Tuesday, November 22, 2011

Frustrating Carrier Tricks: Medicare vs Group

Basic rule: your group is under 20 lives, Medicare is "primary."

But what does that mean?

In simple terms, it means that if you're on Medicare, but still actively at work and on the group insurance there, your group plan becomes a sort of supplement to Medicare. Not so difficult in theory, but in practice, well, sometimes carriers make it too hard.

Take, for example, Anthem (please!).

One of my small groups has a simple plan: $30 office visit co-pays, a $5,000 deductible and some co-insurance for big-ticket items, and a prescription drug benefit. Next March, their employee Mary will turn 65, and Medicare will become the primary health insurance on her claims.

Mary's employer asked me how that would work, and requested that information in writing from Anthem. Seems pretty simple to me. Anthem knows how Medicare works, they know that it's primary for this group, and they know this group's benefits structure.

Piece of cake, right?

Well, no.

After repeated phone calls and emails, further and further up the Anthem food chain, this is what I got in email today:

"... I did hear back from customer service who confirmed we do not have something like this. You are correct that there would be too many variances with how the claims will process. We will need to see the Medicare EOB & then determine which policy is the primary. The claims area will then key the claim into the system ... they will input the information from Medicare. All of this information is taken into account, while viewing the members benefits. I hope this helps."

No, Tracy, it does not help. This is very simple: Anthem insures the group, and knows exactly how and what it will pay. This should not be a deep, dark state secret.

Cough. It. Up.
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