Health insurance transfer question?

Question

My grandmother recently had a stroke and has both medicare and a secondary insurance. She has been in a nursing home for the last couple of months getting occupational therapy. On April 19, the secondary insurance found that it was not medically necessary for her to continue receiving care at the nursing home while medicare found it was medically necessary. They also said they would knock grandma off the policy. I would like my grandfather to change secondary insurance companies; however, believe the coverage denial and knocking off the policy might hurt the propects of grandma being able to get coverage. Should the determination be challenged prior to any insurance shift?

Answer 1

Insurance is bizarre. You need to speak with someone knowledgeable and who can look at the actual policy as well as any proposed ones, etc. Consider the following resources:

contact your local Area Agency on Aging

http://www.n4a.org/aboutaaas.cfm

"Health Insurance Counseling - helps beneficiaries understand their options and rights under Medicare, Medicare+Choice and Medicaid and obtain information on Medigap and other insurance alternatives. "

is one specific service they offer.

To find Area Agencies on Aging and Title VI programs across the country, call the nationwide, toll-free Eldercare Locator at 1-800-677-1116.

The nursing home may have someone with the expertise to help BUT I'd STILL confer with someone from AAA--Area Agency on Aging not the auto folks :)

Consider an independent insurance agent--again, would double check with AAA but some of the leg work may be done by others first.

Good luck.

Answer 2

You didn't say what type of secondary insurance so I will guess that it's a Medicare Supplement.

First off - they cannot knock grandma off of the policy. It is against the law and Medicare regulations. The insurance company could have it's license pulled if it does.

Second - Medicare will only pay for short term skilled nursing up to 100 days and only then if there is a chance of grandma getting better and leaving the home within that 100 days. If Medicare decides there is no chance of her getting better they can decline coverage at any time within that 100 days. If they decline coverage then the insurance company will decline coverage because a Medicare Supplement will only pay for Medicare approved procedures. If she has a long term care policy that policy will then take over. If she doesn't have a long term care policy your grandparents will have to use (spend down) their assets and income until they qualify for Medicaid. At that time she may have to move because the home she is in may not be Medicaid approved. The secondary insurance is not knocking her off and will still cover other procedures, just not the home.

The coverage denial will not prevent grandma from being able to get other insurance coverage but being in a nursing home will hurt her chances with most Medicare Supplements. Medicare Advantage plans will accept her in a home but will not pay for the home either.

Answer 3

they arent going to "knock her off." that is against the law. just because shes accessing care doesnt mean she is going to be canceled (she cant).. however.. they can do an internal audit to see if its medically necessary that she continue at the rate of care she is receiving. if there is a cheaper and equally efficient method, they will stop paying for what she is doing and recommend different treatment. about other insurance.. she now has a pre-existing condition so that may be difficult (im not sure if its different for medicare supplement plans).. perhaps you need to contact her agent or the insurance company direct to get the facts because something isnt right.

Answer 4

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