Complaint Review: Humana Health Insurance - Internet

The reason Doctors, nurses hspitals, ect are saying they will quite and close is because they love the way things are right now. The majority of there money is coming from Medicare, Medicaid.. I was a Case manager for United Health Care for several years and do not even know where to start with the amount of Medicare abuse and fraud that I saw with my own eyes. 

I tried to discuss with managers but was reminded that my own job would be on the line. With a one payer source it woud be so much easier to monitor medicare fraud and abuse. Right now the way things are set up virtually every hospital, clinic, doctor, nurse, hospice, physical, and every type of therapy is committing medicare abuse. If they actually do get caught, right now it is just a "billing error".

Say a podiatrist cuts your grandfather's toenails because he is diabetic but bills for amputation of 3 toes. 80% to medicare, 20% to Medicaid and if the patient does not know any better, such as the elderly they are also billed say about another 20%. And any other insurances they may have are billed a "portion".

 In some instances a facility may be paid 3 times from three or four different insurances for 1 bogus claim.  Now do you get it?? Do you understand why everyone in the medical profession does not want it to change??

Hi Cathy,

First off, my best to you and best wishes for your mother.  I've been there, and it isn't easy.

To the issue here...Why your mother's Medicare Advantage plan was terminated.

To help, realize that Medicare Advantage, as offered by any insurer, is NOT a supplement plan.  It is a Medicare Replacement plan, regulated by Medicare, where the Medicare benefits are administered and paid by the insurance company (Humana in this case).  They often offer some additional benefits, such as dental, vision, or hearing benefits (sometimes), coverage for routine care not normally covered by Medicare (annual physicals), etc.  During this time, essentially, the Medicare Advantage plan is your mother's Medicare benefit plan.  A Medicare Supplement does not replace the Medicare benefits, but instead assists with or in some cases pays the remaining beneficiary responsibility after the Medicare percentage is paid.  Supplements are regulated by State Department of Insurance offices for the most part.

In the benefit package your mother received, specifically the Evidence of Coverage, there should be a page that says the "service area" of the plan she was on.  This is because CMS (Centers for Medicare and Medicaid Services), the regulatory agency (Medicare, in general speak....don't you love these terms?) approves plans for coverage in specific areas depending on the type of plan.  These service areas, depending on the type of plan or area (normally population) can be a single county, a state, several counties, or in some cases just one city.  If you live outside of those service areas, or you move outside of the service area, you are no longer eligible for that plan.  Each plan, in effect, is eligible for only one service area...

...You can see the difference if you compare the numbers on the website and the numbers on your mother's old coverage.  The format should be Hxxxx-xxx.  Those first four "x"'s are a contract number, and the second three are the "benefit package".  A certain plan type (contract) may be available in every state, but the "benefit package", in essence the actual plan and coverage, is in effect only in the CMS approved service area for that benefit package.

For example, to clarify it a bit, if you have HMO A in Dallas and you move to New Orleans, HMO A probably isn't approved by CMS for coverage in New Orleans.  So the member has to choose a new plan within 90 days.  CMS has what's called a "special election period" for this that will allow the member to re-enroll.  It doesn't mean that the company doesn't have a plan available in New Orleans, they may even have a nearly identical HMO B available in New Orleans...but Plan A wasn't approved for New Orleans, so it isn't part of their service area.

Everything hinges on these service areas.  Your mother wasn't disenrolled because of her condition, CMS doesn't allow that, and if you believe that is what happened I strongly encourage you to file a complaint with CMS so it can be investigated.  What it sounds like happened is your mother's plan was ONLY applicable to a specific service area, and when she moved out of the service area it started the clock ticking on the 90 days.  This is the same with every Medicare Advantage company, as the service areas are approved and set by CMS.  Humana may have plans available where your mother is living now, but they aren't the SAME plan (even if the benefits are identical) because your mother is now in a new service area.

To the important part, however:  Your mother cannot be denied a Medicare Advantage plan based on her health, with one exception.  CMS requires that a Medicare Advantage Organization (MAO...more lingo) accept any applicant who is Medicare eligible for a Medicare Advantage plan, with the exception of those who are diagnosed with End Stage Renal Disease.  If your mother or you on her behalf (as a duly authorized representative) chose to enroll her in one of the 12 plans available in her service area tomorrow, as long as there was an open or effective CMS enrollment period, Humana would have to accept her unless she had ESRD.  In short, the only pre-existing condition clause under Medicare Advantage plans is ESRD, and that's a denial set by Medicare itself.

I know this is trying, and I apologize for what you've been going through with this.  Keep your chin up, however, and try to get a SEP to get your mother enrolled in a Medicare Advantage plan if you need to...with Humana or anyone else.  Otherwise, remember your mother DOES still have her Original Medicare coverage...or you can try to get a Medicare Supplement, but because those are not controlled/regulated at the Federal level, state rules for coverage and enrollment will apply.

I hope Obamacare passes also.  I get so tired of those who have health care telling those without it that they are better off without socialized medicine.  Any healthcare is better than none. You don't seem to have any problem with other socialized programs such as public schools, fire and police protection.  Not to mention Medicare and Social security even the V.A.  These are all social programs.  I hear the idiots on the right complaining, "Why should they have to pay for someone else to get health care?"  Well, why should I have to pay for their children to go to school or for them to have police and fire protection.  If anything should socialized, it should be healthcare.  I hope and pray that we are seening the beginning of the death of the insurance industry.  They are bloodsuckers and leaches, all of them.  No industry should be allowed to profit from the suffering of others.  It is unconscienable but true that their profits go up with the death rates of their clients.

I really hope Obamacare goes through so I can say I told you so. If you want to hand over your freedom of choice to the government, fine. Give it six months after that and you'll be begging for the way it is now. This is how Hitler took over Germany, by the way.

Humanarep,  I'm certain that as an employee of an insurance company you have excellent insurance so you couldn't care less about people who don't, and can't get insurance.

You are dutifully spouting canned lies that you know are not true in your desperation to keep the same obscenely expensive system we have now.  You know it's crap and so do we.  It's a fact that we have the worst health care system in the industrial world and it's in the insurance industries best interest to keep it that way.  Do you REALLY think we have competition now, a bigger bunch of thieves does not exist (well, maybe used car salemen) and they stick together.

Obama is honestly trying to improve it and I sure hope he does. 

You should be ashamed of yourself.  Canada's system is far superior to ours, it's embarrasing. 

I don't know anything about Humana at all.  When my wife got sick our insurance company (not Humana) contributed to making a horrific situation even more unbearable.  They made lots of mistakes, and every mistake required a phone call from us to resolve, and a long wait, and often several attempts.  She had to have surgery using special equipment, and there was only one hospital in the county we lived in that had the equipment.  It was out of network.  They told us they would treat it as in network, I asked if that meant that it would be 100% covered (our out of pocket had been used up for the year) and was told yes by a case worker assigned to my wifes case by the insurance company.  We had to wait about a month to get in.  The week before the procedure I called the case worker and told her that I wanted it in writing that the entire balance for the procedure would be paid by the insurance company and that we would owe nothing.  She assured me that this was the case - but I insisted on getting it in writing.  She said she couldn't issue a letter but would talk with someone etc and get a letter issued to us.  3 hours later the phone rings and another person from the insurance company explains how the insurance company WILL treat the procedure as in network by paying the contract rate, but that the hospital had no contract with the insurance company - so they would charge more than the contract rate and we would end up having to pay somthing.  From looking at past EOBs the contract rate was about 60%-70% of the original billing - so in a $200,000 procedure that would have cost us $60,000 - $80,000!!  The insurance company caseworker - almost cost us big time!  And at the end of the day they would never have made it right, there would not have even been a point in asking them too.  It would have been tough luck for us.  JERKS!  $450.00 spent on airfare saved us $60k - $80k, but if I hadn't demanded it in writing we would have been in a real fix!  Don't trust any insurance company and if they tell you anything don't believe it unless it is in writing!  I don't think that they had anything to gain by tricking us - they ended up paying the contract rate either way - just to an in network provider - I think their systems and staff are just so bad that you can't rely on anything they tell you.  The problem is that protecting us from things like that is not enough of a priority to build procedures and systems that are capable of giving the customers reliable information.

I would gladly pay higher taxes to receive the kind of health care that Canadians receive.  The insurance industry is an evil empire which feeds off the blood of its victims.  They are predators.  Humana should be prosecuted for exploitation of the elderly. 

Yeah right, Bubba Lee. How much are taxes in Canada again?

Humana employee wants to politicize issue- this is not helpful to the OP.  Mom was dropped for reasons of "profit", not availability of care-

Humana was anything BUT honest.  In fact they flat out lied about not offering plans in my mother's area when they offered me 12 Medicare Advantage plans in the same area.  The only way there will be no competition is if there is no form of Public Option.  The entire premise of the Health Insurance Industry is to profit off of someone elses suffering.  The only way they make money is to take your money and not give it back when you are sick you need it. Especially vulnerable are those who cannot defend themselves such as those with Alzheimer's What could be more sinister than that???  I'm not worried about insurance paying for her nursing home.  She lives with me and I give her full time care.  What I want is her medical bills paid.  My mother paid her premiums faithfully for many years.  She should get all that money back.  I live for the day when Insurance companies are banned from profiting from their practice of exploitation of our nations sick and desperate.  Shame, Shame, Shame on all of them.

So to the idiots who think Obamas health care plan is going to spike health care costs.

Stupid people thoght this in the 1950s in Canada.

Doctors found that having been relived of the burden of dealing with hundreds of medical insurers, people they could not turn away but could not pay and so on that their costs fell so much that they could make as much and serve the needs of patients!

Wake up and smell the coffee, I would return to the USA and work as is my right if I could afford health care!!!!

IF Obama's plan goes into effect you will still have to pay for coverage - I work for a company that owns hospitals and every doctor I see is against this policy which in essence will put alot of Doctors, Nurses, Hospitals etc etc out of business

For further reference - I did my Social Work internship at a nursing home and Medicare does not pay for nursing homes, retirement homes, long term care.  Since your Mother does suffer from Alzheimers there are few options for you and her - In home 24 hour care which you will have to pay for or a nursing home.  If she has no long term care insurance in place all her assets will be liquidated to pay for her care - she will not be eligible for Medicaid until she has no assets at all unless you can cover the cost of care which runs about $5,000.00 a month and up

Good luck - been there done that and it is very hard on one emotional and financially

I don't know where you're getting these facts, but thousands of doctors will quit practicing if Obama-care goes through. Quite simply, it will pay doctor's less, so those that can quit practicing will get out. It will also establish a government monopoly on healthcare. Common sense will tell you that if a company (or in this case the government) has no competition for a service, the price will skyrocket and quality will plummet. I will admit that managed care isn't perfect, but at least you can choose your coverage and how much you want to pay. Trust me, it's just another way big brother can control you and get more of your money.

Again I'm sorry about your mom's plan, but I don't understand why you're so upset that Humana won't take your mom as a member. If that can't offer services in an area, at least they're being upfront about it.

I called Humana myself and asked about plans available in my area, (my mom lives with me) and was told that there were 12 different plans available to me yet the letter says "Your permanent address is outside Huana's Medicare Advantage service area."  So it cannot be that they dont cover this area or that they simply wanted to put her in another plan.  They wanted to be rid of her because they no longer wanted to cover her increasing bills.  You can't be serious about Medicare benefits dropping if Obama's health plan passes.  What we need is single payer!  Cut the insurance companies out completely.  Why should they profit from the suffering of others?  Put that 33% profit back into the system to cover people who would not have healthcare otherwise. 

I am an employee of Humana. I won't say otherwise. It sounds like Humana doesn't have a market or ability to sell medicare based policies in your particular area, so of course they're going to recommend that you sign up your mom with another carrier. I don't know who this Franzg guy is, but he's totally stupid. I can't say if your premium went up or not, but if it did, I don't think he realizes that everything is going up in price due to the crappy economy. I also don't think he realizes that if that healthcare bill passes, Medicare benefits will drop sharply, doctors will get paid less, many doctors will quit practicing, and your premiums will skyrocket to whatever ridiculous price the government sees fit to charge. Basically, they'll have a total monopoly on healthcare with no competition. Sounds like 1945 Germany to me.

Humana's CEO got $6.5 million last year as a reward for raising our premiums by 12%. Please complain to the DOI- there are 40-50 million uninsured Americans as a result of these sleazy practices.