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On Thursday I visited LMG and  had an interesting experience...They said they were not seeing any cash paying patients..They only wanted  patients with a supplement NOB insurance .

I thought this very strange and some what suspicious of their motives ....could it be they have found a market niche  where they bill your insurance North American price(s) for any treatment

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I had been going to a certain clinic for years and they recently told me that my U.S. insurance was no longer paying for my office visits because the visits were no longer connected to my surgery. What one has to do with another I do not know? They would no longer see me for any visits. Shortly thereafter, I received a call from my insurance's fraud investigation department saying that they were investigating the clinic. Apparently, the clinic was charging my U.S. insurance company $450 USD for office visits, which is usually MUCH less in Mexico. They also charged them $45,000 USD for a surgery that they arranged, which really only cost $15,000 USD, a $30,000 mark up. The insurance company was also under the impression that the surgery and office visits were being done in the U.S. and not Mexico. They do not pay for office visits or surgery in Mexico unless it is an emergency, which they were was not. I had no idea this was going on. Fortunately, I am not being held responsible for any of the fraudulent charges. On an added note, if you do a Google search on a doctor that runs a clinic, you can find out his previous criminal background in the U.S. This may help you figure out what they are up to. 

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I too find their MO for medical care confusing.  I recently had a very good office visit with a physician who recommended an MRI. Because my NOB insurance didn’t cover it, I was told I had to take care of it my own.  Very confusing and time consuming process for me, a non professional.  After waiting for several weeks for the doctor to review the test, I was told he hadn’t had time to study it yet but to go get a colonoscopy.  And yes, I’d have to do that on my own too.  No idea how or with whom to schedule something like that.  Needless to say, I’ve gone to a different doctor and won’t be going back to I just don’t u derstand what kind of medical service they’re providing.

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  • 1 year later...

I am considering moving to Jalisco state from Costa Rica to access LMG services, to access filing claims to my US insurance carrier under their Medicare Advantage program. A good decision? I cannot tell if the comments in this communication stream after 2/15/19 are describing LMG or some random clinic. 

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Medicare Advantage policies in the US are mostly of the HMO type although a few can also be PPO.  They are also very location centric meaning they cover a finite 'location' where they will cover Docs, Hospitals, Services and maybe Medicines. For example mine covers me 'only' within a few.... probably 25.... sq miles of my home where I have a specific PCP who can also refer me to an in-service specialist/service. Not state-wide and surely not out of the country! Advantage policies in less populated areas can cover as much as a state.  An Advantage policy WILL cover one for 'emergencies only' while traveling or on vacation out of your home jurisdiction, mostly out of pocket and on a reimbursement basis. You have suggested that you are 'moving to Jalisco', not vacationing there.

Traditional Medicare and a Medicare Gap policy, as well as Advantage policies, do NOT cover one in a general sense.... as in living/staying..... out of the United States and surely not IN MEXICO!    Others here may/will chime in to discuss what LMG may or may not be doing in this respect but whatever they are doing, if not for emergencies only while on 'vacation', can be considered Medicare Fraud.

YMMV

 

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On 2/15/2019 at 3:44 PM, lakeside7 said:

On Thursday I visited LMG and  had an interesting experience...They said they were not seeing any cash paying patients..They only wanted  patients with a supplement NOB insurance .

I thought this very strange and some what suspicious of their motives ....could it be they have found a market niche  where they bill your insurance North American price(s) for any treatment

Many in the medical profession prefer cash and no bill to avoid paying taxes, depriving the government of much needed cash!

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7 minutes ago, joco69 said:

Many in the medical profession prefer cash and no bill to avoid paying taxes, depriving the government of much needed cash!

Yes, if you ask for a bill they often charge you more.

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I used to know a person in Mazatlan that got caught in the business of billing the insurance companies in the U.S. at U.S. codes prices for procedures performed at Mexican price , then the Dr. would take "care" of her for doing this.  I do understand that there need to be coding for both worlds of pricing.....how to fix this?  It turned into a true mess for all involved and was caught by the military medical system so you know messy it got!  Just beware.

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On 10/3/2020 at 2:54 PM, RickS said:

Traditional Medicare and a Medicare Gap policy, as well as Advantage policies, do NOT cover one in a general sense.... as in living/staying..... out of the United States and surely not IN MEXICO!    Others here may/will chime in to discuss what LMG may or may not be doing in this respect but whatever they are doing if not for emergencies only while on 'vacation' can be considered Medicare Fraud.

RickS above is correct. I have sold Medicare Supplements in my past life and have starred at the billboard outside San Antonio Hospital in disbelief, advertising for patients with US and Medicare insurers. Absolutely, if you live here in MX and are not just travelling through, you'd better understand what your Medical provider in MX is doing with your insurance and what you are allowing them to submit, otherwise for residents you may be participating in a form of Medicare or Insurance fraud! 

Most Medigap and Medicare Advantage Plans (Part C) state directly from Medicare.gov:

  • Covers foreign travel emergency care if it begins during the first 60 days of your trip, and if Medicare doesn't otherwise cover the care.

  • Pays 80% of the billed charges for certain medically necessary emergency care outside the U.S. after you meet a $250 deductible for the year.

Foreign travel emergency coverage with Medigap and Advantage Plan policies has a lifetime limit of $50,000.

Check your Medigap, Advantage Plans and US Health Care insurance in detail so you don't get yourself in hot water by a medical facility trying to bend the rules to their benefit. From experience on the Insurers side, they don't care and won't care if you say, "well I didn't know", and neither will Uncle Sam.

 

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8 hours ago, Jubilacion said:

RickS above is correct. I have sold Medicare Supplements in my past life and have starred at the billboard outside San Antonio Hospital in disbelief, advertising for patients with US and Medicare insurers. Absolutely, if you live here in MX and are not just travelling through, you'd better understand what your Medical provider in MX is doing with your insurance and what you are allowing them to submit, otherwise for residents you may be participating in a form of Medicare or Insurance fraud! 

Most Medigap and Medicare Advantage Plans (Part C) state directly from Medicare.gov:

  • Covers foreign travel emergency care if it begins during the first 60 days of your trip, and if Medicare doesn't otherwise cover the care.

  • Pays 80% of the billed charges for certain medically necessary emergency care outside the U.S. after you meet a $250 deductible for the year.

Foreign travel emergency coverage with Medigap and Advantage Plan policies has a lifetime limit of $50,000.

Check your Medigap, Advantage Plans and US Health Care insurance in detail so you don't get yourself in hot water by a medical facility trying to bend the rules to their benefit. From experience on the Insurers side, they don't care and won't care if you say, "well I didn't know", and neither will Uncle Sam.

 

Jubilacion I am not sure if you quite understand some peoples experience and that what you are saying is rather a broad generalization of the facts. But let me share our experience;

My wife has a Advantage Plan and I have a supplementary coverage with Aetna

We took our respective polices into the the very efficient young lady at SAH and she took all the details and long story short, my wife does have coverage for treatment in MX, mine will only cover  me for emergencies up 60 days from leaving the USA, regardless if I am in MX or traveling the world. To be doubly sure  I contacted my US Ins Broker who sent me a copy to verify the coverage. Now I do believe the hospital has to obtain consent / authorization etc.

The fact that I have this 60 days window is particularly good because I do not have to purchase "extra" polices when traveling

Now you seem to have experience in selling supplemental policies which appear to contradict what we have been told, and I will be interested for your observations as we maybe totally misinformed. 

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.... and lakeside7 I am not sure that you quite understand that Medicare w/supplement and/or Medicare Advantage Part C does not cover you, other than has been stated above, while on vacation or traveling outside of the United States.  It's just does not!  If it did, millions of people a day would be flocking to Mexico to live.

In another Post you said that you have IMSS. People traveling or on vacation in Mexico are not able to obtain IMSS coverage so you must be Residente. Does Aetna know that you reside out of the country?  When you need to 'use' your Medicare in Mexico are you going to tell the insurance company that you were 'just traveling'?

But believe what you want....  I just wish I could to be listening in on that call the Mexican hospital makes to Medicare "to obtain consent / authorization".

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18 hours ago, lakeside7 said:

Now you seem to have experience in selling supplemental policies which appear to contradict what we have been told, and I will be interested for your observations as we maybe totally misinformed. 

Lakeside7, I admit at one time I could say with 100% certainty you are being mislead, but today out of the business for a few years that certainty may be only 85-90%, but I'm fairly current since I have been reviewing lot of plans lately because I come of Medicare age in November.

What SAH told you was correct with your Medigap coverage, foreign coverage begins during the first 60 days of your trip, BUT I don't know how in the world it would ever cover you in MX you if you are living here unless you (or SAH which is also you authorizing the insurance charge) fictitiously claim you were only traveling. I'm aware of a Medigap insurer asking for proof of travel like the departure date with airline ticket, gas receipts, hotel recipts etc. Remember, insurers do not want to pay claims and are naturally suspicious of foreign travel claims. The intent of international emergency coverage is that your trip begins in the US, not in Mexico or another foreign country. It's essentially travel insurance only from the US.

Your wife's Medicare Advantage policy where someone (I think SAH) told her she has routine coverage in Mexico outside of similar emergency coverage as your Medigap policy... I just don't believe it.

I highly encourage you to call her Advantage Plan insurer (not your broker/agent) and get it straight from them. Play a "what if" game with them. Don't just ask if she has emergency coverage (she does) but spell out some questions like, "What if we snowbird in Mexico... or "What if we're going to spend a few months travelling internationally... etc. ...does my Medicare Advantage plan have coverage for non-emergency procedures? Followed by, "What coverage does my Advantage Plan have internationally if we're away from the US for OVER 60-days?"

If the answer is positive to either of the above from the insurer, please let us know the name of the insurer, it would certainly change my tentative decision on the Medigap or Advantage Plan for my personal Medicare. Good luck! I hope we're proven wrong.

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VERY straightforward, clear and valuable information Jubilacion!   Except I would maybe change your "fictitiously" word to "fraudulently".

And I second your request for the name of the Advantage Plan insurer if they cover his wife like the OP suggests that SAH says they will/do. Of course even if they did/do for some strange reason....Advantage Plans are 'regional or location centric' and that policy will not necessarily cover you or me in our US home location. My Advantage policy is not the same as one by the same exact company's offering in a city 60 miles away! The 'market' determines what they will/have to offer and how much they charge for 'each part'.

Again.... very nice response to this guy in his 'time of need'.

 

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Just to keep the pot boiling.....You may have heard and attended to days Seminar Hosted by LMG ( Lakeside Medical Group  to promote Advantage Plans. The main speaker was a Jeff Goble who I think operates out of Cal. Also on hand was a Dr. Ian who is on the medical staff of LMG. This doctor was a bit of a lose cannon who seemed to be over the top in his comments about the services and treatments that are currently being carried out for existing patients.

Let me emphasis that Jeff in no way made any "false" claims or suggestions. He reminded the audience that you must have Medicare Part A&B in order to qualify for a APlan and residence address

Many attendees like me do not have APlans are are paying significant amount of monthly premium fees. 

Now that we have your attention perhaps you can explain/share with "us" who many be considering switch to a APlan and "saving money" what are the Pro's and Con's of each policy.  

Whilst many people maybe circumventing the necessity of having a " residence address " in the US there are I believe a number who do have residence in both countries.

Rick, you mentioned "People traveling or on vacation in Mexico are not able to obtain IMSS coverage so you must be Residente". You can be/obtain Permenate and still have homes in both countries, best as I recall as long as you met the income requirements there is no other qualification..is there?

For myself I see it as a loop hole that you may or may not choose to take...and the longer you live in Mexico you begin to see and experience many loop holes as the normal everyday Mexican experience, a facilitator for this and for that... want to get to the head of the line ..who is the person to pay....taking too long to process your Probate, find a facilitator to help you and how much!!!. If you want to live out your dreams in Mexico then you better start thinking like a Mexican and not a Gringo...and lastly. but not to get political...... but many of us feel we have paid our dues and more, to the US Government and if there any "benefits" available then we want them...... and not hand outs to "others"

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Ask them to pay and not collect from you nor make you sign any promissory notes if they are so sure about things.  You have been warned

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36 minutes ago, Intercasa said:

Ask them to pay and not collect from you nor make you sign any promissory notes if they are so sure about things.  You have been warned

Spencer I very much value your legal options which from time to time you share with us..and your observation above is well taken

However it does  not seem that long ago when you mentioned that is was Illegal for Hospitals in Guad to prevent you from leaving until you settled your bill....BUT they did..and I guess still do!

I hope that any persons looking at this debate and have had any medical procedure done using their APlan at SAH will share their experience..not if the experience was good or bad but the cost was covered by their plan...also maybe if you have had any clients who may have had problems, please share

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Jubilacion

What SAH told you was correct with your Medigap coverage, foreign coverage begins during the first 60 days of your trip, BUT I don't know how in the world it would ever cover you in MX you if you are living here unless you (or SAH which is also you authorizing the insurance charge) fictitiously claim you were only traveling.

With respect I would suggest that there are quite a number of people with homes in the US and Mexico and are legit..why in the world would having a home/vacation place here or any place overseas disqualify you?   Yes I agree the insurance companies are looking for reasons/excuses not to pay...much like having a pre conditions...my god most of the Gringos here have some sort of pre condition and may as well never buy any insurance. likewise  having S Dakota plates this is an other loop hole that is being exploited.

I think this discussion is great to have and share, but as I previous mentioned living in Mexico begins to show you another side of living your life...and as I type another example of MX life comes to mind...all drivers are expected to carry car insurance...how many do....how many just take off when involved in a accident...to us gringos this deplorable ... but in the real world it happens frequently

Let me digress.... and share my experience with using Mexican Notaria in preparing a will, you give him all you details etc, only to find out latter that when  your partner dies there is a huge Probate bill..but why you ask  only to find out that the first Notaria screwed up..how many friends do you know or have heard of have similar issues..you try your best to cover all bases BUT....

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Yes illegal for hospitals to do that and some retain documents, people will do illegal things unless challenged and with an overburdened and underfunded legal system with a 1% conviction rate for reported crimes many with low moral standards will take their chances. 

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I think that this discussion, while interesting and with many twists and turns, has drifted from the basic thought:  

Can a US citizen use either their Original Medicare w/Supplement coverage or the newer (2003) Medicare Advantage Part C insurance coverage for other-than-Emergencies while traveling abroad. That's it. That's the question.

And the answer is a resounding NO!  There are no Medicare programs or laws or policies that are in place.... and ever likely to be put in place.... that will allow it.

No matter how much we wish we could, or how many people think/hope/have been told they can, and even have 'authorities abroad' telling them that they can 'arrange it', it just isn't going to happen outside of the allowed Emergency option.  And any attempt to pretend like they are traveling when they are really living Abroad, even if for only several months out of the year, and then attempt to use use their Medicare coverage could be construed by the insurance company and/or Medicare to be Insurance Fraud.  

Lakeside7, we are just trying to help, but WE aren't the ones who will/can determine your fate if you try to use Medicare other than as described. Jubilacion has given you the 'golden recommendation'. And IT is the only way you are going to be sure about any of this. His recommendation started off by saying "I highly encourage you to call her Advantage Plan insurer (not your broker/agent) and get it straight from them, etc etc..."

Peace

 

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On 10/6/2020 at 8:17 PM, lakeside7 said:

SNIP......

1)  With respect I would suggest that there are quite a number of people with homes in the US and Mexico and are legit..why in the world would having a home/vacation place here or any place overseas disqualify you?  

On 10/6/2020 at 6:27 PM, lakeside7 said:

SNIP.......

2)Many attendees like me do not have APlans are are paying significant amount of monthly premium fees. 

.........

3)Now that we have your attention perhaps you can explain/share with "us" who many be considering switch to a APlan and "saving money" what are the Pro's and Con's of each policy.  

....... 

4)For myself I see it as a loop hole that you may or may not choose to take...and the longer you live in Mexico you begin to see and experience many loop holes as the norm....

 

 

(This will be a long Post, so those of you who are not the least bit interested can just cruise on by)

 

Expand the above quotes....

 

 

lakeside7, to address some of your comments and questions from the above quote.....

1). Having a home abroad surely does not disqualify one... not at all. Medicare could care less what you own/where. What 'disqualifies' one is trying to use Medicare out of the US for other than emergencies while traveling.  

2) This.... high premiums of up to $300 per month for a Supplement policy.... is exactly why millions of folks try/use a Medicare Advantage program in the first place. But there are other things that 'might' make one hesitate in getting, as you call it, an APlan. See the following for a partial explanation.

3) The short version:  In 2003 Medicare started offering a different version of Medicare called Medicare Advantage, Part C. These programs are NOT run by Medicare but by private-party insurance companies like Aetna, United Healthcare, et al. These programs MUST meet certain Medicare rules but have the option to offer different coverages and different pricing structures. This is not the place to describe just HOW an APlan can offer such good pricing... like $0 premiums!.... but there are good reasons. One of the reasons... and it is one of the largest ones.... is that ALL APlan policies are run like an HMO... the plans are location specific, there is an In-Network requirement. One can ONLY go to Doctors, Hospitals, etc who are qualified APlan insurance company... In-Network it is called.... and your current Doctor/Hospital of choice possibly may not be in the Network. This way the APlan 'has control over' the Doctors etc. and can control costs. 

Another requirement of an APlan is that you must have a specified PCP (Primary Care Physician) that the plan recognizes and he/she must be seen every time first. This PCP and your APlan 'controls' your use of the Network.  If you think you need an X-Ray or a Colonoscopy or a eye exam or a bad rotator cuff looked at, you can't just waltz into that Specialist's office, you must first go to your PCP and then he/she must refer you to that Specialist.... and that Specialist must also be In-Network!  

Same with hospitals, even emergency rooms... you can only go to ones that are In-Network. If you favorite hospital is not In-Network you can go there but you will pay a much higher cost out of pocket to do so. 

Also, similar to Original Medicare, with an APlan there are usually out of pocket costs such as deductibles, office visit payments, drug deductibles, Out Patient hospital visits, MRIs etc etc that one must pay when they are visited. My office visit cost is $10 but an annual extensive medical checkup is $0.... the insurance company wants to keep you healthy and well. A visit to my orthopedic Doc Specialist is $40 for an office visit.

And with an APlan policy, meds are usually covered but with some deductibles and without an additional monthly premium for Plan D drugs. If one has Original Medicare, Plan D drug coverage is NOT covered but for an additional $ premium ($45/mo?)one can add it on.  As example my APlan deductible for my high blood pressure med is $2 for a month's supply at a local pharmacy OR I can get a 90-day supply of it mailed to me for $0. Some meds are higher... $10-$40 co-pay.... at a local pharmacy but certainly not outrageously high unless one is on a exceedingly expensive drug like maybe for RA. And for all of this I am paying nothing extra for Plan D drugs. 

But with an APlan I can't just waltz into a doctors office or hospital for a non-emergency reason in, say, Poughkeepsie N.Y., and expect to not pay an arm and a leg for that visit. But I CAN do that with Original Medicare/Supplement...assuming that particular Doc in Poughheepsie is taking new Medicare patients!...and not pay a dime as it is covered by those policies. It's part of why one is paying up to $300 per month.

I could go on but these are I think the highlights of the differences between an APlan and Original Medicare w/Supplement as you are doing with Aetna. So why would the 22-million-in 2019 citizens change to an APlan with all these extra restrictions?  Well IMO it is usually because of the cost differential.... the monthly premium is usually between $0-$50 per month with these plans... mine has been $0 for the last 14 years.... instead of maybe $150-$300 per month depending on one's exact Medicare Supplement Policy coverage. So if one is fairly healthy, why pay $150-$300 per month for something one will rarely use when one can pay $0 plus a few minor charges occasionally.  I can tell you that I am multi-thousands ahead of the game... let's call it $40,000... but I've been a pretty healthy guy. IF something BIG were to happen to me... heart attack or cancer.... I am still covered quite well by my APlan, cannot be charged more than $7,400 annually and can always change back to Original Medicare "any" time I wish without penalty. In those 14 years I have never paid out more than about $500 a year for all my medical needs and most years it is only about $200 total.

4) loopholes: you are speaking here of life in Mexico and yes there seems to always be a loophole one can test. BUT this discussion is about United States Medicare insurance. IMO trying to come up with loopholes with one's medical insurance is playing with fire. Trust me, there is no better qualified entity than Medicare or an Insurance company in finding their own loopholes with which they can try to deny payment. Why serve them up with an easy one. 

Hope this helps lakeside7

 

 

 

 

 

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