I’M A GEEZER (it beats the alternative). I currently am insured by Anthem’s Simply healthcare Medicare Advantage plan.
For me, it simply is a mistake.
PUTTING IT SIMPLY, Simply's main problem is it’s Member Services that, since January 1, seems to be staffed by people who are unable to comprehend simple English.
Because Simply has a unique way of handling referrals – something not covered in the Evidence of Coverage (EOC) – I am forced to deal with Member Services.
- For example, in order to see an ophthalmologist, I am forced to see an optometrist; my Primary Care Physician (PCP) – who I see quarterly – cannot make a referral to an ophthalmologist, despite the fact that I am a Type 2 diabetic. A visit to an ophthalmologist for a diabetic is required in the EOC.
Now, the optometrist was a good guy and – although he, too, thought having a referral through his office was something my PCP could/should do – and he made the referral. (I still have been unable to contact the ophthalmologist’s office; another problem.)
Referrals to an orthodontist has to be approved not by Simply but by its contract agency based on a general dentist’s recommendation.
ANYWAY, I sent an email to Simply's Member Services and asked what I needed to do to see a dental specialist.
- Funny enough, Simply lists pedodontists! it ins list of dental providers. A pedodontist, according to the Kool Smiles web site1 is a dentist who specialize in pediatric dentistry – dentistry for your children. Mind, my Simply is a Medicare Advantage plan for people 65 years old and older (please, not “65 or over). I seriously doubt a person on Medicare age needs a pedodontist.
In my initial email I provided my Member ID and my email for the reply.
Several days later I noted the message light on the phone blinking.
Someone in their Member Services mentality called. Based on the caller’s comments, it was blatantly obvious that the caller had no concept of my query.
I sent another email, again specifying what I needed and explicitly telling Member Services to reply by email – NOT by phone.
Proving Member Services simply can’t comprehend English*, a Sweet Young Thing (SYT) called the house. Remember? I specifically wrote to respond by email. I want to avoid “he said, she said” debates. The SYT launched into her spiel, but I managed to stop her in mid-sentence – that would have been rude, but she failed to follow instructions --- and finally convinced her to put the information into an email.
- * Over the years I have successfully labored as a newspaper reporter and editor, a PR flack, and a technical writer in the U.S. and elsewhere.
The email arrived … it failed to accurately respond to my query and it included what, I’m sure, the SYT thought helpful – three dentists in my ZIP code – but distant from my residence.
At this point I simply gave up on Simply Member Services..
Had the SYT simply responded to my query:
- Can I see any provider on the list? Yes/No
- No
- Probably “General Dentistry”; I could gave found a practitioner close to my residence
One other simple complaint about Simply: The company has too few providers in my area. If I want to travel to Miami – I don’t – than Simply might be acceptable.
Simply can be compared to a store that advertises a product at an unheard of low price, but only has one or two of the sale items – maybe in the future it will come closer to meeting its members’ needs.
SINCE I JOINED MEDICARE, I have had four plan providers, one twice (and on January 1, 2019, thrice): AvMed, Humana, United Healthcare’s Preferred Care Partners, and now Anthem/Simply.. None have been wholly satisfactory.
Humana introduced me to “capitated” Primary Care Physicians (PCPs). Basically that means that while Humana has a long list of providers, each PCP had a much shorter list of providers to whom the patient could be referred.
Lesson learned: I now check to assure that my PCP can refer me to any provider on the plan’s roster.
United Healthcare/Preferred Care offered a $45/month Over The Counter (OTC) allowance the first year I was with the plan. Then, the allowance was reduced to $25 per quarter.
United Healthcare didn’t give me the providers I wanted; another strike against the company. On the other hand, all my prescriptions were no cost (either Tier 1 of Tier 2); more on that later.
Simply was not as generous with its OTC allowance as United Healthcare HAD been – it’s allowance is $25/month, and, like United Healthcare, all my medications were free to me but my providers were not the ones I wanted (specifically Hollywood Memorial and my vascular surgeon).
- The local Publix supermarket pharmacy gets all my business. Publix absorbs the cost for several of my medications; the insurer never sees a charge for the medications Publix gives free to all who need the drug.
All of the one-time plans had my current PCP so at least I knew my doctor.
Which brings me to AvMed.
AvMed was my first Advantage plan provider. When I was shopping, I talked to several plan representatives. What the AvMed rep told me – which proved to be true – is that while AvMed only offered five “free days” in a hospital, most hospital stays were five days or less. Three operations (at Memorial) later, I’m satisfied the AvMed rep was right. (The three operations were (1) an open Abdominal Aortic Aneurysm repair (a/k/a Triple A), (2) a FemPop bypass, and (3) a hernia repair.)
Because of my vascular history, when I was with Preferred Care I got a referral to a vascular surgeon at a prestigious clinic/hospital. The surgeon ordered – for the same day – an ultra-sound scan and an MRI. With my AAA, first there was the ultrasound, to determine if there WAS an aneurysm and where it was hiding. The dye and MRI came later so the surgeon knew exactly what was needed.
Had the ultra-sound (ordered by my then PCP) failed to show the aneurysm, a referral to the vascular surgeon and the dye and tube would have been unnecessary.
- I am what is known as a Claustrophobic with a capital “C.”
Why order all the tests simultaneously rather than serially? Money, Money for the clinic/hospital. Money for the vascular surgeon. Would United Healthcare care? No and no again. The taxpayer would have paid the bill. (Medicare plans get more than my token monthly payment; the more the plan spends, the more the Federal government pays to the plan.)
AvMed and I parted company once when either AvMed canceled my then PCP’s practice or my then PCP’s practice canceled AvMed.
I left AvMed again because it was charging me what I deemed too much for one of my prescriptions.
The drug had a co-pay for a 90-day supply of $75 – more than the local pharmacy changed retail.
Both United Healthcare and Anthem’s Simply list the medication as Tier 2: $0 co-pay. AvMed lists the medication at Tier 3.
Suffer the loss of my preferred hospital and vascular surgeon or spend $300/year for co-pays (that I might claim as a tax deduction). But, based on past experience, get Member Services personnel who know how to comprehend simple English.
Tough choice.
Sources
**1. http://tinyurl.com/y9qvcwlx
PLAGIARISM is the act of appropriating the literary composition of another, or parts or passages of his writings, or the ideas or language of the same, and passing them off as the product of one’s own mind.
BCPLANNER: Comments on Simply insurance
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