Illinois Retired Teachers: Are the details regarding our Medicare Advantage PPO misleading?

“You have the ability to see any Medicare provider without the constraints of a network.”
Then why are there networks? In my opinion the above statement is misleading, especially when the details are closely examined.

“Your health insurance does not cover what its says is covers. You, personally, must pay whatever amount that out-of-network hospital wishes to charge you.”
– My own paraphrase

Unfortunately, I am forced to paraphrase what I have in (emailed) writing from the State of Illinois Retiree Medicare Advantage Program provided by the State of Illinois UnitedHealthcare Medicare Advantage PPO.

“When any out-of-network provider is not willing to bill UnitedHealthcare directly, the retiree can be billed for any amounts above the Medicare Allowable amounts. The retiree is financially responsible for whatever charges the provider designates as billable.”
– My own paraphrase

Why must this be my paraphrased message?
The bottom half of the email response I received from UnitedHealthcare has the following at the bottom of the page.

“This e-mail, including attachments, may include confidential and/or
proprietary information, and may be used only by the person or entity
to which it is addressed. If the reader of this e-mail is not the intended
recipient or his or her authorized agent, the reader is hereby notified
that any dissemination, distribution or copying of this e-mail is
prohibited. If you have received this e-mail in error, please notify the sender by replying to this message and delete this e-mail immediately.”

I choose not to martyr myself as a whistle blower by stating the actual words of the email. I will disclose nothing that would allow me to be sued or prosecuted.

However, here is the specific written information given to all retired teachers as stated in the actual “Your Retiree Healthcare Decision Guide” for employees who need the more expensive PPO coverage. (None of this is about being taken to the nearest hospital as an emergency – such as an accident or a heart attack.)

TRAIL Booklet



“With the UHC PPO, you will not have the restrictions of out-of-network coverage. So even though UHC has a network of providers, if you receive care from a provider not in the UHC network (i.e., an out-of-network-provider), the PPO plan pays those providers the same amount Medicare would have paid; you pay the same out-of-pocket percentage as if you had received in-network care.” page 15

Also on page 15, posted as a jpeg above, is the following:

“You must pay the bill and submit a request for reimbursement to UHC for payment. UHC will then reimburse you the Medicare allowable amount, minus any deductible or coinsurance for which you are responsible.” (bold face is mine)

You are responsible for the rest, whatever the total may be.

When the bill goes to you for whatever an out-of-network charges you, you are financially responsible for the bill.
Remember that an out-of-network provider has no obligation to charge the same as an in-network provider. That is why they are out-of-network. The same out-of-pocket percentage of a larger amount could be a hell of a lot of money, money you accepted as a personal debt.

Above is a scan of the actual program.”Without the constraints of a network” is not totally accurate in my opinion.

Is this misleading, a lie, misinformation, a scam, disinformation, fraud, an egregious error, political-corporate collusion, theft, or any one of the above? Only a lawyer could figure out which it is. Because of the corruption called government in Illinois, many of us no longer trust the goodwill of the state legislature.

Part 2: —————–

After days of spending hours on the phone with local hospitals and the employees and supervisors of the UnitedHealthcare Medicare Advantage PPO, I was told repeatedly that additional information was not available to me, an employee covered by the plan, in writing.
A secret-public healthcare plan?
Finally, one supervisor emailed me the statement below.
“When any out-of-network provider is not willing to bill UnitedHealthcare directly, the retiree can be billed for any amounts above the Medicare Allowable. The retiree is financially responsible for whatever charges the provider designates as billable.”
– My own slightly paraphrased account for reasons mentioned above

This is what harms, financially and emotionally, retirees across America. Information distributed by UnitedHealthcare Medicare Advantage PPO, chosen by Illinois politicians, can break retired teachers who believe the broadly stated language in this plan without seeking further details which are difficult to obtain.
What other secret-public healthcare language exists in a longer list of detailed billing information? Why is this information not readily available to all potential members prior to their making a momentous decision?

Please get this information out to all of the Illinois retired teachers in your contact lists. Retirees must demand to be given factual, detailed, and unobscured information regarding their selection for coverage.

(I offer one suggestion for all Illinois retirees regardless of what state you may personally reside in today. Stay in-network. The pressure of unexpected bills and personal responsibility for debt should not be risked while you are undergoing serious illness and/or surgery.)

—–

 

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About Ken Previti

https://reclaimreform.com/
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6 Responses to Illinois Retired Teachers: Are the details regarding our Medicare Advantage PPO misleading?

  1. 2old2tch says:

    I am convinced that insurance carriers go to school to learn how to write incomprehensible explanations that will stand up in court once the lawyers decipher it. No explanations should be sent to policy holders unless the policy documents can be paraphrased by a high school student in terms that their younger siblings will understand.

  2. Opa says:

    Now in the second year of the UHC PPO. Have experienced no problems after the initial confusion of many providers who, perhaps, didn’t like the traditional UHC plans that have been around for years. Understanding the difference was the key to their willingness to participate. One local clinic agreed reluctantly to “give it a try” in year one. In year two, no issue at all. In fact, for most providers it is better than what we SURS folk had before, namely Medicare + CIGNA. CIGNA could only pay when the state provided the funds, meaning a wait of 9-12 months was common. UHC pays promptly and, as best I can tell, just as much. We had large 6-figure bills for major surgery and spent only the out-of-pocket max of $1300. We also travel a lot and have received service outside of IL without problem. I have heard that, for unclear reasons, Mayo in Arizona will not accept the plan, but in Rochester it does. Go figure.
    Retired colleagues who didn’t trust the plan in year one stayed with traditional Medicare and bought supplements. Once the IL Supreme Court ruled the state could not charge us premiums for our healthcare, most have joined UHC in year 2. Those of us who “gambled” in year one got our premiums refunded. Those who bought supplements, got nothing back. I realize TRS folk don’t have the same in and out options that SURS offers (why, I don’t know). However, so far my conclusion is that UHC PPO is a perfectly good plan and works well. My only concern is that Rauner’s current negotiations with AFSCME could lead to changes that we won’t like at all.

    • Ken Previti says:

      I live about five miles between the two hospitals closest to me in Florida. Neither is willing to accept the Illinois UHC PPO without billing me directly and having me forward bills to the insurance company. I was told by people who work in the billing departments at each hospital that I would be at great financial risk to go to any doctor or hospital outside of network no matter what the “large print” claimed.

      • Opa says:

        That’s interesting, but also unfortunate. I have former colleagues across the country and have yet to hear of anyone experiencing what you have. I do know that Mayo Clinic in AZ has declined to accept the UHC-IL plan, but Rochester does. Go figure.

  3. Daniel A Ferreira says:

    The key is: Medicare provider.

    • Ken Previti says:

      I live about five miles between the two hospitals closest to me in Florida. Neither is willing to accept the Illinois UHC PPO without billing me directly and having me forward bills to the insurance company. I was told by people who work in the billing departments at each hospital that I would be at great financial risk to go to any doctor or hospital outside of network no matter what the “large print” claimed.

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