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How does out of network coverage work with Medicare Advantage?

jack3454

Super Genius
229
I met a person with a MAPD who has cancer. He wants to go to a cancer hospital outside of his rural area, but the hospital he wants is out of the plans network.

He has a PPO and the plan coverage states that he can get out of network care at a higher cost sharing percentage, only that the facility must accept medicare.

In your experience do these cancer hospitals accept out of network coverage at all? I checked their website and only a couple medicare advantage are listed. Im just trying to figure out if that means they will not treat anyone unless they have an insurance listed, or if they’ll still treat someone but they’ll be out of network?
 
Call the hospital, ask if they will accept the plan as OON. If they say yes, advise the customer that he will meet his OON MOOP.
That being said, maybe consider switching him to a plan where the hospital is in-network?
 
He wants to go to a cancer hospital outside of his rural area, but the hospital he wants is out of the plans network.

Depends on who you ask . . .

There are agents on the forum that say if you have a PPO plan you can go anywhere, including cancer specialty hospitals.

The truth is, you can go to any hospital that agrees to let you in with your coverage.

The insurance carrier rules about par/non-par aren't helpful when you want to go to a non-par provider for care. You really need to look at how the provider feels about your coverage.


https://health.usnews.com/best-hospitals/rankings/cancer

The top 3 hospitals according to the link are MD Anderson, Memorial Sloan Kettering and Mayo.

MD Anderson
If you are enrolled in a managed care plan (HMO, PPO or POS), your treatment at MD Anderson may be covered by insurance. Before scheduling an initial appointment, please call your health plan/insurance company and ask if you have access to health care services at MD Anderson. We encourage you to refer to Questions to Ask Your Insurance Company when speaking to your insurance provider.

If MD Anderson is not a participating provider, you may still be able to receive treatment here. Contact your insurance company and ask about obtaining authorization. It is important to note that some benefit plans utilize what are referred to as "narrow" or "limited" networks; that is, they further narrow or limit the choices of doctors and hospitals that their customers can use. Often, these networks exclude MD Anderson. Additionally, some plans, such as HMO’s, have primary care physician referral and/or other authorization guidelines.

[EXTERNAL LINK] - Insurance Plans

Memorial Sloan Kettering

MSK has relationships with many common healthcare providers. Even if your insurance company does not have a relationship with MSK, or if you don’t have health insurance, we encourage you to call us. There may be other ways we can help, for example, through our Financial Assistance program.

Before contacting your insurance company, you may find it helpful to review Questions to Ask Your Insurance Company.

[EXTERNAL LINK] - Insurance Information

[EXTERNAL LINK] - Questions to Ask Your Insurance Company


Mayo

Your Mayo Clinic doctor will decide which procedures, tests and other consultations you may need. However, many health plans require pre-certification and sometimes predetermination of medical necessity prior to care being rendered. In addition, some services may not be a covered benefit for some plans. Investigating coverage requirements and limits can take up to six weeks, and some services require pre-certification staff to supply photos and medical necessity information to your insurance company.

For example, services that may require pre-certification include outpatient and inpatient hospital services, observation services, invasive procedures, CT, MRI and PET scans, and colonoscopies.

Patients are responsible for knowing the pre-certification requirements of their health plans. Mayo Clinic highly recommends that you contact your insurance company to determine benefits and coverage for the Mayo Clinic location at which you plan to be seen.

Managed care plans such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs) may deny or reduce benefits if care is obtained outside of the established network or authorization of the plan.
Patients' plans that require prior authorization or pre-certification may provide only a reduced insurance payment if not previously authorized. In such cases, the patient will be financially responsible for more — possibly all — of the provided services.
A pre-service deposit may be required for nonauthorized visits.
To avoid paying a pre-service deposit or experiencing either denial of payment or a reduction of benefits, Mayo Clinic highly recommends you contact your insurance carrier prior to services to determine plan requirements or limitations to receiving care at the Mayo Clinic site at which you will receive services.

[EXTERNAL LINK] - Insurance approvals: pre-certification and prior authorizations - Mayo Clinic

Your client needs to go beyond the list of carriers listed on their site and review the conditions under which the provider MAY be willing to accept your non-par insurance coverage.
 
Depends on who you ask . . .

There are agents on the forum that say if you have a PPO plan you can go anywhere, including cancer specialty hospitals.

The truth is, you can go to any hospital that agrees to let you in with your coverage.

The insurance carrier rules about par/non-par aren't helpful when you want to go to a non-par provider for care. You really need to look at how the provider feels about your coverage.


https://health.usnews.com/best-hospitals/rankings/cancer

The top 3 hospitals according to the link are MD Anderson, Memorial Sloan Kettering and Mayo.

MD Anderson
If you are enrolled in a managed care plan (HMO, PPO or POS), your treatment at MD Anderson may be covered by insurance. Before scheduling an initial appointment, please call your health plan/insurance company and ask if you have access to health care services at MD Anderson. We encourage you to refer to Questions to Ask Your Insurance Company when speaking to your insurance provider.

If MD Anderson is not a participating provider, you may still be able to receive treatment here. Contact your insurance company and ask about obtaining authorization. It is important to note that some benefit plans utilize what are referred to as "narrow" or "limited" networks; that is, they further narrow or limit the choices of doctors and hospitals that their customers can use. Often, these networks exclude MD Anderson. Additionally, some plans, such as HMO’s, have primary care physician referral and/or other authorization guidelines.

[EXTERNAL LINK] - Insurance Plans

Memorial Sloan Kettering

MSK has relationships with many common healthcare providers. Even if your insurance company does not have a relationship with MSK, or if you don’t have health insurance, we encourage you to call us. There may be other ways we can help, for example, through our Financial Assistance program.

Before contacting your insurance company, you may find it helpful to review Questions to Ask Your Insurance Company.

[EXTERNAL LINK] - Insurance Information

[EXTERNAL LINK] - Questions to Ask Your Insurance Company


Mayo

Your Mayo Clinic doctor will decide which procedures, tests and other consultations you may need. However, many health plans require pre-certification and sometimes predetermination of medical necessity prior to care being rendered. In addition, some services may not be a covered benefit for some plans. Investigating coverage requirements and limits can take up to six weeks, and some services require pre-certification staff to supply photos and medical necessity information to your insurance company.

For example, services that may require pre-certification include outpatient and inpatient hospital services, observation services, invasive procedures, CT, MRI and PET scans, and colonoscopies.

Patients are responsible for knowing the pre-certification requirements of their health plans. Mayo Clinic highly recommends that you contact your insurance company to determine benefits and coverage for the Mayo Clinic location at which you plan to be seen.

Managed care plans such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs) may deny or reduce benefits if care is obtained outside of the established network or authorization of the plan.
Patients' plans that require prior authorization or pre-certification may provide only a reduced insurance payment if not previously authorized. In such cases, the patient will be financially responsible for more — possibly all — of the provided services.
A pre-service deposit may be required for nonauthorized visits.
To avoid paying a pre-service deposit or experiencing either denial of payment or a reduction of benefits, Mayo Clinic highly recommends you contact your insurance carrier prior to services to determine plan requirements or limitations to receiving care at the Mayo Clinic site at which you will receive services.

[EXTERNAL LINK] - Insurance approvals: pre-certification and prior authorizations - Mayo Clinic

Your client needs to go beyond the list of carriers listed on their site and review the conditions under which the provider MAY be willing to accept your non-par insurance coverage.
Show me this agent that says you can go anywhere with a PPO MAPD
 
Depends on who you ask . . .

There are agents on the forum that say if you have a PPO plan you can go anywhere, including cancer specialty hospitals.

The truth is, you can go to any hospital that agrees to let you in with your coverage.

The insurance carrier rules about par/non-par aren't helpful when you want to go to a non-par provider for care. You really need to look at how the provider feels about your coverage.


https://health.usnews.com/best-hospitals/rankings/
Your client needs to go beyond the list of carriers listed on their site and review the conditions under which the provider MAY be willing to accept your non-par insurance coverage.

Thank you very much for the information. I will need to get more info from the providers and see how they feel about the MAPD he has.
 
Call the hospital, ask if they will accept the plan as OON. If they say yes, advise the customer that he will meet his OON MOOP.
That being said, maybe consider switching him to a plan where the hospital is in-network?

Thank you, I will do that. As far as switching him, I could not find a single plan in his area that would be in network for the hospital unfortunately.


Show me this agent that says you can go anywhere with a PPO MAPD

Even on the hospital website it says it doesnt accept all medicare supplement plans let alone the MAPDs. Which is surprising because I was told if medicare pays, supplements will pay, but apparently this isnt the case.
 
Thank you, I will do that. As far as switching him, I could not find a single plan in his area that would be in network for the hospital unfortunately.




Even on the hospital website it says it doesnt accept all medicare supplement plans let alone the MAPDs. Which is surprising because I was told if medicare pays, supplements will pay, but apparently this isnt the case.

They only need to accept Medicare. The hospital will not bill the insurance company.
 
They only need to accept Medicare. The hospital will not bill the insurance company.

I don't know precisely how the rules work, but there are some exceptions to that statement.
 
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I don't know precisely how the rules work, but there are some exceptions to that statement.
Not really. It just appears that way. What @Chazm says is correct.

Providers used to bill supplement carriers but that was back in the stone age. Today Medicare knows everything there is to know about you and your Medicare supplement. It's even listed on your account with Medicare.gov.

What's confusing is that there are still some providers that don't know that. They're easy to spot. They're the ones that insist on a copy of your Medicare supplement card.
 
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