage garnishment or go bankrupt or you impoverish yourself to be a dual on Medicaid/Medicare. What’s especially galling is that CMS underwrites a good bit of Advantage Plans. They siphon off $ from original MediCARE for Advantage. All done under the illusion of creating a more “choices for consumers” via underwriting insurers who trot out Advantage plans; and taking $ away from Original MediCARE. What a steaming load.

Single Payor needs to happen in the US. Whether it’s MediCARE for all or the Kaiser model (Alva oh lucky you!) of HMO systems.

I am new to medicare (as of 1 dec) finally....ive heard too many “advantage” nightmares. I went straight medicare with plan f and part d. My mom has the original supplement plan and never pays a penny for anything except copays for her meds....i used to work in the medical field and at one point did insurance billing....the crap plans that are so well advertised, basically shoved down our throats, are no advantage to a patient, as someone on the forum mentioned not too long ago...

Thanks for all the helpful answers. We unfortunately didn't have any choice in selecting the plan as it is the one our former employer contracted with for retirees. Employer heavily subsidizes the premium for my husband and we pay more for mine since I was dependent on his, but the monthly total is still extremely reasonable. Today I waited on hold forever, only to find out the agent handling our case couldn't find a form I'd sent on October 31st that he had acknowledged receiving. I had to send it again to a different email address. I do think one of the problems was poor documentation of need and level of function by the hospital. I'm goi g to check out the NYT Times article right away.

Herein lies the problem with the Medicare Advantage plans. Little to no cost to you, but when you need medical attention you find out how little is actually covered and the hoops you need to go through to get that coverage. Could be the hospital billing dept. used the wrong code. Did your husband sign an ABN (advanced beneficiary notification)? If so, was it explained correctly? Is the hospital/rehab in the network? Did he need to get a referral for the surgeon/hospitalization/rehab? Was he in the hospital for a minimum of three days?

The groundwork is relentless....to protect yourself in the future my advice is to check out the supplemental F plan. You can enroll now at a cost of about $235 per month. Covers mostly everything and no need for referrals.....and you are covered in all 50 states. Plus all major insurance carriers have the exact same plan. We learned the hard way....I am not a solicitor for the insurance industry.....just a graduate from the school of hard knocks.

Good luck to you and I hope this is just a hiccup that will resolve itself and you will receive full reimbursement. Getting proper medical treatment should not be this hard......especially when you are under enough stress to begin with.

Well, my mother has this super crappy new Medicare PPO plan thru Blue Cross that works a lot differently than standard Medicare, and may be similar to what you're dealing with. When she needed rehab after a bout in the hospital with pneumonia, a few rehabs wouldn't take her.....said they were "full". To make a very long story short, I later found out those rehabs weren't full at all......they just wouldn't take any more Medicare PPO plan patients! Apparently, there are only a certain number of beds allotted towards each insurance plan. When that number is reached, everyone else presenting with that type of insurance is DENIED. Hopefully my gibberish makes sense.

So I wound up putting my mother in a rehab unfit for a dog because Medicare PPO plan sucks, basically. Took me 5 days to get her out of there and into a good place and that's how I found out about all of this Medicare nonsense.

I wonder if your plan was rejecting the FACILITY and not the need for rehab?

Just read in the Sunday New York Times under a title of most frequently asked questions about Medicare that many advantage plans deny care and that only 1% actually will protest that denial with an appeal, that often when they do the denial is withdrawn and the care is given. Access this article if you are able. This apparently is VERY COMMON with medicare advantage programs. Article is named Six Top Questions about Medicare by Mark Miller andis in the Business Section of the November 3 New York Times under "retiring". I know you can get this on google. Good luck.

Sorry, this is why I don't do Medicare Advantages. They are suppose to follow Medicare guidelines. Is it they are turning down care or care in that particular Rehab. I had a friend who needed surgery. The surgeon was Medicare and within walking distance from her home. (She lives in a city) Medicare Advantage said she couldn't use him, not in their network. Next open enrollment she went back to Medicare with a suppliment.

Hopefully, someone on the forum uses a Medicare Advantage. My supplimental is thru my DHs employer. Never have these problems.