Tag: insurance

Snake oil

Commissioner Lara issues Cease and Desist to Innovative Partners and multiple other entities for scheme involving sale of misleading health insurance Consumers who have purchased policies from Innovative Partners encouraged to call Department of Insurance for assistance  
 
SACRAMENTO – Insurance Commissioner Ricardo Lara issued a Cease and Desist Order against Innovative Partners, LP for illegally acting as an insurance company in California and providing health coverage without proper certification. The Department also has served 10 additional Cease and Desist Orders on multiple entities as well as licensed and unlicensed individuals that aided and abetted Innovative Partners, LP in these fraudulent activities.
“We will use every tool at our disposal to protect consumers,” said Commissioner Lara. “When Californians purchase health coverage they deserve the full confidence the coverage they are promised will be there when they need it. Selling insurance without the proper licensing or certification is against the law and puts consumers health and financial well-being at risk.”   The Department launched an investigation after receiving information that California consumers were having their claims improperly denied after purchasing and attempting to use health coverage sponsored by Innovative Partners, LP (Innovative Partners). The investigation found that beginning in 2023, Innovative Partners defrauded victims by selling them limited or non-existent health coverage and convincing them they were purchasing comprehensive insurance plans. Many of these victims believed they were speaking with representatives from Covered California and purchasing comprehensive Blue Shield or Aetna policies. However, when the victims attempted to use their coverage, they found the coverage was limited or non-existent and would not cover the medical expenses they were told were covered with their policy.  
Innovative Partners is not partnered with Covered California. Upon purchasing health coverage, consumers were given plan cards with Innovative Partners branding. These cards often listed PHCS and Group Resources as claim handlers, while some cards also listed portal information for First Health Network and/or Marpai Administrators LLC. Other plan cards also included Teladoc Health Inc. contact information.
Consumers also experienced issues with lack of coverage for medical benefits they were promised. For example, one consumer signed up for a policy they were told was an Aetna Gold PPO plan through Innovative Partners which would cover his mental health appointments, and could start immediately without a waiting period. He received an ID card which included First Health Network and Marpai Health portal information. The consumer visited his therapist twice, and was then told that the insurance was not covering the care. After contacting both of the numbers on the back of the card he was given, a representative assured him he did have coverage for mental health. Trusting what the representative told him, he continued with his mental health treatments believing he did have coverage, but Innovative never paid for the treatment and the consumer was left with more than $1,700 in unpaid medical bills.
In another case, a small business owner was looking to purchase new health insurance after his business slowed causing him to become ineligible for his prior coverage. The consumer stated that the issue began after he tried to purchase a policy through Covered California and gave up due to cost. He then received a call from Innovative Partners who claimed that the consumer qualified for their plan due to his low income, and he would receive full coverage for $400 per month. Upon signing up, the consumer specifically asked about E.R. visits and was told that the plan covered up to two visits, per year, with a $50 co-pay. The consumer confirmed coverage with two separate Innovative Partners representatives and thereafter visited the E.R. using his Innovative policy. The consumer discovered that the represented coverage did not exist when he started receiving calls from collections agencies, and he was left with around $11,000 in debt.
Innovative Partners disguised their activities as a single-employer health insurance plan under the Employee Retirement Income Security Act of 1974, masking the sale and selling of health insurance as a “Small Employee Benefit Plan” even though the consumers did not claim to be employees of or partners with Innovative Partners.
Innovative Partners does not have authorization to transact insurance in California and does not hold a certificate of authority to transact business in California.
Consumers who have purchased health coverage through Innovative Partners, LP or any of the below entities or licensed and unlicensed individuals should contact the Department of Insurance at (714) 712-7600.
Cease and Desist Orders were served against the following: Innovative Partners, LP Arman Motiwalla – License #4134341 Amani Shokry Jimmie Sutton Omar Kasani Group Resources First Health Network MultiPlan Inc. PHCS Marpai Administrators LLC Teledoc Health Inc.  

PEO Caught With No Coverage By WCAB Judge

Proven illegal MEWA organizations, including the American Labor Alliance and CompOne USA.

Vol: 35 | No: 2 | Published on: January 22, 2025

A workers’ comp claim by an employee of a Professional Employer Organization is exposing some of the industry’s dirty secrets. The claim was headed to resolution through a compromise and release settlement, but a vigilant workers’ comp judge blocked the deal. He questioned the adequacy of the offer and repeatedly demanded to know if the PEO had insurance. It admitted it didn’t and that’s generated a host of other issues for the PEO and several other employers.

Employers Outsourcing is the original defendant in the workers’ comp case. It was a claim filed by Martin Vazquez for cumulative trauma (CT)  injuries to multiple parts of his body, including his head, hand, eye, and upper extremities.

Employers Outsourcing initial appearance was alongside something called Firestone Labor Union and Prime Administrators. Firestone was providing Vazquez with purported workers’ comp benefits under ERISA.

The scheme appears eerily similar to what was marketed to California employers by the now discredited and proven illegal MEWA known as American Labor Alliance and CompOne USA.

Workers’ Compensation Appeals Board records indicate that Employers Outsourcing repeatedly avoided answering questions about its workers’ comp coverage or carrier. Finally, a diligent workers’ comp judge, Hon. James Finete, ordered Employers to disclose the name of its carrier, “Petitioner took the position that so long as it identified itself as an employer that it was not required to disclose its insurance carrier,” he noted in a report.

Judge Finete forced the issue of disclosure after Employers sought to join the insurance carrier of another employer on the claim but not the employer itself. Meanwhile, Employers still had not disclosed the identity of their own carrier.

When faced with sanctions for failing to disclose the name of its carrier, Finete says that Employers changed its story. “In the response, Petitioner did an about-face and asserted that ‘there is insurance in place but have chosen to utilize the union benefits for this claim.” Employers continued to assert that it was not required to disclose its insurance coverage.

Lots of Big Dirty Secrets

The case sheds light on several dirty industry secrets. Among them is that workers comp defense attorneys routinely represent and protect uninsured employers and get settlements approved through the WCAB. The employer pays those settlements directly to the injured employee. The employer’s uninsured status is kept out of the case—read hidden from the Judge—which allows them to avoid any penalties for operating illegally.

Certain PEOs, TEMP agencies, and private employers are flaunting Labor Code section 3700’s requirement that they be insured or possess a valid certificate to self-insure. Worse, they are getting away with it.

Defense attorneys who asked to remain anonymous and others familiar with the industry explain.

Word is that illegally and intentionally uninsured employers such as temporary services and PEOs sometimes provide legitimate employers with false certificates of insurance. In addition, they skip paying workers comp premium and settle and pay claims themselves. There are no reserves or anything else. Their payroll and premium are not reported to the Workers’ Compensation Insurance Rating Bureau. The scheme is so pervasive in California that ratemaking is likely to be adversely impacted for honest employers.

The scofflaws become more competitive relative to their honest competitors because they charge less for “workers’ comp,” avoid paying premium and just pay claims as they happen. In some cases, one organization has multiple Tax IDs and buys insurance under the smallest or the one with the least dangerous classes. If claims get too big in the others where they don’t report payroll, they report the claim under the insured entity.

Defense attorneys tell Workers’ Comp Executive that intentionally uninsured employers deserve a defense “just like any other criminal.” However, they say attorneys can’t turn them in because of privilege issues.

Workers’ Comp Executive’s investigation reveals that a surprising number of defense attorneys represent these businesses and that WCAB judges almost never ask about insurance because “as long as the claim gets paid who cares?”

No UEBTF…Yet

Department of Industrial Relations officials note that the Uninsured Employers Trust Fund pays injured workers when employers have no insurance. The fund is then supposed to collect any judgment from the illegally uninsured employer. The workers’ comp judge can make a claim to the UEBTF on behalf of the worker if their employer is uninsured but is not required to do so. However, if the uninsured employer is paying the claim, there is nothing for the UEBTF to do.

Nor are judges required to report uninsured employers to those who enforce and have the power to shut down the uninsured.

The UEBTF hasn’t been joined to this case, but the WCAB’s case management system shows that numerous other staffing agencies and employers have been joined.

Those include:

  •   Horizon Personnel Services,
  •   Simplify HR and
  •   J&J Snack Foods.

Starr Insurance and the Travelers have also been pulled into the proceedings. Case documents say that Employers provided PEO services for Horizon Personnel but confirmed that it did not have a workers’ comp insurance policy.

When the issue of joining the UEBTF to the case was raised, Employers argued against the idea. To support its argument, Employers claimed to have coverage for Vazquez’ workers’ comp claim.

“The insurance in place that EO referenced in the Objection dated December 22, 2023 referred to coverage by co-employer and EO affiliated company, Simplify HR, Inc., whose California workers’ compensation insurance carrier for the relevant time period was State National Insurance Company, Inc., and by the jobsite, J&J Snack Foods, whose California workers’ compensation insurance carrier for the relevant time period was, on information and belief, Travelers Property Casualty…EO itself does not have a California workers’ compensation insurance policy covering this claim.”

As a CT claim, there is a one-year window of exposure preceding the date of injury that can extend liability for the claim to other employers who might have employed Vazquez during this period. “Rather than join UEBTF on a CT claim, this Court attempted to determine whether there was other coverage available to this Applicant via the other putative employers disclosed by Petitioner,” noted Judge Finete.

MEWA Connection – DIR Fails

Employers’ initial appearance in the case was in conjunction with Firestone and Prime Administrators. Details from the case show that Employers was providing benefits to Vazquez through Firestone’s workers’ comp program, with the claims administered by Prime.

The organization and the benefits offered by Firestone appear to follow the scheme referenced above that Marcus Asay orchestrated through American Labor Alliance and CompOneUSA. Like Firestone, Asay’s program claimed to provide ERISA-based workers’ comp benefits under the rules of a multi-employer welfare arrangement (MEWA) as an entity claiming exception from California workers’ comp laws. Asay claimed that the organizations and products were exempt from state regulation. California has no such exemption.

Filings in the Vazquez case included a letter from the Manock Law defending the benefits that Firestone was providing. Previously, Charles Manock defended Asay and American Labor Alliance  in front of the California Department of Insurance as it sought to shut it down and in related court actions.

The California Department of Insurance found that Asay’s program was illegal. The Department of Industrial Relations held that the benefits did not satisfy the requirement that an employer obtain workers’ comp insurance or a certificate to self-insure.

Case Proceedings

The WCAB notes that it gave notice of intent (NOI) to join Simply HR, J&J Snack Foods, and Horizon Personnel on March 4, 2024. Finete ordered Employers to serve notice of intent for joining them to the case.

On April 3, 2024, Employers attempted to walk through a Compromise and Release settlement for $80,000 with a different workers’ comp judge but was rebuffed. The workers’ comp judge said the issue couldn’t be settled due to the potential sanctions Employers was facing. The day after the C&R was rejected, Employers belatedly served the NOI on the other parties.

Judge Finete issued an order suspending action on the C&R and set a trial for last May. Employers filed a premature petition for reconsideration, which automatically stayed the trial. A new trial has not been set, but there is a mandatory settlement conference next month.

Copies of Judge Finete’s opinion and order dismissing Employers’ petition for reconsideration is available in our Resources section or by clicking here.

Posted in and tagged staffing/PEO, WCAB

Operating Without Workers’ Compensation Insurance in California

I. The Problem: Operating Without Workers’ Compensation Insurance in California

  • Legal Mandate: California Labor Code Section 3700 unequivocally states that all employers with one or more employees must provide workers’ compensation benefits. This explicitly includes employees hired through staffing agencies. Both the staffing agency and the client company can share responsibility for worker safety and workers’ comp coverage.
  • Tactics to Avoid Coverage:
    • Misclassification: A common tactic, especially for staffing agencies, is to misclassify employees as “independent contractors” to avoid paying workers’ comp premiums, payroll taxes, and other employee benefits. California has been aggressive in cracking down on this.
    • “Underground Economy”: Some businesses simply operate completely off the books, without any insurance.
  • Risks and Consequences of Non-Compliance: California imposes some of the most severe penalties in the nation:
    • Criminal Offense: Failing to have workers’ compensation coverage is a misdemeanor under California Labor Code Section 3700.5.
      • Punishment: Up to one year in county jail, and/or a fine of up to double the amount of the premium that would have been necessary to secure coverage (but not less than $10,000).
      • Subsequent violations lead to even harsher penalties (e.g., up to one year in jail and a fine of triple the premium, but not less than $50,000).
    • Civil Penalties (Fines):
      • Stop Order: The California Division of Labor Standards Enforcement (DLSE) can issue a “stop order,” prohibiting the use of any employee until coverage is obtained. Failure to observe a stop order is a misdemeanor (up to 60 days in jail and/or a $10,000 fine).
      • Stop Order Penalty: A penalty of $1,500 per employee on the payroll at the time the stop order is issued, up to $100,000.
      • Penalty Assessment Order: The greater of (1) twice the amount the employer would have paid in premiums during the uninsured period, OR (2) $1,500 per employee. If an injured worker files a claim, the uninsured employer can be assessed a penalty of $10,000 per employee on the payroll at the time of injury, up to a maximum of $100,000.
    • Personal Liability: If an employee is injured while the employer is uninsured, the employer is personally responsible for all medical bills, lost wages, and disability benefits. This can be financially devastating.
    • Civil Lawsuits: Injured employees can file a civil action against the uninsured employer in addition to filing a workers’ compensation claim. In these civil cases, the employer is presumed negligent and loses common law defenses. The employee may also be entitled to have their attorney’s fees paid by the employer.
    • Uninsured Employers Benefits Trust Fund (UEBTF): This state fund pays benefits to injured workers of illegally uninsured employers. However, the UEBTF then aggressively pursues the uninsured employer for full reimbursement, plus penalties.
    • Business Reputation: Operating without proper insurance can severely damage a business’s reputation and trust among employees and clients.

II. Prosecution and Enforcement in California

California employs multiple agencies and strategies to prosecute uninsured employers, including staffing agencies:

  1. California Department of Insurance (CDI) – Fraud Division:
    • The CDI’s Fraud Division is a key player in investigating workers’ compensation fraud, including “premium fraud” (employers misstating payroll or employee classifications) and “uninsured employer fraud.”
    • They work closely with local district attorneys’ offices across the state to prosecute violators.
    • The CDI maintains a public website listing Workers’ Compensation Fraud Convictions, detailing the name, case number, county, description of offense, and amount defrauded. This is a valuable resource for finding specific prosecution examples. (e.g., you can browse monthly conviction lists from 2020-2024 on their site).
    • Source: Workers’ Compensation Fraud Convictions – California Department of Insurance
  2. Local District Attorneys’ Offices (DA’s):
  3. California Division of Labor Standards Enforcement (DLSE):
  4. Workers’ Compensation Appeals Board (WCAB):
    • If an injured worker files a claim against an uninsured employer, the WCAB hears the case. If an award is made to the worker, the UEBTF pays, and the employer is then pursued for reimbursement and penalties.
    • Recent legislative efforts (like the Senate Bill S847 mentioned in one search result from May 2025) are aimed at strengthening the Director of the DIR’s ability to identify uninsured employers, place liens on their property, and recover funds for the UEBTF.

III. Resolution and Solutions

When a staffing agency or other employer is found operating without workers’ compensation insurance in California, the resolution typically involves:

  1. Securing Immediate Coverage: The business is compelled to obtain workers’ compensation insurance. Stop-work orders remain in effect until this is done.
  2. Payment of Fines and Penalties: Substantial civil penalties and administrative fines are assessed for the period of non-compliance.
  3. Restitution: If an employee was injured, the employer must reimburse the UEBTF for any benefits paid to the injured worker.
  4. Criminal Prosecution: Depending on the severity and intent, individuals responsible within the staffing agency can face misdemeanor charges, potentially leading to jail time. Felony charges are possible for more severe fraud or repeat offenses (e.g., lying to reduce premiums, as mentioned by the Shasta County DA).
  5. Liens and Asset Forfeiture: The state can place liens on the employer’s property (including real estate) to recover unpaid benefits and penalties.
  6. Increased Scrutiny: Staffing agencies, in particular, face ongoing scrutiny due to the shared responsibility for temporary workers and the historical issue of misclassification.

In essence, California’s system is designed to make operating without workers’ compensation insurance extremely costly and legally perilous for any employer, including staffing agencies, with a focus on protecting injured workers and maintaining a fair business environment.

find specific articles of these happenings and prosecutions in california

You’re in luck! California is very active in prosecuting workers’ compensation fraud, including cases where employers (sometimes staffing agencies or companies using their services) operate without proper coverage. The California Department of Insurance (CDI) is a key player and publishes information on convictions.

Here are some specific articles and resources detailing prosecutions in California:

1. Recent Convictions and Press Releases from the California Department of Insurance (CDI):

The CDI has a dedicated section for “Workers’ Compensation Fraud Convictions” where they list recent cases. This is an excellent source for specific examples.

  • San Jose security company owner sentenced in $3.4 million workers’ compensation fraud case (May 19, 2025):
    • Details: Raul Chavez, owner of Tactical Operations Protective Services (a company providing security guard, staffing, and patrol services), was sentenced for a six-year scheme to underreport payroll and avoid paying workers’ compensation premiums. He concealed over $3.4 million in payroll, resulting in $205,565 in unpaid premiums. He pleaded guilty to felony premium fraud, received 180 days in county jail, two years probation, and ordered to pay restitution.
    • Relevance: This is a very recent and highly relevant example, as it directly involves a company that performs “staffing” services.
    • Source: California Department of Insurance Press Release
  • CDI Workers’ Compensation Fraud Convictions Database:
    • The CDI explicitly states they post convictions for violations of various codes, including Labor Code Section 3700.5 (failure to secure payment of compensation). You can browse monthly lists of convictions.
    • How to use it: Go to the CDI’s website and navigate to their “Workers’ Compensation Fraud Convictions” page. From there, you can select specific years and months to see detailed lists of convictions, often including the name of the convicted party, the county, a description of the offense (which often includes operating without coverage or premium fraud), the amount defrauded, and the punishment imposed.
    • Source: Workers’ Compensation Fraud Convictions – California Department of Insurance

2. Local District Attorney (DA) Offices Prosecutions:

California’s county District Attorney offices are on the front lines of prosecuting these cases. Many have dedicated fraud units. While I can’t link to every single case, here are examples of their programs and what they report:

  • Merced County District Attorney: Their website highlights that it is illegal for an employer to operate without workers’ compensation insurance (CA Labor Code Section 3700.5) and outlines the penalties, including up to one year in jail and/or a fine of up to double the premium owed, but not less than $10,000. They also mention that they receive reports from the CA Department of Insurance Fraud Hotline.
  • Shasta County District Attorney: Also has a Workers’ Compensation Insurance Fraud Program and details penalties for both employees and employers, including for “Employer Fraud” (lying to their insurance company about the number of employees, which leads to underpaying premiums or operating uninsured).

3. Precedent-Setting Cases (Employer Liability for Bogus PEOs):

Sometimes, the “staffing agency” itself might be operating illegally, or an employer might contract with a “Professional Employer Organization (PEO)” that is bogus and doesn’t provide legitimate workers’ comp. California courts have addressed this.

  • “Precedent: Employer Held Liable For Bogus PEO” (February 12, 2025):
    • Details: This article from Workers’ Comp Executive discusses a landmark decision where an employer, Garcias Pallets, was held liable for over $1.3 million in penalties for operating without valid workers’ comp coverage, despite having contracted with PEOs whose coverage was “bogus.” This highlights the due diligence required by businesses when using labor contractors or staffing solutions.
    • Relevance: This shows how an employer can be held liable even when they thought they were getting coverage through a third party (like a PEO or staffing agency) that was not legitimate.
    • Source: Precedent: Employer Held Liable For Bogus PEO | Workers’ Comp Executive

4. Large-Scale Fraud Rings (often involving shell companies/labor brokers):

While not always explicitly “staffing agencies,” many large workers’ compensation fraud schemes involve networks of shell companies, labor brokers, or fake businesses designed to avoid premiums or exploit workers.

How to find more specific cases:

  • Directly search the CDI’s “Workers’ Compensation Fraud Convictions” database. It’s the most direct route for official convictions.
  • Search District Attorney websites: Look for press releases from California county DAs, specifically for their “Workers’ Compensation Fraud Unit” or “White Collar Crime” sections.
  • Use more targeted keywords: If you know a specific county, industry (e.g., construction staffing, agricultural labor contractors), or a time frame, add those to your search.

These resources provide concrete examples and demonstrate the rigorous enforcement efforts in California against employers, including those in the staffing industry, who attempt to operate without the legally mandated workers’ compensation insurance. Sources

Workers’ Comp Executive

www.wcexec.com

PEO Caught With No Coverage By WCAB Judge | | Workers’ Comp Executive

“The insurance in place that EO referenced in the Objection dated December 22, 2023 referred to coverage by co-employer and EO affiliated company, Simplify HR, …

California Department of Insurance

www.insurance.ca.gov

Workers’ Compensation Fraud Convictions – California Department of Insurance

Enforcement Overview / Fraud Division Overview / Workers’ Compensation Fraud Convictions.

Yrulegui & Roberts

www.rjylaw.com

What is the Legal Definition of Workers’ Compensation Fraud in California?

Some of the most common examples of workers’ compensation fraud in California include: A False Claim by an Employee: As an example, someone might claim they …

California Department of Insurance – CA.gov

www.insurance.ca.gov

San Jose security company owner sentenced in $3.4 million workers’ compensation fraud case – California Department of Insurance

News: 2025 Press Release. For Release: May 19, 2025. San Jose security company owner sentenced in $3.4 million workers’ compensation fraud case. SAN JOSE, Calif …

Merced County

www.countyofmerced.com

Workers’ Compensation Insurance Fraud | Merced County, CA – Official Website

– District Attorney. – About Us. – Units. – Fraud Unit. – Workers’ Compensation Fraud.

www.wcexec.com

PEO Caught With No Coverage By WCAB Judge | | Workers’ Comp Executive

Does medicare pay for Nursing Home? (Maybe!)

The video explains Medicare’s coverage for skilled nursing facilities, highlighting the differences between Original Medicare and Medicare Advantage plans regarding rehab services.

Highlights

  1. Coverage Breakdown: Medicare covers 20 days in skilled nursing facilities at no cost, with a copayment for days 21-100.
  2. Inpatient Requirement: A minimum of three days of inpatient hospital admission is required to qualify for skilled nursing care.
  3. Advantage Plan Issues: Medicare Advantage plans can deny coverage decisions made by doctors, giving insurers the power over patient care.
  4. Appeals Stress: Many patients face a complicated appeals process while in recovery, adding extra stress during their medical crisis.
  5. Switching Plans: Patients can return to Original Medicare during open enrollment, but may struggle to find a suitable supplement plan due to health issues.

Keywords

Medicare, nursing home, skilled care, Advantage plans, coverage eligibility.so it’s important to understand the benefits from Medicare for Skilled Nursing Facility certainly before you end up in a Skilled Nursing Facility you need to understand what your coverage is so you know how things are going to be handled and we don’t have any surprises and obviously if we’re headed to a Skilled Nursing Facility we don’t want any surprises so when we’re talking about skilled nursing care with Medicare we’re not talking about long-term care we’re talking about rehab

00:27

so where you would go if you say had a stroke or if you had hip replacement or something where you needed Rehabilitation to gain Improvement before you go back home so it’s really important to understand because there are two completely different ways that this can be handled within Medicare and the main differences are whether you’re on original Medicare with a Medicare Supplement Plan or whether you have chosen to go with a Medicare Advantage plan so we need to understand what we need to know before we get there

01:00

so first thing to understand is the coverage so Medicare covers the first 20 days in a skilled nursing facility at no cost so there’s no co-pays no coinsurance covered under part A from day 21 to 100 they also cover but there’s a 200 copay that goes along with it obviously a significant amount of money now the good side of that a Medicare supplement or a Medicare Advantage plan usually covers that out of pocket expense so pretty much there can be up to 100 days of coverage in a Skilled Nursing Facility now keep in

01:36

mind in order to qualify for skilled nursing care there’s other parameters so what needs to happen is you need to have at least three days inpatient hospital admission to qualify for skilled nursing care now this can get a little crazy and a little gray and I’ve seen it happen many times when you’re in the hospital you could be there a day or two days or three days and you certainly think it’s impatient because you’re there you’re staying the night but hospitals can classify it as observation as opposed to

02:07

inpatient and I really don’t have the answers to why they do it as observation because it doesn’t make a lot of sense but if it is observation you wouldn’t qualify for skilled nursing care or rehab after the hospital state it has to be inpatient hospital admission three days or more and then you get discharged to a skilled nursing facility for Rehab again after a stroke after a hip replacement surgery knee replacement surgery something significant where obviously you can’t just go home you need rehab to be able

02:39

to get back to where you can take care of yourself so here’s where we reached the problem with original Medicare with a Medicare Supplement Plan generally it’s not a problem generally the doctor makes the decision if you need to stay you’re going to stay and they’re going to pay Medicare Advantage is different where the decision lies not with the doctor but with the medical plan they make the determination on whether or not you’re going to be able to say whether or not they’re going to pay for you to

03:10

stay in a Skilled Nursing Facility so I’m gonna go through an article here that’s in the Kaiser Family Foundation they published it very creditable third party no obligation group that covers a lot of senior stuff and Medicare stuff and this article gives the breakdown on how things work and how they differ so we start here after 11 days in a St Paul Minnesota Skilled Nursing Facility recuperating from a fall Paula Christopherson 97 so she fell she was in the hospital for a number of days released to a Skilled Nursing Facility

03:44

as anyone would expect well was told by her and sure that she should return home but instead of being relieved Christopherson and her daughter were worried because medical team said she wasn’t well enough to leave this seems unethical said her daughter who feared what would happen if the Medicare Advantage plan run by United Healthcare ended coverage for her mother’s nursing home care the facility gave Christopherson a choice pay several thousand dollars to stay appeal the company’s decision or go home

04:17

you don’t want to be in that position at 97 where you just are recuperating from a fall and those are your choices on what you can do to continue your medical care so it’s certainly a scenario that makes things very difficult the article goes on to say half of nearly 65 million people with Medicare are enrolled in Private health plans called Medicare Advantage an alternative to the traditional Medicare program the plans must cover at a minimum the same benefits as traditional Medicare including up to 100 days of skilled

04:51

nursing home care every year but the private plans have leeway deciding how much nursing home care a patient needs in traditional Medicare the medical professionals at the facility decide when someone is safe to go home said Eric Krupa an attorney at the center for Medicare advocacy a non-profit Law Group that advises beneficiaries in Medicare Advantage the plan decides so it’s super important to understand that that you are not guaranteed your benefit days at a Skilled Nursing Facility if you are on a Medicare Advantage plan so you want to

05:29

be well aware of that for sure on how it’s going to be handled my repainter a vice president National Association of State long-term care Omni bugsman program who directs Connecticut’s office said people are going to the nursing home and then very quickly getting denied and then told to appeal which adds to their stress when they’re already trying to recuperate so that’s crazy that you have to appeal while you’re in medical crisis at a nursing home in order to be able to stay at the nursing home so it’s it’s

06:06

certainly complicated and makes things much more difficult than they need to be the problem has become more widespread and more frequent said Dr Rajiv Kumar vice president Society of Post Acute Long-Term Care Medicine which represents long-term care practitioners it’s not just one plan it’s pretty much all that so this appeals process just how much does a person want to fight is where it comes down to where we’re probably going to cover it but you’re going to have to put up a fight if you want us to cover

06:39

it and we’re hoping that you’re really not going to put up that much of a fight so they play the odds and then that’s kind of how it works which is it’s really unfortunate and I’ve had just too many calls from people that have had a husband or a wife or a sibling or a friend in a nursing home that is being told that they have to go home and they’re not ready to go home and they want to know how to get off the Medicare Advantage plan and get back to original Medicare and in Most states you can if you’re in

07:09

a health situation you won’t be able to you can come back to original Medicare during an open enrollment period also another time locked scenario but you likely wouldn’t be able to get a Medicare Supplement Plan because of a health situation one other quick story Patricia Maynard 80 a retired Connecticut school cafeteria employee was in a nursing home recovering from a hip replacement and believe me hip replacement is almost common practice these days if you make it through life without a hip replacement you’re

07:38

fortunate you’re you’re well above the odds they have become very commonplace and obviously after a hip replacement you’re not going to jump up go walking and get in your car and drive home you’re going to need rehab to be able to get back on your feet and do the things that you’re supposed to do so hers was in December when her I don’t know why they keep using United Healthcare as an example but they do plan notified her it was ending coverage and her doctors disagreed with the decision if I stayed I would have to pay

08:07

or I could go home and not worry about the bill the average daily cost of a semi-private room that’s with a roommate is 415 dollars a day according to a state survey but going home was also impractical I couldn’t walk because of the pain so mayor to peeled the company and the company reversed the decision but a few days later she received another notice saying that they’ve decided to stop payment again over the objections of her medical team the cycle continued 10 times so she had to appeal 10 times and each time they said okay

08:44

you’re okay and then they denied it again and again this is not a rare occasion this is a pretty common occasion if you know anybody that works in a nursing home just ask them how it’s handled under that type of situation and I spoke with somebody that worked in a nursing home and they said what they have to do is every day fill out a form on why the person needs to stay and the Medicare Advantage Representative makes a determination on whether or not they agree and if they don’t agree they don’t pay and then it’s on the

09:17

patient to figure out what they’re going to do from there on original Medicare with the supplement it’s almost reverse where they might keep them there too long because they want to continue to Bill Medicare which is also not a great scenario but likely better to have over coverage than certainly under coverage but that is how things function and if you if you’ve had any experience with it please leave a comment in the video below help others understand that this is how things work in skilled nursing

09:48

care so first off you have to qualify you have to have three days of inpatient hospital admission so observation doesn’t count has to be inpatient and then difference between being on original Medicare with a supplement where it’s pretty much what the doctors say now you can make the decision yourself to go home if you’re ready to go home and they’re saying no we want to stay a little longer because we’re getting paid for you to be here that’s certainly a a case as to where it can happen but you can always make the

10:17

decision where you’re ready to go home Medicare Advantage they’re going to make the decision on whether you’re ready to go home or not so kind of crazy on how that functions but that’s a big reason that I just don’t offer Medicare Advantage because I don’t want this type of situation to come back to me and say why did you set us up with this kind of plan where my spouse or sibling or loved one whatever it may be is now in Jeopardy because they’re being booted out of a Skilled Nursing Facility so I

10:50

hope you understand how this works I hope you find it helpful and we’ll show you right now how to download my book have a fantastic day thank you for taking the time to watch my video hope you found it very helpful a couple of other things that you’ll also find very helpful number one download a copy of my free book Medicare made clear I spent a lot of time and a lot of effort putting this together and it has everything that you need for Medicare now and in the future down the road I have videos in the book I have all the links that you

11:19

need for things that you’ll want to do within Medicare you can access it right in the book very easy to do just visit medicareonvideo.com forward slash free book and you can download it for free you can save it on your computer you can save it on your iPad it’s great resource to have again for now and in the future another thing that you’ll find helpful is down the road when you come into Medicare sometimes it makes sense to do a price check on your Medicare Supplement Plan so I made it very easy

11:49

to do that as well just visit Medicare pricecheck.com put in your basic information and we’ll email you look quote on your same plan that you have right now A G or an N or an F whatever it may be and likely we’ll be able to save twenty to sixty dollars a month in premium because a lot of times plans come out with better rates so if we can get a better rate for the same plan that we currently have just makes a lot of sense and then obviously take advantage of all the information on my website at medicareonvideo.com I have everything

12:23

that you need right there for understanding Irma understanding employer work coverage everything that you need especially in the guides and forms section you’ll find right there so we update everything every year so everything should be up to date and current with the right deductibles and premiums and things like that hope you found all this helpful have a fantastic day wait don’t go anywhere there’s a couple more videos right here that you’ll find very helpful with your Medicare Journey so take just a minute

Medicare for dental implants?

Medicare generally does not cover dental implants, but there are exceptions for medically necessary treatments and options through Medicare Advantage plans.

Highlights

  1. Original Medicare (Parts A and B) typically excludes dental implants and surgeries.
  2. Medicare Part A may cover hospitalization costs for dental procedures deemed medically necessary.
  3. Conditions like oral diseases might qualify for partial coverage of related oral surgeries.
  4. Medicare Advantage (Part C) plans may include dental coverage, including implants.
  5. Review your plan details and consider switching plans during enrollment for potential dental benefits.

Keywords

Medicare, dental implants, coverage, insurance, oral surgery.

how to get Medicare to pay for dental implants if you’re considering dental implants but are worried about the cost you might be wondering if Medicare can help let’s break down the details to see how Medicare can assist first it’s important to know that original Medicare plans which include Parts A and B generally do not cover dental implants this includes both the surgery and the implants themselves however there are some exceptions and Alternatives you should be aware of Medicare might cover certain aspects of your treatment if

it’s deemed medically necessary for example if you need hospitalization due to a dental procedure Medicare part A could cover the hospital costs but not the dental care itself if you have a condition that could worsen if left untreated such as oral disease that could affect other health issues like heart disease diabetes or lung infections Medicare might cover the oral surgery related to the dental implant procedure this could cover between 30 to 50% of the oral surgery costs another option is to look into Medicare

Advantage part C these Plans offered by private insurers can include additional benefits not covered by traditional Medicare such as Dental Services some Medicare Advantage plans may offer limited dental coverage which could include dental implants to find out if your plan covers dental implants check your evidence of coverage notice or use the Medicare Plan finder to see the specific benefits and network providers if your current Medicare plan doesn’t include Dental Services you might be able to switch to a plan that does especially during the annual enrollment period this could help you get the coverage you need for dental implants in summary while original Medicare doesn’t typically cover dental implants there are scenarios where Medicare might help with related costs and Medicare Advantage plans can offer more Comprehensive Dental Coverage always consult with your health care provider and review your plan details to understand your specific options

5 thing Medicare does not cover (and how to get them covered)

Medicare Coverage Overview:

  • Medicare consists of two main parts: Part A (hospital insurance) and Part B (medical insurance).
  • Most medically necessary services like emergency room visits, doctor’s office visits, hospital stays, diagnostic testing, and many non-self-administered medications are generally covered by Medicare.
  1. Cost Sharing Responsibilities:
    • Individuals typically need to pay some portion of the costs for covered services unless they have a Medicare Supplement plan (Medigap), which helps cover these costs.
  2. Key Areas of Non-Coverage:
    • Common services that Medicare typically does not cover include routine eye exams, hearing aids, dental services, comprehensive routine physical exams, and long-term care.
  3. Importance of Supplement Options:
    • Individuals may consider additional insurance options or Medicare Advantage plans to cover what traditional Medicare does not.
  4. Highlighting the Need for Awareness:
    • Understanding these gaps in coverage is crucial for individuals approaching Medicare eligibility to avoid unexpected medical bills.

Key Conclusions

  1. Future Medical Expenses:
    • Medicare beneficiaries should plan for out-of-pocket expenses resulting from services not covered by Medicare, which can lead to significant financial strain.
  2. Supplementary Plans Are Beneficial:
    • Medicare Supplement plans or Advantage plans can provide additional coverage, but potential enrollees must assess their health needs, budget, and the offerings in their area.
  3. Proactive Healthcare Management:
    • Seniors should be proactive about their healthcare management by understanding the distinctions between the services covered by Medicare and those that require alternative coverage.
  4. Professional Guidance Recommended:
    • Consulting with financial advisors or insurance experts can aid in navigating the complexities of Medicare and finding the right supplement or Advantage plans.
  5. Comprehensive Benefits Assessment:
    • Evaluating personal healthcare needs and expenses is essential for budgeting and ensuring adequate health coverage, thus preventing reliance solely on Medicare.

Important Details

  1. Specific Non-Covered Services:
    • Routine Eye Exams: While Medicare provides coverage for surgical procedures such as cataract surgeries and glaucoma treatments, it does not cover routine eye exams, glasses, or contacts.
    • Hearing Aids: Medicare does not cover hearing aids or routine hearing tests. Beneficiaries can consider Medicare Advantage plans which might cover some hearing needs, or join discount programs for hearing aids.
    • Dental Coverage: Traditional Medicare lacks coverage for dental services including exams and procedures. There are Medicare Advantage plans offering limited dental benefits, standalone dental plans, or discount plans.
    • Routine Physical Examinations: Medicare covers a specific annual wellness exam, not a full routine physical that includes blood work and other comprehensive tests, which are not covered under traditional Medicare.
    • Long-Term Care: Medicare may cover limited inpatient rehabilitation in skilled nursing facilities, but it does not cover long-term custodial care—meaning assistance with daily activities like bathing or dressing is not included.
  2. Financial Impact and Planning:
    • The average annual cost of nursing home care can range from $90,000 to $100,000. Hence, financial planning is crucial for potential Medicare beneficiaries to prepare for these costs.
    • Medicaid may serve as a resource for individuals with limited income to help cover nursing home expenses.
  3. Tailored Insurance Solutions:
    • It’s suggested that individuals consult agents or independent brokers to analyze their unique needs and identify suitable Medicare Supplement or Advantage plans. Free quotes and personalized assistance are available from specialized agencies.
  4. Contentious Nature of Routine Physicals:
    • Medical professionals have been debating the effectiveness and necessity of full routine physical examinations due to concerns over excessive testing, false positives, and escalating medical costs.
  5. Engagement with Healthcare Professionals:
    • When attending healthcare appointments, beneficiaries should clearly communicate their requirements (e.g., specifying the need for a Medicare wellness exam rather than a physical), thus avoiding misunderstanding with their healthcare providers, and possible unexpected charges.

By understanding these core aspects of Medicare coverage and the associated costs, individuals can make informed decisions about their health coverage and take proactive steps to manage their healthcare expenditures effectively. Recognizing what is and isn’t covered under traditional Medicare allows for better financial planning and reduces the likelihood of unpleasant surprises down the road.