How Does Ma Ppo Out-of-network Reimbursement Work?

[Joe R]

I am in my initial open enrollment period and my retiree group health plan from my former employer will be ending when I start Medicare in about a month. I had been considering a High Deductible F Plan, but I do have one provider who I see regularly who does not accept any insurance including Medicare. Right now I pay his bill in full and submit an out-of-network claim. Part of the provider's fee I end up eating as it is considered beyond usual and customary, and the rest gets paid at 60%.

I want to continue seeing this provider once I go on Medicare. In the hope of getting some of his fee covered, I have started looking at a UnitedHealth MA PPO plan which is the only MA plan of that type offered in my area. It shows a $75 copay for an out-of-network specialist visit. Will I still be able to submit an out-of-network claim with the providers bill and get reimbursed the way it works with my current group plan? Will the fee still be subject to a "usual and customary" limit? A UnitedHealth "advisor" said there would not be a limit on an out-of-network claim, but I can't believe that is correct.

 

[MBSC]

I would not make a Medigap/Medicare Advantage decision based on one provider. With that said...

Will I still be able to submit an out-of-network claim with the providers bill and get reimbursed the way it works with my current group plan? Yes, submit the bill, proof of payment, and the Medical Reimbursement Form in this link. https://www.uhcmedicaresolutions.co...esources-plan-material/ma-medicare-forms.html

Will the fee still be subject to a "usual and customary" limit? A UnitedHealth "advisor" said there would not be a limit on an out-of-network claim, but I can't believe that is correct.
Yes, the MA plan uses the traditional Medicare fee schedule rate as the Usual and Customary Rate (UCR) in this scenario. Medicare fee schedule rates are low compared to commercial insurance rates.