CASE FLASH: MEDICARE HEALTH PLAN ACCOMMODATIONS FOR RELIGIOUS NEEDS

Ms. N receives her Medicare health coverage from a Medicare private health plan. She has had arthritis in her knee for several years, and her condition has grown more severe in recent months. Ms. N’s doctor strongly recommended that Ms. N have knee surgery. However, Ms. N’s religion only allows her to have bloodless surgery (a type of procedure that avoids blood transfusions and minimizes blood loss). Ms. N knew that she must see doctors in her plan’s network for the surgery to be covered. However, none of the surgeons or anesthesiologists in her plan’s network performed bloodless procedures. Ms. N knew of a hospital that had a surgeon and anesthesiologist who performed bloodless surgeries, but they were out of her plan’s network.

Ms. N called the Medicare Rights Center to ask a hotline counselor about her options. The counselor explained that Medicare private health plans must accommodate plan members’ religious beliefs, so that they can access Medicare-covered services. The hotline counselor encouraged Ms. N to formally request that the out-of-network surgery be covered (request “prior authorization”). She encouraged Ms. N to write a letter to her plan explaining that to abide by her religious beliefs, she needs a bloodless surgery, and that no in-network provider performs this procedure. The counselor also told Ms. N that she should ask her primary care physician to write a supporting letter explaining the medical necessity of the surgery and the religious necessity of the bloodless procedure, and to send the doctor’s letter to the plan with her own.

Ms. N followed the counselor’s advice. She heard back from the plan that it granted the prior authorization. The plan arranged to pay the out-of-network surgeon and anesthesiologist for the bloodless surgery, and Ms. N only had to pay her usual, in-network copayment.

-Adapted from: “ MEDICARE WATCH, a biweekly electronic newsletter of the Medicare Rights Center”, Vol. 11, No. 12: June 10, 2008.

 

06/08