Medicare advantage plan

[youbet]

You bring up a good point. One of the big risks to only Part A and Part B with nothing else could be that OUTPATIENT surgical procedures and such are covered under Part B. An outpatient procedure can be expensive, as you mentioned. But the big risk I see is if one is not "admitted" to a hospital but instead taken in the hospital for "observation." Even though in the hospital for several days, I think this is billed under Part B, not Part A. Anyone who has seen a bill for several days in a hospital knows this can be a huge amount. That 20% with no supplemental or secondary insurance could be a very large amount (and no max cap). Especially if this happened several times in a year. For that reason alone I would never personally go without secondary coverage.

Yep. As you say, the vast majority of folks will pay more for premiums for their supplemental policies than the supplemental policies will pay towards their bills (the 20%). But we still carry it because any one of us could be a person who winds up with health issues where 20% of the Medicare approved amounts is a large number. Your example is great.

It's kinda like insurance on your home. Very few will collect more than their premiums over the years add up to. But a small minority will have a major house fire or similar disaster. So we all carry home insurance.

It's insurance.

 

[FLJim]

Getting close to signing up for Medicare, and I'm considering an advantage plan because of the cost savings. In general they seem to be the "WD-40" of the Medicare world, everyone loves to hate them, but I've got a couple of friends that really like there's, so I'm looking to see if there are others that are having a good experience with them.

I can't recall any product being sold HARDER than Medicare Advantage. That should worry anyone who thinks about it. We have been on regulard Medicare with a good supplement for 10 years and would never consider MA.

 

[youbet]

I can't recall any product being sold HARDER than Medicare Advantage. That should worry anyone who thinks about it. We have been on regulard Medicare with a good supplement for 10 years and would never consider MA.

Several posters have used the term "good supplement." I wonder what you mean by that? Are there "bad supplements?" What criteria are you using?

 

[RetMD21]

MA in SW MO.....no extra premium and all those benefits that are free such as dental, free well visit, small co pays for tests.........colonscopy was nearly free, major surgery and 3 days in the hospital was around $500 including the surgeon fee.
I mean really guys...........this was a lot better than my group insurance when I was working.
why would I want to pay over $200 a month more for zero out of pocket when 0 out of pocket pays for 95%?
You cost shared during your working years........99% of you did.
Yes I understand if you are sickly once you were retired...........90% of you are not that way.

just go to several insurance brokers that sell this stuff and compare. The problem is that most will stop at 1 broker and then reply on what is said at the barber shop..
Anyway.......this conversation is way to exhausting so I am done. Thanks for reading.

This is why these threads are somewhat pointless. If what you care about is the lowest premium and you don't have any concerns about networks or MA imposed treatment limitations you get one answer. If you worry about being denied care or having access to network facilities you get another. The difference in perspectives results in different best options. Some MA plans have good networks and access to out of network providers and facilities. Many people are happy with MA plans and never face meaningful limitations. On the other hand, the fact that the MA plan has worked for you doesn't negate the limitations.

Some/many people like to insist that their choice is superior. I hope a few people are open to learning something.

 

[Rjhasti]

This is why these threads are somewhat pointless. If what you care about is the lowest premium and you don't have any concerns about networks or MA imposed treatment limitations you get one answer. If you worry about being denied care or having access to network facilities you get another. The difference in perspectives results in different best options. Some MA plans have good networks and access to out of network providers and facilities. Many people are happy with MA plans and never face meaningful limitations. On the other hand, the fact that the MA plan has worked for you doesn't negate the limitations.

Some/many people like to insist that their choice is superior. I hope a few people are open to learning something.

you gave the answer in your post........"some of good networks". So go to several brokers and find the MA with good networks. Pretty simple really.

 

[ejman]

Medicare Advantage plans are great as long as you don't get old and seriously ill. I have a serious chronic illness that requires many medical interventions from many specialties. People with Advantage plans report incredible levels of difficulties in getting approvals for needed treatments. With my standard Medicare and plan G supplement I have none of those issues.

 

[saydiver]

In 2021 3.2 million Americans had traditional(original) Medicare without a supplemental plan.

https://www.kff.org/medicare/issue-brief/a-snapshot-of-sources-of-coverage-among-medicare-beneficiaries/

 

[NoEZmoney]

MC Advantage Plans great until you get really sick

So my brother and SIL had Advantage plans to avoid premiums. All went well until a couple cancer diagnosis and blown knee joints. On the knees, SIL was told she really needed full replacement on both but doc said it was borderline and insurer only approved 2 partials. Well both failed and so she got more surgery and had 2 full knee replacements. This 7 year hassle involved a lot of pain and inconvenience.

My brother had milignant melanoma, prostate cancer, and a pre-cancerous cyst on pancreas, and other issues. Because of having to stay in-network, there were several delays and very limited access to any surgeon with robotic specialty. He had to wait for months and they did "old-school radical prostatectomy" which left huge scarring, resulting in a large abdominal hernia that needed surgery but had poor result.

He then had other surgeries (gall bladder, Whipple procedure) and it took forever to get insurance approval each time.

You see Advantage plans are managed by insurance claim adjusters who can take as long as 60 to 90 days to approve treatment coverage. They delay to avoid paying quickly, it's true.

Recently MAYO Clinic in Rochester issued letter stating that certain MC Advantage plans would no longer be accepted. Same goes for Scripps Medical in SoCal for Humana Advantage and others. REASON: Slow pay or not agreeing to reimbursements based on Medicare approved rates.

Traditional Medicare is administered by govt and 95% of docs in USA accept payment guidelines. Advantage plans often require limited in-network medical facilities and docs. My bro and SIL complain that their docs leave network all the time due to insurance reimbursement so they seem to always be getting a PA initially until they find a new doc.

Advantage plans are great until you really need healthcare and everyone will have a series of serious medical issues as they age. I pay a little now so I won't be having fewer choices later.

Here's an article that explains other issues regarding Advantage.

https://truthout.org/articles/older-americans-feel-trapped-in-exploitative-medicare-advantage-plans/?utm_source=facebook&utm_medium=boost&utm_campaign=120203481829490458&fbclid=IwAR1mxkyQNfn8y4OsUJwhs1hZqNoW7lWnyWG_Cy7CPNjPedU_vICiYZEIuM0_aem_ASyyjPtGdZcm_520OpC7sVPxWYFnPyOW7uu9a2fxBavStEVIv5R5lUHBgBxT-EaMfRnpwiLxtG_H008TqX3xWm6_

 

[sengsational]

you gave the answer in your post........"some of good networks". So go to several brokers and find the MA with good networks. Pretty simple really.

Nothing simple about selecting a limited network plan. You really can't know what roadblocks the insurance company will throw up when you try to use the service providers they contract with. The only thing you get are "star ratings", which are manipulated heavily. I've been on limited network plans for 10 years from the market place, and here's an observation...if I have an encounter that goes as planned, I get spammed over and over to complete the survey, and they ask questions only that will get full marks. They don't survey you when they deny you services or when things don't go as planned. When you are sitting with this super wonderful broker you're talking about, he or she can't answer basic customer service questions like "will my GP be able to schedule me within 5 days". Buying other products, these kinds of metrics are known. Buyers, even with the help of a broker, simply don't have the data to do a good job at shopping. It's complicated and there's no supporting historical data, so no way to be a good consumer. So people make a decision on whether or not they get a free pair of glasses.

 

[Sulli]

Medicare Advantage definitely isn't for the wife and I. We travel just too much. Friends that have it said as they got older they wish they had not done it.

 

[RetMD21]

you gave the answer in your post........"some of good networks". So go to several brokers and find the MA with good networks. Pretty simple really.

A solution for the simple issue.If you don't care about possible denial of care you are set!

 

[RetMD21]

Several posters have used the term "good supplement." I wonder what you mean by that? Are there "bad supplements?" What criteria are you using?

The supplements all do the same thing. The difference between insurers comes down to rate increases and potentially leaving the business.

 

[Texas Proud]

We used to have a very good GP. He didn't belong to any network. He ran an old-school independent office, still associated somehow with the local hospital. He did charge significantly less than other Drs of the time. We were his patients for many years. I often overheard him say to other patients, "It isn't that I don't accept xyz insurance, it is that they don't accept (pay) me". IOW, he didn't want to join some network and overcharge for his office visits just to have that insurance company cut the agreed payment and show the patient how much they saved. The restrictions and paperwork that the insurers put on the Dr's was overwhelming.

Just my take but he DID overcharge for his services if the insurance paid him less.... they will pay him a flat amount... if he charges that amount he gets 100% he billed...


He just did not like what they were willing to pay... he wanted more... so he "overcharged" all his patients as the 'going rate' was what insurance would pay...

 

[FargoI]

Bravo for soliciting input from others!

IMHO... Be extremely careful with Medicare advantage plans. The allure of free gy memberships, free meal, transportation allowances, debit cards for free OTC items will be of little value if one's current or future providers do not fully participate.

Regardless of current diagnosis of cancer inquire if National Cancer Institute Centers of Excellence fully participate in the plan. Specifically inquire about MD Anderson, John's Hopkins, Dana Farber, Memorial Slone. Where one has a propensity for material eye disease, inquire if the redound Eye hospital in one's region fully participates.

Look out for clauses that say one can go to any Medicare Participating provider - these are often very gratuitous marketing slogans, and the reality is care received out of network is NOT a cake walk.

Most MAP require prior approvals for anything that is costly. Inquire if a like for like clinicians preforms the first level review. Generally if one's trusted orthopedic surgeon set out a care and treatment plan, one does not want a clerk, LPN or RN deciding of the well credentialed physician specialist treatment plan is the best for the patient.

Look up the salary for the exec running the MAP company - the salaries in the tens of millions are generated on the backs of subscribers who experience delays in care or outright denials.

Obviously, I am jaded. I have spent the better part of the last three years assisting municipal workers who are being forced into MAP plans, in lieu of traditional Medicare coupled with a medigap plan regain control of their plight.

Traditional Medicare Parts A and B coupled with a supplement plan (Medigap) essentially have no obstacles to obtain care nationwide. MAPs frequently have narrow networks that are geographically bounded.

 

[mathjak107]

we know someone who used to brag about how little they pay for their advantage plan ..

i tried to warn them that the saying NOTHING IS A PROBLEM UNTIL ITS A PROBLEM was created for these plans .

sure enough she was diagnosed with pituitary gland cancer.

one side was cancerous and the other side was not in good condition.

her doctors wanted both sides removed


well her for profit insurance company denied both sides …only the cancerous side can be removed

her doctors argued that not for profit medicare always pays for both halves .

the insurers reply was DONT TELL US WHAT MEDICARE WOULD HAVE DONE , YOUR PATIENT DOESNT HAVE MEDICARE so you can’t say what they would have allowed .

needless to say she had to wait until the other side showed cancerous, which it did and first had to be dealt with

 

[mathjak107]

Bravo for soliciting input from others!

IMHO... Be extremely careful with Medicare advantage plans. The allure of free gy memberships, free meal, transportation allowances, debit cards for free OTC items will be of little value if one's current or future providers do not fully participate.

Regardless of current diagnosis of cancer inquire if National Cancer Institute Centers of Excellence fully participate in the plan. Specifically inquire about MD Anderson, John's Hopkins, Dana Farber, Memorial Slone. Where one has a propensity for material eye disease, inquire if the redound Eye hospital in one's region fully participates.

Look out for clauses that say one can go to any Medicare Participating provider - these are often very gratuitous marketing slogans, and the reality is care received out of network is NOT a cake walk.

Most MAP require prior approvals for anything that is costly. Inquire if a like for like clinicians preforms the first level review. Generally if one's trusted orthopedic surgeon set out a care and treatment plan, one does not want a clerk, LPN or RN deciding of the well credentialed physician specialist treatment plan is the best for the patient.

Look up the salary for the exec running the MAP company - the salaries in the tens of millions are generated on the backs of subscribers who experience delays in care or outright denials.

Obviously, I am jaded. I have spent the better part of the last three years assisting municipal workers who are being forced into MAP plans, in lieu of traditional Medicare coupled with a medigap plan regain control of their plight.

Traditional Medicare Parts A and B coupled with a supplement plan (Medigap) essentially have no obstacles to obtain care nationwide. MAPs frequently have narrow networks that are geographically bounded.

we have a high deductible F PLAN from humana . we pay 100 bucks a month compared to 3400 a year for a conventional plan .

we bank most of that difference

the amazing thing is they pay for both our gym memberships . we belong to 2 m one is 50 a month normally and the other 30

 

[NXR7]

her doctors argued that not for profit medicare always pays for both halves .

the insurers reply was DONT TELL US WHAT MEDICARE WOULD HAVE DONE , YOUR PATIENT DOESNT HAVE MEDICARE so you can’t say what they would have allowed .

needless to say she had to wait until the other side showed cancerous, which it did and first had to be dealt with

As an attorney once told me, "A person who does not know their rights has no rights."

Pic is from this page: https://www.medicare.gov/basics/get.../compare-original-medicare-medicare-advantage

Ray

 

[mathjak107]

As an attorney once told me, "A person who does not know their rights has no rights."

Pic is from this page: https://www.medicare.gov/basics/get.../compare-original-medicare-medicare-advantage

Ray

however the gotcha is you don’t have medicare ..you can’t say what medicare would have allowed in your specific case and the insurers know this .

so without being able to say exactly what medicare would have allowed you are subject to what they decide to cover .

it doesn’t matter that someone else’s case was covered by medicare as no two are the same

GOTCHA… it sounds great that they have to cover what medicare does , but the catch 22 is you can’t say what medicare would have allowed when you don’t have medicare.

so as long as nothing is a problem there isn’t a problem, until it’s a problem

 

[NXR7]

however the gotcha is you don’t have medicare ..you can’t say what medicare would have allowed in your specific case and the insurers know this .

so without being able to say exactly what medicare would have allowed you are subject to what they decide to cover .

it doesn’t matter that someone else’s case was covered by medicare as no two are the same

GOTCHA… it sounds great that they have to cover what medicare does , but the catch 22 is you can’t say what medicare would have allowed when you don’t have medicare.

Ummm, yes, Medicare Advantage subscribers do have Medicare. That's why it's called Medicare Part C. It's just the claims processor that is different but they have to run under the same rules for what conditions to cover. As the link from the federal Medicare web site and pic I posted shows.

And the diagnostic coding is what determines what the case is. And why there are appeals processes. The private insurance carrier providing Medicare Part C coverage is never the final arbiter but too many people do not know their rights. If I or my family member received the determinatiom you mentioned I would have seeked legal counsel for how to proceed.

And why the IG released the results of a study a year or two ago saying that Medicare Advantage providers were found to be requiring conditions and extra tests that they were not allowed to do. And that they inappropriately denied treatment between, I think it was,12% and 20% of the reviewed cases.

Because they do have to cover what Original Medicare does but many times refuse illegally. It would be interesting to read the letter denying coverage because it sounds like you got the information secondhand. And yes, they did get such a letter.

There is only one pituitary gland so I'm unsure what you meant by one side having cancer and having to wait for the other side to get cancer. It's the size of a single chickpea. That's the problem with getting information secondhand.

Ray

 

[mathjak107]

Ummm, yes, Medicare Advantage subscribers do have Medicare. That's why it's called Medicare Part C. It's just the claims processor that is different but they have to run under the same rules for what conditions to cover. As the link from the federal Medicare web site and pic I posted shows.

And the diagnostic coding is what determines what the case is. And why there are appeals processes. The private insurance carrier providing Medicare Part C coverage is never the final arbiter but too many people do not know their rights. If I or my family member had the condition you mentioned I would have seeked legal counsel.

And why the IG released the results of a study a year or two ago saying that Medicare Advantage providers were found to be requiring conditions and extra tests that they were not allowed to do. And that they inappropriately denied treatment between, I think it was,12% and 20% of the reviewed cases.

Because they do have to cover what Original Medicare does but often refuse illegally. It would be interesting to read the letter denying coverage because it sounds like you got the information secondhand. And yes, they did get such a letter.

Ray

no , advantage plans are administering their version of medicare ,it is not the same as having not for profit govt medicare in the drivers seat

the for profit insurer determines your course of treatment. you can try to fight it but many times you lose

in the case i mentioned it went thru the appeals process and was denied repeatedly because it was not able to be determined what govt medicare would have done in this specific case because she didn’t have govt medicare.

so it doesn’t matter what the general terms are as far as covering what medicare would .
the ruling sided with the insurer.

there are specific treatment paths that would likely have had a different outcome with govt medicare like this one.


there are similar stories like this on all forums that discuss differences between the two.

hospitals have been dropping advantage plans left and right all over the country . if not totally then with individual ones they have trouble with while govt medicare is no problem

one hospital listed below found a 22% denial on advantage plans vs 1% on govt medicare and so they are dropping all advantage plans . other hospitals have done the same

Stillwater (Okla.) Medical Center has ended all in-network contracts with Medicare Advantage plans amid financial challenges at the 117-bed hospital. The hospital said it made the decision after facing rising operating costs and a 22% prior authorization denial rate for Medicare Advantage plans, compared to a 1% denial rate for traditional Medicare.

according to a study by kaiser

in the case of Medicare Advantage plans, physicians submitted more than 35 million requests for prior authorization to insurers in 2021, and more than 2 million of them – or about 6 percent – were fully or partially denied, according to the Kaiser Family Foundation’s new report on more than 500 Advantage plans.


Only about 11 percent of the denials were appealed, but the vast majority of those appeals succeeded in getting a full or partial reversal of the original denial but still hundreds of thousands of advantage plan subscribers were left denied

Here are 13 more recent instances of hospitals dropping Medicare Advantage contracts:

In October, the Nebraska Hospital Association issued a report detailing how Medicare Advantage is "failing patients and jeopardizing Nebraska hospitals," 33% of which do not accept MA patients. The report cited negative patient experiences, post-acute placement delays, and administrative and financial burdens on hospitals that accept MA patients.

York, Pa.-based WellSpan Health will no longer accept Humana Medicare Advantage and UnitedHealthcare-AARP Medicare Advantage plans starting Jan. 1. UnitedHealthcare group MA PPO and Humana employer PPO MA plans will still be accepted.

Greenville, N.C.-based ECU Health said it anticipates it will no longer be in network with Humana's Medicare Advantage plans starting Jan. 1.

Raleigh, N.C.-based WakeMed went out of network with Humana Medicare Advantage plans in October. According to CBS affiliate WNCN, the plan provides coverage to about 175,000 retired state employees. WakeMed cited a claims denial rate that is "3 to 4 times higher" with Humana compared to its other contracted MA plans.

Zanesville, Ohio-based Genesis Healthcare System is dropping Anthem BCBS and Humana Medicare Advantage plans in 2024.

Brunswick-based Southeast Georgia Health System will terminate its contract with Centene's WellCare Medicare Advantage plan on Dec. 8. The system said it started negotiations with the carrier after years of "inappropriate payment claims and unreasonable denials."

Nashville, Tenn.-based Vanderbilt Health went out of network with Humana's HMO Medicare Advantage plan in April.

Fayetteville, N.C.-based Cape Fear Valley Health dropped UnitedHealthcare Medicare Advantage plans in July.

Corvallis, Ore.-based Samaritan Health Services ended its commercial and Medicare Advantage contracts with UnitedHealthcare. The five-hospital, nonprofit health system cited slow "processing of requests and claims" that have made it difficult to provide appropriate care to UnitedHealth's members, which will be out of network with Samaritan's hospitals on Jan. 9. Samaritan's physicians and provider services will be out of network on Nov. 1, 2024.

Cameron (Mo.) Regional Medical Center stopped accepting Cigna's MA plans in 2023 and plans to drop Aetna and Humana in 2024. It plans to continue Medicare Advantage contracts with UnitedHealthcare and BCBS, the St. Joseph News-Press reported. Cameron Regional CEO Joe Abrutz previously told the newspaper the decision stemmed from delayed reimbursements.

Stillwater (Okla.) Medical Center has ended all in-network contracts with Medicare Advantage plans amid financial challenges at the 117-bed hospital. The hospital said it made the decision after facing rising operating costs and a 22% prior authorization denial rate for Medicare Advantage plans, compared to a 1% denial rate for traditional Medicare.

Brookings (S.D.) Health System will no longer be in network with nearly all Medicare Advantage plans in 2024, with the exception of Medica. The 49-bed, municipally owned hospital said the decision was made to protect the financial sustainability of the organization.

Louisville, Ky.-based Baptist Health Medical Group went out of network with Humana's Medicare Advantage plans in September, Fox affiliate WDRB reported. The system will also go out of network with UnitedHealthcare and Centene's WellCare on Jan. 1 without a new agreement in place.

DOES THAT SOUND THE SAME TO YOU AS GOVT MEDICARE ?

 

[NXR7]

You're talking about two different things: the standard of care and the payment to the hospitals. Hospitals are dropping certain Medicare Advantage plans from being able to be used because the private insurer has developed a reputation for late and low payments as well as excessive pre-treatment authorization requirements. All of those raise their costs so they are just making that problem go away. I would, too.

The government does not determine the course of care, correct.

You and I are actually in agreement on the premise and that's why I have always had Original Medicare plus a supplement. It costs me $4,000 a year, every year, and goes up a bit each year but I know my costs are essentially fixed and I can go about anywhere for treatment.

 

[mathjak107]

You're talking about two different things: the standard of care and the payment to the hospitals. Hospitals are dropping certain Medicare Advantage plans from being able to be used because the private insurer has developed a reputation for late and low payments as well as excessive pre-treatment authorization requirements. All of those raise their costs so they are just making that problem go away. I would, too.

The government does not determine the course of care, correct.

You and I are actually in agreement on the premise and that's why I have always had Original Medicare plus a supplement. It costs me $4,000 a year, every year, and goes up a bit each year but I know my costs are essentially fixed and I can go about anywhere for treatment.

denials are an issue as well , it isn’t two different things

“ Among the most commonly cited reasons are excessive prior authorization denial rates and slow payments from insurers. Some systems have noted that most MA carriers have faced allegations of billing fraud from the federal government and are being probed by lawmakers over their high denial rates.”

https://www.beckershospitalreview.c...opping-medicare-advantage-left-and-right.html

 

[MichaelB]

Ummm, yes, Medicare Advantage subscribers do have Medicare. That's why it's called Medicare Part C. It's just the claims processor that is different but they have to run under the same rules for what conditions to cover. As the link from the federal Medicare web site and pic I posted shows.

no , advantage plans are administering their version of medicare ,it is not the same as having not for profit govt medicare

I agree with NXR7. Medicare Advantage plans are required to administer the same coverage as Medicare traditional. They can, and do, limit their provider network, but they cannot refuse to cover a treatment or service covered by Medicare.

Medicare Advantage plans often include drug coverage and other services not covered by Medicare, such as dental.

 

[mathjak107]

wrong ,,, did you read the links.

did you google it ?

in theory they are supposed to but YOU DONT HAVE GOVT MEDICARE to say when you are denied what govt medicare would have allowed in your case .

not everything is black and white . i witnessed it first hand

many things if you google it are denied , yet the problem is you can’t say what government medicare would have done .

that is why law makers are trying to get this corrected fully .so far no luck on a wide scale of having one central gate keeper for both.

saying we cover the same things is only in theory until they don’t and the advantage plan gate keepers deny you.

hospitals are seeing way more denials from advantage plans then govt medicare

as well as why should someone have to even try to appeal these denials in the first place from advantage plans if THEY COVERED-THE SAME THINGS-like they are supposed to

 

[ShokWaveRider]

wrong ,,, did you read the links.

did you google it ?

in theory they are supposed to but YOU DONT HAVE GOVT MEDICARE to say when you are denied what govt medicare would have allowed in your case .

not everything is black and white . i witnessed it first hand

many things if you google it are denied , yet the problem is you can’t say what government medicare would have done .

that is why law makers are trying to get this corrected fully .so far no luck on a wide scale of having one central gate keeper for both.

saying we cover the same things is only in theory until they don’t and the advantage plan gate keepers deny you

+100
Some folks "fall" for the advertising and lower costs. They would rather have Gym memberships rather than Top Notch healthcare. Their choice, but when the SHTF they will not be accepted for a Proper supplement, underwriting will make sure of that. Unless you are in a State that allows switching, it would be nice is all states did.

Saying that, Employer sponsored Medicare Advantage is a completely different Animal and cannot be classified in the same class as celebrity touted healthcare.

And NO, it is NOT Medicare, it is a substitute and not a good one at that. The advertising I Deceiving.

We witnessed it also and the results were not good. some are lucky, others are not. Luck is not a thing I want to have in the same sentence as my Healthcare.