Wandering in the health insurance maze | Retired in Chicago - ChicagoNow

We all have stories to tell about hassles with medical practitioners and insurance companies. Stop reading if you don’t want to hear someone else’s.

Humana Gold Plus, a Medicare Advantage HMO, has mostly served me well. It even paid $2,000 toward hearing aids. Those hearing aids caused a recent annoyance — not with them but with Humana, my doctor’s office, and the hearing aid provider.

The story starts in early January when I went to Sonik Hearing at 8 South Michigan Avenue for batteries. That office sold me the hearing aids three years ago when it was HearUSA. The warranty, which included free batteries, was expiring in mid-January.

When I dropped by in the late afternoon, the hearing aid specialist was alone in the office and open to chatting. I mentioned Humana’s generous annual benefit and asked whether I should consider new hearing aids. He recommends replacements every five years, he answered, but we should send the current hearing aids for a factory check while they were still under warranty.

When the hearing aids were returned after three weeks at the factory — much longer than expected — Sonik’s receptionist called to schedule a hearing test. I assumed a test was needed because the hearing aids had to be reprogrammed. Another call from Sonik, this time from its audiologist, recommended that I ask my primary care physician at Advocate Medical Group for a referral, which she had provided in 2016. The audiologist said they’d requested a referral and been denied.

A primary care physician, as most people know, is an HMO’s gatekeeper. My PCP’s office was not swayed by a patient’s making the referral request. Explaining that my PCP is on a leave of absence (who knew), a nurse practitioner emailed that the referral was denied because Sonik Hearing is not in Advocate’s independent practice association. I wanted to argue that my PCP had referred out of the IPA when I bought the hearing aids, but my question about how to appeal wasn’t answered.

The next step was to phone Humana customer service to ask whether a PCP could deny a referral to a practice that, the Sonik receptionist insisted, is in network. The representative never got around to my question because her network list showed neither Sonik nor HearUSA at 8 South Michigan.

It was looking like I might have to pick up the hearing aids I wore for three years and take them for reprogramming to an audiologist in Advocate’s IPA. As I searched Advocate’s site for nearby audiologists, a invitation to chat popped up. The person with whom I chatted could not locate an Advocate-affiliated audiologist closer than Skokie.

After most of last Thursday was consumed by how I was going to get my hearing aids back in working order, it dawned on me that Humana’s other two supplemental benefits, vision and dental, do not require referrals. Had I really needed the referral to HearUSA three years ago? Another call to Humana was in order. A patient customer service person let me rant and then consulted her supervisors after confirming that Sonik is in network. Their opinion was that a referral is not needed to use the supplemental hearing benefit, but I could not get it in writing. The customer service person said she had no way of sending something to me.

The last straw was when I went to Sonik for the hearing test yesterday and found out that the audiologist and the receptionist were asking for a referral and insurance permission not to reprogram my current hearing aids but to sell me new hearing aids. Why they assumed that I want new hearing aids, I don’t know. The audiologist was clearly surprised when I told her that three weeks ago her boss, the hearing aid specialist, had recommended keeping my current hearing aids for five years. He wasn’t there to be asked again, but she could have figured that he would not have sent the hearing aids for a factory check if he thought they should be replaced. The receptionist should have realized I was keeping the current hearing aids when we discussed their return from the factory.

So, all that time on the phone last Thursday was misspent. No claim will be made to Humana; my current hearing aids did not need readjusting. I left wearing them and filing away the audiologist’s recommendation to replace them. “When you have an insurance benefit that entitles you to upgraded technology,” she said, “why not use it?” The hearing aids have never caused me trouble, however, so it seems they deserve another couple of years.

As I walked home, I thought that looking for reliable healthcare guidance is like wandering blind through a maze. The audiologist and the receptionist had me working the insurance angle for a purpose of which I was ignorant. The hearing aid specialist and the audiologist gave opposite opinions. Two Humana customer service representatives also contradicted each other. I could not get anything in writing from Humana. If I decide to replace the hearing aids and do need a referral from my PCP after all, I’ll be on the rollercoaster again.

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A BIT MORE ABOUT MEDICARE ADVANTAGE

Referrals aren’t necessary with traditional Medicare, for which choice is the big selling point. One can go to any practitioner. But I would not have a hearing benefit with traditional Medicare, and I would be paying lots more in premiums than Humana’s $0 a month. I’ll stay with Humana Gold Plus, at least until I replace my hearing aids.

One in three Medicare recipients choose Medicare Advantage, and the number is growing. While traditional Medicare requires buying a supplement and a drug policy, Medicare Advantage combines coverage into a single plan sold by insurance companies. Many Medicare Advantage plans offer additional benefits, such as hearing, dental, and vision coverage and fitness club memberships.

Those bothered by needing referrals from PCPs can choose Medicare Advantage PPOs instead of HMOs. PPOs allow customers to go to network doctors without referrals. Most Medicare Advantage PPOs have monthly premiums, but one, Aetna Value, has no premium. A friend of mine switched to it this year, and I’m eager to hear about her experience.

A new policy allows people insured by Medicare Advantage plans to switch plans between January 1 and March 31 as well as during the fall enrollment period. See medicare.gov if you’re interested.

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