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  #1  
Old 11-09-2017, 08:17 PM
Steve White Steve White is offline
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Default How does this Medicare Advantage PPO work?

It's a retiree medical advantage plan that's available to eligible employees of one of my former employers. I am eligible.

Statements from their description (numbering mine to refer to them later):
1. This plan also gives you the option to see non-network providers typically
at the same cost level. NOTE: Non-network providers do have the right to
not accept your PPO plan for non-emergency care. Please check with your
providers prior to enrolling in the PPO plan.
2. Out-of-network providers are paid what they would have been
paid under Original Medicare.
3. Out-of-network providers do have the right to not accept the
PPO plan for non-emergency care.
4. Out-of-network providers are allowed to “balance bill” the
health plan for excess charges above the Medicare fee
assignment. UnitedHealthcare will pay these charges. You
are only responsible to pay your copayment or coinsurance.

2 & 4 sound contradictory to me. 4 seems to say they'll pay whatever the provider charges. 2 seems to say they'll pay Original Medicare amounts. What's going on?

That carries over a some to 3. If a provider will only get Original Medicare reimbursements, then perhaps I need to be concerned about ones who aren't in-Network. Those doctors may be willing to accept Original Medicare amounts, in which case they'll treat me and their non-network status doesn't matter. But if they're going to get their standard charges even if higher than Medicare, is there any recent any Provider wouldn't treat me?
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  #2  
Old 11-09-2017, 09:12 PM
cincinnatikid cincinnatikid is online now
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This does seem really confusing.

I don't have any specific knowledge, but my guess is that #4 only means "the member isn't responsible for balance billing", which may not be equal to "UNH will pay whatever balance bill the OON provider sends them".

I suspect that there are probably cases where UNH pays less than the balance billed charges (based on UCR, negotiation, or whatever), which could be what leads to #3.
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  #3  
Old 11-10-2017, 02:12 AM
Actuarialsuck Actuarialsuck is offline
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I thought non-PAR providers have to accept 100% of Medicare for Medicare eligible folks if they choose to be a Medicare provider so I'm not sure what 4 is referring to (unless it's for those that don't want to participate).
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  #4  
Old 11-10-2017, 08:17 AM
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Quote:
Originally Posted by cincinnatikid View Post
This does seem really confusing.

I don't have any specific knowledge, but my guess is that #4 only means "the member isn't responsible for balance billing", which may not be equal to "UNH will pay whatever balance bill the OON provider sends them".

I suspect that there are probably cases where UNH pays less than the balance billed charges (based on UCR, negotiation, or whatever), which could be what leads to #3.
Maybe they will pay only the part of the balance bill that brings reimbursement up to what Medicare would pay. Not sure how that squares with premium pricing based on lower negotiated payments, though.
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  #5  
Old 11-10-2017, 10:27 AM
WhosOnFirst WhosOnFirst is offline
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Quote:
Originally Posted by Steve White View Post
It's a retiree medical advantage plan that's available to eligible employees of one of my former employers. I am eligible.

Statements from their description (numbering mine to refer to them later):
1. This plan also gives you the option to see non-network providers typically
at the same cost level. NOTE: Non-network providers do have the right to
not accept your PPO plan for non-emergency care. Please check with your
providers prior to enrolling in the PPO plan.
2. Out-of-network providers are paid what they would have been
paid under Original Medicare.
3. Out-of-network providers do have the right to not accept the
PPO plan for non-emergency care.
4. Out-of-network providers are allowed to “balance bill” the
health plan for excess charges above the Medicare fee
assignment. UnitedHealthcare will pay these charges. You
are only responsible to pay your copayment or coinsurance.

2 & 4 sound contradictory to me. 4 seems to say they'll pay whatever the provider charges. 2 seems to say they'll pay Original Medicare amounts. What's going on?

That carries over a some to 3. If a provider will only get Original Medicare reimbursements, then perhaps I need to be concerned about ones who aren't in-Network. Those doctors may be willing to accept Original Medicare amounts, in which case they'll treat me and their non-network status doesn't matter. But if they're going to get their standard charges even if higher than Medicare, is there any recent any Provider wouldn't treat me?
United is very large company. They also have many product lines including MA. While their networks may be the same, I suspect that they do not overlap completely. However, it is conceivable that they have language in their provider contracts in one line that gives them some leverage in the other lines. They are also big enough that they have some real negotiating power for their members on the balance billing part and are probably able to convince many providers to accept a lower reimbursement. While the paying of the balance bill may seem like altruism, my guess is having to pay on a balance bill makes members upset which would drive down United's star ratings. I'm guessing the higher star ratings more then compensate for added claims cost. I'm also guessing that United has a pretty large network for their MA product which would also limit their liability.
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  #6  
Old 11-10-2017, 10:44 AM
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OON Providers will be paid Traditional Medicare
Some OON Providers will ask for more money than that, but you needn't worry. We'll handle that.

imo
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Old 11-10-2017, 10:49 AM
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MA is still mysterious to me but the idea is "hey, our contracting, analytics, and ability to acquire CMS funds is so good we can give you better benefits than Medicare and still make a profit"

in other words, lol @ single payer

I digress. I assume that the network is not as comprehensive and there are probably utilization controls out the ying. But the cost is usually very low for retirees. I"m unsure if MA premiums are payable from an HSA but I think so.
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  #8  
Old 11-10-2017, 02:16 PM
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Quote:
Originally Posted by Steve White View Post
But if they're going to get their standard charges even if higher than Medicare, is there any recent any Provider wouldn't treat me?
Because the provider has to go through the process of balance billing and collecting that difference from United for every claim. It may not be cost-effective or may be unfeasible for them to do that.
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Old 11-10-2017, 02:21 PM
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Quote:
Originally Posted by Childish Gambino View Post
OON Providers will be paid Traditional Medicare
Some OON Providers will ask for more money than that, but you needn't worry. We'll handle that.

imo


1 says you can go to any OON doctor that will take you. 2 says here is what United will pay that doctor. 3 says that the OON doc has the right not to see you for non-emergency care. 4 details the situation in which the provider might want more than United is willing to pay and reinforces that you pay the same via 1.

that's my interpretation
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  #10  
Old 11-10-2017, 02:27 PM
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Quote:
Originally Posted by mathmajor View Post
MA is still mysterious to me but the idea is "hey, our contracting, analytics, and ability to acquire CMS funds is so good we can give you better benefits than Medicare and still make a profit"

in other words, lol @ single payer

I digress. I assume that the network is not as comprehensive and there are probably utilization controls out the ying. But the cost is usually very low for retirees. I"m unsure if MA premiums are payable from an HSA but I think so.
We could still have a single payer system that is administered by the companies to preserve the efficiency gains of the marketplace.

In other words, MA for everyone.
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