Here’s another story from Patricia Han about her Medicare “Disadvantage” plan:
I started looking for a Medicare Advantage (MA) plan in 2013. I studied every plan in detail. As I have mentioned, I am a nurse and have worked in the insurance industry and since I am disabled, I have the time to do this. I compared all the MA plans with my medical needs, making sure all my doctors were on the plan. Since I only see specialists, I compared copays for specialists. If hospital admission was needed, I also wanted the FREEDOM to choose what Hospital and/or Rehabilitation Facility I went to, to make sure they could meet my needs and NOT THE “NEEDS” OF THE INSURANCE COMPANY.
The plan I choose paid 100% for wound care supplies that were sent to my home, and from 2013 to 2019 this worked just fine (note, not all MA plans pay 100% for wound care supplies). In reviewing the plan for 2020, there was no indication in the either the Evidence of Coverage document or the Summary of Benefits documents indicating that there would be a charge for wound dressings. So, in March of 2020, I was shocked to find out (only after I got multiple bills), that there was now a copay for each shipment of dressings. I called the MA insurance company and they verified there was now a charge of $35 for each shipment of bandages.
I had more than 20 separate bills from January 2020 to March 2020 — at $35 each for shipments of dressings!
My wound care physician’s office would make an order for wound dressings from a Durable Medical Equipment (DME) company, usually ordering several different products all of which were needed for my wound care. However, the DME company used different suppliers or warehouses for different products. That meant that the shipping dates were different for each of these supplies. Each date was submitted to the insurance company and they charged $35 for each separate item! Had all the supplies been delivered from the same warehouse, I could have gotten ALL of the items for $35!
I appealed, but was told I had to appeal each charge separately. In my letter to my MA plan, I noted that this was a change in benefits from the years past and Medicare requires that clients are made aware of any changes to the plan. I informed them in the letter that I had checked the Evidence of Coverage as well as the Summary of Benefits, and nowhere did it say that there would be a charge. The charges were overturned after 3 months (thanks to my aggressive approach, which is time-consuming). However, the problem (and the bills for individual shipments) continued until August 2020 when I received a letter stating they would not review any other appeals for this.
This is one example of why, even when you are proactive and have read the policies, there is still “fine print” that can affect an MA beneficiary with chronic wounds. Even when you read the fine print (all of it!), there are still hidden fees.