Medicare Advantage PPO plans

[Chuckanut]

Before I had my knee replacement regular Medicare supposedly required that I try alternatives such as PT, lubricant shots in the knee, etc.

 

[CRLLS]

Yes. Medicare requires some input on procedures. It doesn't cover every course of treatment. Whether the Dr follows the traditionally course of treatment or jumps right to the most effective but best outcome is a problem. So is treatments that may not be considered "medically necessary". DW and I have had several surgeries since being on original Medicare. None of them required "us" getting approval. Extended PT was always handled between the therapist, the Dr's office and Medicare. The Drs have always gotten approval before scheduling the surgery. They have our Medicare account number before we even see the Dr. so they know what to expect from MC. There can always be a situation where our personal intervention may be required, just like company insurance or ACA coverage. Procedures such as an appendectomy may not be covered depending on the "reasonable and necessary" clause of Medicare. i.e., you can't just ask for an appendectomy because you simply want one. In some questionable cases, the DR may have to provide the argument for "reasonable and necessary".

 

[Katsmeow]

I do not have an MA plan (am on traditional Medicare for reasons that many here have expounded on). I do recall some people indicating that even though a MA may be a PPO plan that doesn't mean all doctors will accept. I seem to recall their being some instances when doctors would take an MA patient as out of network (even though allowed by the plan) but would take someone on traditional Medicare. I don't recall the details and have no personal knowledge. But I might research whether everyone that takes traditional Medicare will tae the MA plan.

 

[Gotadimple]

I do not have an MA plan (am on traditional Medicare for reasons that many here have expounded on). I do recall some people indicating that even though a MA may be a PPO plan that doesn't mean all doctors will accept. I seem to recall their being some instances when doctors would take an MA patient as out of network (even though allowed by the plan) but would take someone on traditional Medicare. I don't recall the details and have no personal knowledge. But I might research whether everyone that takes traditional Medicare will tae the MA plan.

MA is a separate contract from traditional Medicare, and a plan needs to be approved to have a MA contract by CMS. A doctor signs a contract with CMS and they are then able and willing to accept Medicare patients. They can stop at that point and not have a contract for Medicare Advantage because that is a private plan (funded in part by Medicare) with a specific network for the PPO plan vs. the HMO plan. In the case of MA, networks can be broad or narrow depending on the carrier's effort to establish a network - but their network must be approved by CMS if they want a Medicare Advantage contract.

- Rita

 

[VanWinkle]

I am confused about the fear of doctors not being in the PPO Medicare Advantage Plan you choose. What did everyone do during their working years when most corporations and small business were enrolled in HMO or PPO plans with networks of Drs. We all checked to make sure our Drs were in the plan first. Thinking the best doctors accept Medicare but not Medicare Advantage is not realistic. Medicare payments are very low compared to the billed amount.

 

[Dash man]

I am confused about the fear of doctors not being in the PPO Medicare Advantage Plan you choose. What did everyone do during their working years when most corporations and small business were enrolled in HMO or PPO plans with networks of Drs. We all checked to make sure our Drs were in the plan first. Thinking the best doctors accept Medicare but not Medicare Advantage is not realistic. Medicare payments are very low compared to the billed amount.

Nobody pays the billed amount. Medicare does pay quickly and reliably.
Providers have to be under contract with the MA insurers, or they’re considered out of network. Many insurers are difficult to work with. Contracts can end mid year leaving the patient having to find someone new, which can be difficult in some situations.
With Medicare, if Medicare pays, the insurers pays.

 

[VanWinkle]

Nobody pays the billed amount. Medicare does pay quickly and reliably.
Providers have to be under contract with the MA insurers, or they’re considered out of network. Many insurers are difficult to work with. Contracts can end mid year leaving the patient having to find someone new, which can be difficult in some situations.
With Medicare, if Medicare pays, the insurers pays.

What did you do during your working years for insurance? Just curious.

 

[Dash man]

What did you do during your working years for insurance? Just curious.

Not sure of the relevance, but I had a very good plan through Aetna.

 

[Irishgirlyc58]

I am confused about the fear of doctors not being in the PPO Medicare Advantage Plan you choose. What did everyone do during their working years when most corporations and small business were enrolled in HMO or PPO plans with networks of Drs. We all checked to make sure our Drs were in the plan first. Thinking the best doctors accept Medicare but not Medicare Advantage is not realistic. Medicare payments are very low compared to the billed amount.

I wondered the same.
I think part of the issue is that when you get your insurance through your employer you can change insurance companies during open enrollment without going through any type of health screening. This is assuming you live in an area with different insurance options. That isn’t the case for everyone.
Of course the insurance company going out of network can happen mid year even then leaving people in areas without a lot of options high and dry.

But I agree that the problem is there regardless of how you get your insurance. I think there are just more options to change when you are in that larger employer covered pool.

For billing insurance companies are difficult to deal with but then so is Medicare.

 

[Katsmeow]

Thinking the best doctors accept Medicare but not Medicare Advantage is not realistic. Medicare payments are very low compared to the billed amount.

I never said that the best doctors accept Medicare but not Medicare Advantage.

However, my understanding from some people is that some doctors who accept Medicare do not accept Medicare Advantage as out of network.

The reality is that for many specialties where most patients are Medicare age it is impractical not to accept traditional Medicare. (FWIW, in my experience, this isn't always the case for doctors who have tend to treat younger patients. They can turn down Medicare patients without losing much money.)

These doctors also may be in network providers to one or more MA plans. However, they may not want to be an out of network provider for someone on an MA plan because it is a hassle to them.

Also, I would caution people about being too sure on a MA plan that their doctors are all in network. That works until it doesn't. That is, a doctor leaves the network or, well, retires. Or you need a doctor for something new. Or you need to go to a hospital or other facility that isn't in your plan. A few years ago a relative wished her mother could go to the same rehab facility my mother was in. But she couldn't go because she had an MA plan and it wasn't in network. My mother was in traditional Medicare and could choose to go the facility she wanted to go to.

I wondered the same.
I think part of the issue is that when you get your insurance through your employer you can change insurance companies during open enrollment without going through any type of health screening. This is assuming you live in an area with different insurance options. That isn’t the case for everyone.
Of course the insurance company going out of network can happen mid year even then leaving people in areas without a lot of options high and dry.

But I agree that the problem is there regardless of how you get your insurance. I think there are just more options to change when you are in that larger employer covered pool.

For billing insurance companies are difficult to deal with but then so is Medicare.

None of this reflects my experience. Before Medicare I received my insurance through DH's employer. There really weren't significantly different insurance options.

However, it is was a good PPO plan where we could see out of network people. And, you now, the main reason I was ecstatic when I turned 65 was because I could get off that plan and go to traditional Medicare.

Even though I had good insurance with good providers it was a complete PITA to deal with. One of my children had to go the hospital (in network) by ambulance. We had no choice on the ambulance. The ambulance was out of network so we had to deal with balance billing. We also had other medical needs that required out of network doctors. The insurer paid a pittance of the charged amount. That is, let's say the charge was $400. The insurer would theoretically pay 60%. But, they would first cut that $400 down to $150 and then pay 60% of that. Just a real pain to deal with.

Even when there weren't balance billings costs it was still a pain. The out of network people didn't work my insurer. Often it was up to me to file the claim. The insurer might send an inquiry to them and then deny the claim when they didn't get a response. For example, once they sent an inquiry to a provider and denied it when they didn't get a response. She never got the inquiry as they simply addressed it to the very tall building she was in with no suite number. This sounds like it should be simple to resolve but took months. I would call the insurance company on an out of network claim, be told to do X. I would do X. They wouldn't pay. Then I would call back and be told to do Y.

Or I remember the time that there was a series of claims for the same service (different dates of course). They paid a bunch of claims. Then, they abruptly denied a claim. So, I called and pointed out that this was a claim that they were paying. They then said they would pull back all the prior payments.

Also, I hated dealing with co-payments and tracking were I was on the out of pocket maximum. It was just a pain.

Traditional Medicare is worth it to me because I don't have to deal with any of that. Before I was on Medicare I hours every year dealing with bills and deductibles and co-pays and providers, etc.

Now? I have to pay attention to meeting the part B deductible. And, then, I am done. I usually don't sign that I will pay for something if Medicare doesn't pay for it. (I did one time for something under $100). I look at my EOBs occasionally. In the last 3 years I've only had to call a provider about a billing issue once! (And that was easily solved).

You couldn't pay me to have to deal with networks and out of network providers. I do understand some people feel that they must use MA because of the low premiums. But, so far, that hasn't been required for me.

 

[Doribe]

I have a Medicare Advantage PPO with United Healthcare. This is a benefit from my previous employer. The co-pay is the same for in-network and out-of-network. The annual out of pocket is low and there is no maximum. I've been on it for one year and have no complaints.

 

[Pluperfect]

However, my understanding from some people is that some doctors who accept Medicare do not accept Medicare Advantage as out of network.

Can you explain this a little more?

I know some doctors accept traditional Medicare and aren't in any Medicare Advantage networks.

But it sounds like you're saying the doctors have a say as to whether they're "out of network," while it seems to me it's binary--if they're not in network, then they obviously are out of network. If they're out of network, then the MA plan would pay any claims under their out-of-network policy provisions, like the plan pays 60% to the provider and the insured pays 40% to the provider.

But when I think about it, the provider didn't sign up for this, so why should the provider have to split the check? And how would the provider even know what the patient's coinsurance was, if the provider doesn't work with that plan?

Or...is it a case where a provider would find out you have a particular MA plan and would say, "We refuse to treat you because we don't work with your (or any) MA plan. If you want to pay us yourself, up front, fine. Otherwise, we're not treating you." They're out of network because they're not in network (binary), but they refuse to see patients that will require them to participate in any out-of-network process.

Could they do this? Would they?

 

[RetMD21]

Pre-approval? No, but your doc better know what codes Medicare will approve. Braumeister's doc got it right. I've told this story before but my first gyno exam after Medicare kicked in she ordered the usual bloodwork. It included a lipids panel because my total cholesterol runs high, and an a1c because my fasting glucose is usually a bit over 100 and a1c is in the high end of normal. The lab sent me a bill for $800 because Medicare kicked it back as "not medically necessary." I tried to get the office to re-code it. No success. A technicality saved me- they hadn't had me sign the waiver form agreeing to be responsible for whatever Medicare didn't pay.

Goodbye, Doc (even though I really liked her). Hello, requestatest.com. Just had blood drawn this AM. Medicare doesn't cover but there will be no surprise bills.

Yeah, it's complicated. Medicare will pay for lipid screening every 5 years but you can get the tests more often if the office codes you as having an abnormality. I don't think most doctors and offices understand. Especially since Medicare and other insurances all have their own rules. If Medicare determines it isn't covered you get charged the list price unfortunately.

 

[Dash man]

Here’s an article explaining that the Mayo Clinic will not schedule regular appointments with Medicare Advantage in Arizona and Florida. They sent letters to their patients advising them to sign up for regular Medicare and a supplement.

https://www.medpagetoday.com/special-reports/exclusives/101320

 

[seattledan]

This Youtube video convinced me for my personal situation why I would never go with it.

 

[DougJohnson]

I have had a Medicare Advantage PPO for the last seven years. I'm mostly pleased, but I am healthy so far. Only the occasional checkups and screenings.

For the first two years, I was with Blue Cross. I got pissed at them when they lost a claim I filed *seven* times. Never did get paid. I am now with Aetna. I am pleased but have never had to file a claim myself.

Both plans have extensive networks in the Dallas, Texas area and you can see any doctor, it just might cost more. The out of pocket limit would let me find the best doctor if I have something serious. As mentioned, any preapprovals have been handled by the doctor's office.

-- Doug

 

[NoEZmoney]

Older Brother's HMO Plan Good / Not Good

So my older brother retired as a teacher and his retirement health insurance was basically a advantage / HMO from the school district.
Said he always had an HMO throughout his career and felt it a good fit. Low or no premiums, co-pays and deductibles. And he was fine for a few years after retirement UNTIL . . . .. . . had some cancer diagnosis and had to get referrals / approvals and there were delays. Had surgery but old-school prostatectomy (not robotic cuz not a lot of docs on his plan had the newer skills or even offered the procedure).
Years later more bad news --- skin melanoma, major surgery followed by gall bladder removed, partial kidney removed, and grand-daddy "Whipple Procedure" where they removed a cyst and half of pancreas, re-routed his stomach paths (major surgery) and on expensive meds for the rest of his life.
Long-story short: he spends $$$ every year on doc visits, expensive meds that he has to take forever if he wants to stay alive and always falls in a med-donut hole, and his approved docs come and go in network.

Can't speak for Advantage / HMO plans... I'm about to go traditional Medicare A & B with Plan G gap and Plan D Rx plan. All I'll be out is Plan B deductible / yearly and some copays on the drug tiers and have a broader network of docs, clinics, hospitals, etc. But that's just me.

 

[JJpop]

We are happy with our MA plan.
I have access to the Stanford U docs and I like the simplicity of it.
One card and all our medical records,visits, messages, etc. are organized on one website.
I have had a lot of stuff, some very expensive and so far have had no problems.
Our maximum out of pocket is $4500 per year.
Just like with your investments, sometimes simplicity is very helpful.

 

[maestro]

No 'horror story' for me on Humana HMO plan. Zero premium here in North TX for me with adequate drug, dental, vision benefits, plus free gym memberships anywhere with Silver Sneakers. I'm blessed with health at 65 but know that can change in a heartbeat. Never to late to take care of our bodies. Peace and good health to you with your decision.

 

[catii]

Humana PPO, four years, zero problems. Covered cancer, diabetes, & several other diseases, without a single glitch.

 

[jollystomper]

So far in my research I have not seen a difference in Medicare Advantage PPO plans and non-Medicare PPO plans. We have been on Megacorp and Retiree PPO plans for many years and have never had the issues highlighted for Medicare Advantage non-PPO plans.

We have seen, from other folks, issues with non-Medicare HMO plans that are the same issues that Medicare HMO plans have, in terms of networks and authorizations. I am finding it interesting that those against Medicare Advantage are not making a distinction between the HMO and PPO types of Medicare Advantage plans.

 

[Gotadimple]

We have seen, from other folks, issues with non-Medicare HMO plans that are the same issues that Medicare HMO plans have, in terms of networks and authorizations. I am finding it interesting that those against Medicare Advantage are not making a distinction between the HMO and PPO types of Medicare Advantage plans.

In a lot of places, insurance carriers only offer an HMO plan. So sometimes it is hard to find a PPO with a broad network and people aren't familiar with the difference.

- Rita

 

[RASAP]

Anyone considering an MA plan should watch this video. I think it will be well worth your 40 minutes. Christopher Westfall has many good videos dealing with all aspects of Medicare and Medicare Advantage plans. If you don't have much time, skip to about 10:30 in the video.

 

[Teacher Terry]

I have 4 friends with different MA advantage plans and all have encountered various difficulties. They have had to change doctors yearly, had surgery canceled mid year when one provider canceled the insurance halfway through the year and one of my friends has been seriously ill for 3 weeks with both a lung and heart problem and her oxygen level at times has been as low as 80-85.

She’s winded just walking to the bathroom in her small condo. She’s been to urgent care twice and the second time they said her doctor needs to order certain tests and told her which ones. They finally sent her for a pulmonary function test but won’t be able to see the pulmonary doctor at that appointment.

 

[explanade]

My late father had a Medicare Advantage plan.

Once they determined his course, they determined it was too late, that he should go to hospice.

We contacted other providers including UCSF. They were willing to see him but it was up to the Medicare Advantage plan people. They controlled his underlying Medicare benefits so if we wanted a second opinion outside of their facilities, we'd have had to pay fully to have him transported, checked into a hospital outside of the network for examination.

We appealed to their board and they declined. Unless they "release the Medicare funds" we'd have to incur big out of pocket expenses. The appeal process was drawn out and with each day, it was becoming moot.

It was likely the second opinion probably wouldn't have changed the prognosis. But it was clear they were going to stick to what the statistics said about what they deemed to be inoperable brain cancer.

Of course you hear anecdotes of cases of people who survived brain cancer or outlived the prognosis by a lot.

In any event, the experience really alienated us and we moved our mother to a Supplemental F plan, so that we'd always be able to choose whom to see and get second opinions for her.

When I get on Medicare, I may or may not do Medicare Advantage. But I know I will never go on that particular MA plan. Doubt my sisters will either.


So this year, the large provider organization whose doctors we'd been taking our mother to since sent two emails in the last week, touting MA plans. I didn't bother to check but they claimed you could see any doctor including theirs. They cited some study about better results for patients of MA plan. I was thinking about looking into it and then sent another email again pumping up MA plans.

That made me suspicious, probably get a share of the premiums for anyone they sign up through their links. So I didn't follow their links.