Interesting Read for anyone on Medicare + HMO Advantage Plan

Interesting Read for anyone on Medicare + HMO Advantage Plans
Module 11 Medicare Advantage Plans and Other Medicare Plans
and please reference page 18 states:

“If the type of specialist a person needs isn’t available, the plan will arrange for care outside the network”

http://www.cms.hhs.gov/NationalMedicareTrainingProgram/Downloads/Mod11Workbook.pdf

"Before beginning a Hunt, it is wise to ask someone what you are looking for before you begin looking for it."

...Winnie the Pooh (JimmyB. playing Halloween Tricks)
Back to grindstone.
Jimmy B.

CT Scan Has been Schedule!!!!

CT scan has been schedule for Nov. 5 th 2:00 PM at Science Park in Rochester N.Y.

Still trying to setup MRI. I think it needs another referal.

Here goes Nothing!!!!
Jimmy B.

Still Waiting !!!!!!!!!!!!!!!! Preferred Care

Still working on the appeal.
Also, STILL WAITING ON THE DENIAL LETTER THAT THE REFERAL WAS DENIED ON 10/06/2008.

I should Have received the letter in 7 working days.
I think it is comming to me from Pony express.
I only have 60 days to appeal this decision or I can't appeal it.
I have already in their eyes used up one third my allotment time.

JimmyB.

The Plot Thickens--Preferred Care

Information about the National Alliance with CIGNA health care --Preferred Care

As announced in September 2006, Preferred Care, MVP Health Care and CIGNA health care have formed an alliance to offer companies with employees residing in multiple states, including upstate New York, fully insured and self-funded PPO and EPO health benefit plans. Members of these plans will access the MVP Health Care provider network locally and the CIGNA health care provider network in areas outside of upstate New York. Such plans will be offered to qualified employer groups as of July 1, 2007.
Preferred Care’s and MVP’s self-insured and fully insured PPO products will be offered to qualified employer groups through the Alliance. That is, employer groups that qualify for affiliation members can see CIGNA practitioners outside of the Preferred Care and MVP service areas. In those instances, CIGNA will manage their care in accordance with the member’s benefit plans.
Select counties in New York will be a part of the Alliance. For a listing of these counties, and other commonly asked questions and answers about the National Alliance, click here.

For Current Preferred Care ProvidersIf you practice in one of the aforementioned counties in New York, you have received, or will receive, an amendment to your participating provider contract that enables you to see CIGNA members. As a result of agreeing to the terms of that amendment, your name and practice location(s) will be listed on CIGNA’s Web-based and print directories. Therefore, you may treat CIGNA members if you have agreed to the terms and conditions of the amendment.

When treating CIGNA members, you will need to follow the CIGNA member’s plan requirements. Please click here to view the online tools that CIGNA offers to health care providers treating CIGNA members as well as contact information. There is an online demo you can view to see how to register and use the Web site. A sample of a CIGNA ID card you may see when treating CIGNA members can be viewed by clicking here. If you have questions for CIGNA health care about claims submission for CIGNA members after reviewing the information provided here, please call 1-800-8CIGNA (822-4462).

Preferred Care will be ready to work with CIGNA and you to help get payment for covered services in the unlikely event you encounter difficulties. If you are unable to rectify an issue, please contact our Professional Relations Service Center at 1-800-999-3920.

If you still have questions about the alliance, or have not received an amendment to join us in the alliance, please contact your Professional Relations representative.

Updated March 29, 2007

I will keep you posted
Jimmy B.

Still on hold !!!!!!! --Preferred Care Insurance

While I am waiting, I am on the phone with
Medicare Right Center
1-800-333-4114

I told Leslie my brief medical history ha ha. She was quite concern about what has transspired and put me on hold to help to see if this should be a legal issue. I should hear back from their office sometime next week.
In the mean time on the other extension,the case Manager Supervisor From preferred care call me to tell me that Dr. Vaughn from Eastman Kodak (Head of Medical) has contacted them and was quite concern.
Soooooooooooo now let me introduce myself.
You can call me Winne the Pooh and boy!!!! I have stirred up the hornets nest.

A little Consideration, a little Thought for Others, makes all the difference
--Winnie the Pooh

ta ta for now.
I will Keep you posted.
Jimmy B.

Some Good news!!!! ---Preferred Care

I was able to get a hold of my original oncologist at the Wilmot Cancer center here in Rochester who wrote the first letter to Preferred Care back in 2005. That letter help secure out of network service. He agreed that I should continue to receive my care at the Hillman Cancer Center.He is going to write a new letter and attach the old one and send it to preferred care.
Things are starting to fall in place.
As I am writing this I recieved a Phone call From Pittsburgh. Dr. Kirkwood's letter of necessity is on it's way.

P.S. A strange thing came in the mail with no cover letter no nothing from Preferred Care

220 Alexander Street Rochester, N.Y. 14607

It was a 6 page online search in the Preferred Care website:
Http:www.preferredcare.org/findadoctor/startSearch.do
Physician ResultsFor each physician listed below, the first report is only $12.95 and $9.95 for each additional Physician Quality Report on this order only.*Robert F Asbury, MD Rochester, NY MaleOncologyNow you have to pay 9.95 to get a listing ?????

Anyway, The list that was generated was all the Radiation/Oncology 31 doctors names addresses and phone #
"HELLO!!!! knock.. KNOCK HELLO!!!! I guess no one is home. The porch lite is flickering!!!!!
The person who sent me this list doesn't know his radiation oncologist to a medical oncolgist. They are two extremely different species. I would neeed a medical oncologist, DAH...H !

I wonder what else is coming down the road.
Jimmy B.

Here comes the Hoops!!!!!!!!!! ---Preferred Care

AS YOU CAN TELL BY MY HANDWRITING, I AM ANGRY AS HELL AND I WILL NOT TAKE NO FOR AN ANSWER.

After my donut, I am actually happy. Now I have something to pass my time.
This morning I wrote a preliminary appeals letter.
Here goes nothing:

Dear Sir or Madam,
After receiving a verbal denial of coverage on 10/22/08 I have decided to appeal your decision to deny coverage of my recommended treatment plans for Melanoma cancer from Dr. John Kirkwood at the Hillman Cancer Center in Pittsburgh , Pa..

It was stated to me over the phone that the service sought is available locally here in Rochester. I requested numerous times to you staff for a list of specialists in melanoma who could treat my type of cancer including clinical trials locally and none was given.

This is just a prelimarily letter of appeal to get the process started. I will be forwarding more supporting documentation to support my appeal in the near future.

I have enclosed a copy of Dr. Kirkwood’s credentials.

Sincerely,
James M. Breitfeller

After that, I had Medicare file a complaint on my behalf.

I also contacted the New York State Health Insurance Dept.
I am presently waiting for a call back.
In the meantime I found:
ATTORNEY GENERAL Andrew Cuomo COMPLAINT FORM
State of New YorkOffice of the Attorney General Consumer Hotline For the Hearing Impaired
HEALTH CARE BUREAU 1-800-428-9071 TDD 1-800-651-7820The CapitolAlbany, NY 12224-0341
http://www.oag.state.ny.usTel. (518) 474-8376 Fax (518) 402-2163
So if you don't hear from me for awhile, I am only a key stroke away.

It is time to roll up the sleeves!!!!!!!!!!!!!!!

Wish me luck
Jimmy B.

Managed Care Bill of Rights Article 44 of the New York State Public Health Law---Preferred Care

Managed Care Bill of RightsArticle 44 of the New York State Public Health Law

gives these rights to enrollees of managed care organizations. You may also ask the health plan for this information before you join the plan.

* You have a right to know what health care must be given to you by the plan, as well as any limits on care, and which types of health care are not covered.

* You have a right to know about any treatments or health care which your plan needs to approve in advance.

* You have a right to know what steps you can take if the plan will not cover a service. This includes the toll-free phone number of the person who will review the plan's action, how long it will take until the review is done, how to appeal the plan's action, and how to file an independent external appeal with the State.
* You also have a right to have someone speak for you in any disputes with the plan.

* You have a right to know, each year, how the plan decides on how much it will pay to doctors and health providers who belong to the plan.* You have a right to know about any fees you will have to pay, any amount you have to pay yourself before the plan will start paying, and any caps (maximums) or yearly limits on plan payments.

* You also have a right to know what you will have to pay for health care not covered by the plan.

* You have a right to know about what you will have to pay if you go to a doctor who is not part of the plan, or if you get care that the plan has not approved in advance.

* You have a right to file a grievance about any dispute between you and the plan, and you have a right to know just how a grievance should be made.

* You have a right to go to the emergency room 24 hours a day for any health problem that threatens your life. You do not need the plan to approve this in advance.

* You have a right to a list of the plan's doctors, as well as to learn which doctors are taking new patients.You have a right to know how you can change to a new doctor within the plan.

* You have a right to a see a doctor outside the plan if the plan does not have a doctor who can meet your health needs, but your primary doctor must set this up for you.

* If you need to keep on seeing a special doctor (specialist), you can ask to be allowed to see that doctor as needed, without going through your primary doctor. Your plan must explain to you how you can do this.If you have a very bad health problem that requires you to be seen by a special doctor for a long time, you can ask to have your special doctor be your primary doctor. The plan must tell you how to make such a request.

* If you have a very bad health problem that requires you to be seen by a special health care center (for example, a hemodialysis center) for a long time, you can ask to go there when you need to, without going through your primary doctor. The plan must tell you how to make such a request.

* You have a right to know how you can have input in how the plan makes its rules.

* You have a right to know how the plan meets the needs of plan members who don't speak or read English.You have a right to know the correct mailing address and phone number to be used by plan members who need to know something or who need the plan to approve a health service.

* You have a right, as a female enrollee, to see a plan gynecologist or obstetrician for at least two exams per year and for all pregnancy care, without a referral from your primary doctor.* You have a right to a list that the plan updates once a year, of the name, address and phone number of each health care provider who belongs to the plan. This includes special doctors (specialists).

* You also have a right to know the level of training that the plan's doctors have, and which ones have advanced training so they can practice in special health areas (board certification).

I don't Think They can deny me base on Acticle 44

We Shall see.
Jimmy B.

Medical Insurance denied my request for out of network service !!!! Preferred Care Advantage

Medical Insurance Preferred Care Advantage has denied my request for out of network service !!!! I am outraged!!!

I was forced to switch to Preferred Care Gold Advantage due to being on LTD for two years on August 1st 2008. Prior to switching products, Perferred care allowed me to recieve out of network care due to the lack of specialists in Rochester N.Y.

All I can say is that I am going to fight this to the end.

Today at about 1:00 pm I recieved a call from my PCP (Primary Care Physician) stating that my insurance has denied my request to see my Oncologist in Pittsburgh.

I also got a call Preferred Care stating that there is a product called Preferred Care worldwide that has service anywhere and was asked if it is one that Kodak uses. I told them that I don't think it was part of Kodak's health package.

So I called my Caseworker from Preferred Care Polly Johnston. She said she would look into it. I also called Kodak (Joann Powell) From EK Benefits. I didnot call the Kodak Employee Service Center because it just takes my phone call offshore to an Phippene Call Center.

So now my blood pressure is through the roof. I started to make a list of people I would contact if it is not resolved in my favor.

NEW YORK STATE ATTORNEY GENERAL Andrew Cuomo NEW YORK STATE Congresswoman Louis Slaughter
News Media channel 8 9 10 13

Pss, I also contacted Kodak's Head of Medical.
Now I just have to hope that they reconsider my situation.
I could use all your help. Please say a prayer that thing will get resolved

10//6/08 A New CT Scan is being Scheduled

I would just like to let everyone to know that we are presently setting up another CT scan and visit to Pittsburgh. I am having a little trouble getting a referal due to the medical insurance change to medicare and Preferred Care advantage. It looks like I have to start the process over due to the medical visit is out of network. There alway seems to be alot of hoops to jump through. I will let you know when everything is set up.Presently, I am in good spirits and my health seems fine. The leasion on my back appears to be getting smaller. I think my immune system is still active from the clinnical trial. That's a good thing. I do get tired easily, but that could be from the chemo.
That is it for now, stay in touch.
Jimmy B.