HMO Coverage

[eyeglow]

What is the name of your state?What is the name of your state? California

In Jan 05, my health insurance changed my policy and will only pay 80% of my injectable medications. At the time I was using a very expensive drug to control three of my diseases. I sought funding to pay the balance which is $222. per month. After 5 months, I finally found the funding for the drug but when they called the insurance company they (the funding company) found out that the insurance company wanted them to buy the drug only from there pharmacy. However, the funding company said they needed to buy the medication from there pharmacy. So, it was a no go in getting back on the drug that has saved my life for almost 6 yrs. My doctors suggested getting on another drug that is only done inside the clinic by infusion only. Since my health insurance will only pay 80% of all injectables, my doctor and I felt that the other drug might be the way to go since it is by infusion. Now the insurance company has said that I would still have to pay 20% because the actual drug comes in a bottle which has to be injected into the infusion bag. So in there eyes, they are classifying any infusion as an injectable. Medicare doesn't so how can this health insurance do that. As it stands right now I will not be able to use any drug that would help me since they are either by injection or infusion. Is this legal to do and is there anything I can do about this? I'm on SS and have Medicare plus the supplemental health insurance which they now tell me that Medicare doesn't pay anything because my supplemental is an HMO. I need some help.

[purple2]

It is legal for your insurer to not offer payment under circumstances outlined in your policy. There is nothing you can do to force them to pay. However, you may follow your appeal process, which is described in your policy.

[MissAnnie]

This doesn't make any sense. You say that you have medicare and a supplemental HMO insurance policy, meaning Medicare is the primary insurance company and the HMO is secondary,,,If this is the case, then for an infusion therapy in the office, medicare should pay 80% as the primary insurance, and then the claim would be filed to your supplement for further payment...I have never heard of a situation where medicare will not pay because a patient has an HMO...the only situation that I can think of is that you enrolled in a medicare HMO program, meaning the HMO takes the place of your Medicare...I'm in NC, so I'm sure some of the programs are different, but we have UnitedHealthcare Medicare Complete, Partners Medicare Choice, etc. And these policies have changed their reimbursement for injectibles and infusion over the past few years...These treatments used to be covered at 100% w/ a copay on $10-$20, but now alot of them pay at 80%. I recenly became aware of a patient advocate program located in Virginia who will pay the coinsurance remaining after insurance payment for Rx, injectibles and infusion therapy..I'll do some research to see if the program is available in your area.

[purple2]

"meaning Medicare is the primary insurance company and the HMO is secondary"

Not necessarily true. There is not enough information in her post to suggest which insurance is primary. The law dictates which insurer is primary based upon several factors that were not discussed here. We don't know what parts of Medicare she has either, to determine if Medicare would even cover the office infusion.

[eyeglow]

My HMO is Health Net Senority Plus. When I joined many years ago I was told it was a supplemental health insurance and what ever Medicare didn't pay for they would pick up the balance. However, it seems that in Jan they made it a Medicare HMO which means that Medicare pays Health Net for services but it's Health Net that decides which ones will be covered. Now Health Net covers just about the same thing as if I only had Medicare... Almost everything is at 80%. As far as Medicare they've told me that because I have an HMO I can't apply for help from them to cover the balance of my drug. If I had the supplemental insurance I could ask for help.

What blows me away is that I did find the funding to cover the balance of the drug and the HMO said that the funding company needed to buy the drug from there pharmacy. And then the funding company said they needed to buy from THERE pharmacy. It's like being in a pharmacy war.

I can't believe that an HMO can do or has the right to do that to people. Especially doing it to a person that needs the drug to stay alive. They didn't want to pay the balance so I found funding... I can't see the big deal about where the drug is bought from... Is the cost of a drug (which there can't be that much difference between pharmacys) worth a life?

Thanks for listening and the help....

[eyeglow]

I forgot to answer the question about which part I had with Medicare... I pay for Part A & B....

Thanks

[purple2]

That clarifies things, since it's a Medicare HMO and you have no other insurance besides Medicare.

The Medicare HMO is allowed to make rules as to where drugs are purchased. They aren't forcing you to use certain pharmacies; they're just refusing to pay for items not purchased within the guidelines of your insurance policy.

This is really a standard practice. It may not seem fair, but it is legal. You can certainly write to your HMO and protest the policy. It may not result in anything, but it may be worth a shot.

You can also explore other coverage options. There may be a Medicare supplementary policy you could purchase, or other insurance options. People are allowed to have multiple policies.