AARP Medicare Advantage United Healthcare plan refuses to cover non-hospice medical services

[el94466864]

Both of my parents have had an AARP Medicare Advantage plan from United Healthcare (UHC). In both cases, after they went onto hospice, UHC refused to cover any non-hospice services (those that are not related to their terminal prognosis), even though the Evidence of Coverage contract says they would. (Note that hospice-related charges shift to Original Medicare, even if one is on a Medicare Advantage plan.)

For example, my father has a pacemaker, which undergoes routine evaluations. Those evaluations are not hospice-related. Just because someone is on hospice does not mean that they are ready to die based on a problem with their pacemaker. However, UHC is refusing to pay claims related to the pacemaker and insisting that the claims be submitted to Original Medicare instead.

When I called UHC about this and spoke with a supervisor, he said that there were "hidden things" that do not appear in the Evidence of Coverage.

In addition to having a higher cost for patients (deductible and co-pay that the Medicare Advantage plan does not have), this also presumably is more expensive for taxpayers, because UHC continues to collect the premiums from Medicare but then refuses to pay the claims and re-directs them to be paid by Medicare.

For reference, here is the language in the Evidence of Coverage:

"For services that are covered by Medicare Part A or B and are not related to your terminal prognosis: If you need non-emergency, non-urgently needed services that are covered under Medicare Part A or B and that are not related to your terminal prognosis, your cost for these services depends on whether you use a provider in our plan’s network and follow plan rules (such as if there is a requirement to obtain prior authorization):
· If you obtain the covered services from a network provider and follow plan rules for obtaining service, you only pay the plan cost-sharing amount for in-network services
· If you obtain the covered services from an out-of-network provider, you pay the cost-sharing under Fee-for-Service Medicare (Original Medicare)"

[GailL1 · Accepted solution]

Actually, there is a choice here and one that may require a bit of paper work submission but it comes out better for the beneficiary in covering the specific service that is not linked to the hospice condition.  (see the part below that I highlighted in red)

Medicare.gov- Medicare Hospice Benefits Publication 

Read page 2 and then read page 7.  The following is from page 7 - copy/ paste

Hospice care if you’re in a Medicare Advantage Plan or other Medicare health plan:

Once you start getting hospice care, Original Medicare will cover everything you

need related to your terminal illness, even if you choose to stay in a Medicare

Advantage Plan or other Medicare health plan.

If you were in a Medicare Advantage Plan before starting hospice care, you can stay in that plan as long as you pay your plan’s premiums. If you choose to stay in your plan, your plan will still cover:

•  Any extra services that are medically necessary (like dental and vision benefits).

•  Covered services for health problems that aren’t related to your terminal illness.

You have the option to get these services from Original Medicare, or your Medicare Advantage Plan. If you get them from Original Medicare you may have to pay a copayment. If you get them from your plan (like getting them from a network provider if you are in an HMO plan), you’re only responsible for your plan’s copayment. If you paid a copayment under Original Medicare, keep your receipts. Your plan must reimburse you for the extra amount you paid.

•  If your Medicare Advantage Plan offers a plan with drug coverage, you’re covered

by the plan for drugs not related to your terminal illness.

  If your plan doesn’t cover services from out-of-network providers, Original Medicare  will cover services that aren’t related to your terminal illness.

[el94466864]

Thanks so much for providing some Medicare documentation that further supports the fact that UHC should be fully covering the cardiology visit claims, or, if those claims are first submitted to Medicare, that UHC should be covering the copayment portion that Medicare does not pay.

The problem is that UHC is denying these legitimate claims, and, when I called, they told me that they have policies on reimbursing services, which are "hidden from the Evidence of Coverage contract." I suspect that many subscribers just end up paying for these out-of-pocket, even though UHC should be paying. This "hidden" policy sounds like fraud to me, and AARP should not have their name affiliated with UHC, if UHC is fraudulently denying claims of likely thousands of subscribers who end up on hospice.

[GailL1]

@el94466864 

It is a different process since the patient/insured is now under the Hospice umbrella of care; which at the present time is only covered by Traditional Medicare.  UHC is just letting the traditional program take the lead and making the decision as to what is appropriate care when someone is in Hospice and needs care that seems outside the realm of the Hospice care.  

Medicare will cover the care if they deem it appropriate in this instance.  IF Medicare deems it appropriate, they will cover their Medicare rate for the service at 80% and the patient/insured will pay the other 20% - you submit this payment receipt to UHC and they will reimburse you for this.  

When a patient/insured enters Hospice care, it is a difficult time for them and their family and it is a difficult time for an insurance company or Medicare.  Decisions like this have to be made and the insurance company does not want to get it wrong so they take 2nd chair to Medicare’s decision making as to what is appropriate and what is not.  Your patient’s outside hospice care may seem clear to you but a decision does have to be made and UHC wants the entity in charge of this special Hospice care to take the lead.  

It does get tricky sometimes and certain outside Hospice care could put this Hospice coverage under scrutiny and could possible be grounds for removal from the Hospice care.  Pure and simple, that’s why UHC is taking 2nd chair here and letting Trad. Medicare make the decision of coverage as to it’s appropriateness.  

They will reimburse the patient/insured if Medicare pays the claim.

You are just working under a different set of rules under the Hospice care supplied by Traditional Medicare.

You might ask why the MA plan continues and why premiums are still being paid.  This answer is simple - like the Medicare Hospice booklet that I linked, there maybe certain MA benefits that would be fine outside of the Hospice care - dental might be one or perhaps certain DME coverage that the patient/insurer needs to function - these are patient specific.  

There is nothing sinister going on here - it is just that things are getting done under Hospice care in a different manner - that’s it.  

UHC, under the MAPD plan,  does not want the decision of what care outside of Hospice care,  is acceptable when Medicare is the Hospice provider.  Go thru Medicare and if they approve the care, they will pay their part and the patient will pay their part and then the patient will get reimbursed from UHC for this care service that Medicare has approved as appropriate under Hospice care.