How to make insurance provide coverage to those that need it?

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I have been fighting with Medicare Advantage plan, Preferred Care (owned by United), as they do not honor their responsibilities, as outlined by Medicare. In addition, when I contact Medicare, depending on "person", I get someone helpful, but have to allow 30 days for insurance co to respond, then when I call Medicare back, they say they have no authority on Advantage Plans??? In the meantime, my father is being denied NEEDED care.

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All Medicare Advantage plans have to cover everything Original Medicare covers. If the service you are talking about is in the "Medicare and You" booklet, it has to be in your Medicare Advantage policy (but Medicare Advantage plans also often cover additional services and almost always have different co-pays and deductibles than is explained in the Medicare and You booklet).

So are you talking about an Original Medicare service or an additional service you think the policy says is covered? Once you are sure it one or the other, you have to follow the steps outlined in the insurance policy for appealing its decisions (which are basically the same as the procedures in the Medicare and You booklet).

However as someone else has noted, if this is for a medical service that neither Original Medicare or the Advantage insurance covers, you would be wasting your time.
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You do realize that there r doctors who do not except Medicare. Same with supplimentals, only certain doctors will be covered. The in and ut of network thing. Try your Office of the Aging. See if they can help you in understanding why your Dad isn't getting care he needs. If your Dad is low income he may get help with Medicaid. Be aware that deductables can be high.
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I read that Medigap is being fazzed out. Only those already on it will be able to keep it. Humana seems to be an area thing. No doctor in my area, a few years back, have heard about them. I find that supplimentals don't pay much. You have to meet the deductables.
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ssands1: I also have Medicare and Medicare Supplemental (through AARP, United Health Care, Plan F.) Are you getting confused with Medicare.gov and Medicare Supplemental? The phone # for United Supplemental is 1-800-523-5800. I don't understand why you are waiting 30 days for an answer. You stay on the phone with them until you get a satisfactory response and ALWAYS get the person's name. It would be in your father's best interests to set up online accounts with Medicare.gov and his Medicare Supplemental. AND MY INSURANCE AGENT WAS DEFINITELY IN MY CORNER, snowquail, with no cost to me or my Medicare or my Medicare Supplemental.
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You have reached a dead end with your "United Advantaged Plan". And yes "Medicare" has no involement with them other than to send them the money sent in from sociai security..

You need to drop this plan and pick up another "Advantage Plan" that has the benefits you want. Look at Anthem, Humana, Aetna or AARP. ehealthmedicareplans will help you compare plans.

Another option is to get "original" Medicare with Medigap (also called Medicare Supplement). Read everything on medicaresupplement

Remember agents get commissions and give kickbacks. So they are not necessarily in your corner.
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ssands1: I strongly suggest that you find an insurance agent to work on your behalf. We did here in Maryland, free of charge. If not, then I would #1 sign up for online, #2 get the name of the person you speak to each time you call and #3 call every day! When you say you are calling Medicare and get a response-"they don't have any authority on Advantage Plans."- are you sure that you're calling the right Medicare?
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Be aware, Medigap does not offer prescription plans. My Mom gets state help.
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Contact your local SHIP volunteers! State Health Insurance Assistance Program.
They can assist hands on to resolve your issues with MEDICARE, SUPPLEMENTS, & ADVANTAGE plans. They also assist finding a new plan if your are unhappy with the one you have.
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This might be a long shot, but you could research which federal and state legislative committees have jurisdiction over or focus on health care (specifically health care providers), contact them, explain the dilemma and ask if there are federal or state statutes which address standards of performance by the health care providers. Maybe someone who's running for re-election would be willing to add a constituent rescue to his/her platform of accomplishments.

A long shot, and perhaps questionable in terms of your specific situation, is to also research locally and nationally as to whether United has been sued for similiar behavior and lack of cooperation. If so, you might want to consider consulting an attorney for some extra legal muscle in dealing with United.

If you don't mind the publicity, you can reach out to media, such as local news channels. They enjoy coming to the rescue of citizens battling big business.

In the meantime, I would start researching Medigap or other plans. The kinds of problems you're having are a primary reason why we've stayed away from these companies that repeatedly send out solicitations and actively recruit clients.
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It sounds like you may need to read the fine print on the coverage he actually has to make sure the services your dad needs are actually covered by his plan. I had this issue with a client that needed adult day services. Those services were not covered under the plan she had. She actually had to switch to another plan. The catch will be whether or not you can actually switch your dad (if his services are not provided for in his current plan) right now. You may have to wait until open enrollment in November I believe.

If your dad needs Home Health Services then you do need to have an order (or prescription) from his doctor stating he needs those services. Home Health Services usually covers services from a nurse, home health aide, medical social worker, PT, and OT. If your dad needs regular in-home attendant care (help with activities of daily living) then this is different from Home Health Services. These are the services that may not be covered by his plan. These services are sometimes covered by Long-term Care Insurance or Medicaid if he is low income. A Vet can get these services under the Aide & Attendant Program. Medicare does not cover long-term care. Good luck!
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