Medicare advantage plan

[Teacher Terry]

or die.

That’s what MA plans are counting on. 60 minutes did a segment on this.

 

[Dash man]

When you hear that Medicare Advantage plans have to cover everything Medicare does, remember Medicare Part B only pays 80%. This is how some cancer patients get into financial hardship if the MA plan only covers 80% of a cancer drug. Reading the fine print is critical with MA plans. Some plans will only pay the 80% and the difference has to be made up by the patient.
MA plans backed by state governments, unions or company retiree health plans tend to be better at covering cancer drugs. My father-in-law survived urothelial cancer with no cost with his union MA plan. But getting approvals for scans and surgery were a pain and delayed treatment.

 

[ShokWaveRider]

It is not always that a patient can die waiting for approvals. I was at my specialist eye doctor's yesterday for a Glaucoma analysis and treatment. She thanked me for having proper Medicare. She shared that she stopped taking a certain companies MA plan as the waiting for approvals allowed 3 of her patients in 2023 to go legally blind, and it was irreversible. She said she cannot deal with that. She promptly scheduled me for Laser surgery next week for one eye and the following 3 weeks for the other without any hesitation at all, knowing it was fully covered. She also commented that I was lucky that my annual eye exam optometrist caught it otherwise I would have needed a different course of action if left alone.

 

[Gotadimple]

@mathjak:
Obviously you have your opinion. But Medicare Advantage is 'govt Medicare'. A plan who wants to sell it has to be willing to provide ALL the services covered by traditional Medicare.

@dashman Govt Medicare pays at 80% of the approved charges. This means a fee schedule that the provider who accepts assignment agrees to. That does not mean that the Medicare Advantage plan only pays 80%, they pay based on fee schedule from the health plan, and a co-pay system that can result in far less than the 20% that govt Medicare doesn't cover.

@ Pluperfect Accepts assignment means that a provider agrees to accept the Meedicare rates - a fee schedule - plus meet certain requirements regarding being certified to accept Medicare. The physician cannot bill any charges in excess of the fee schedule.

In comparison, Medicare Supplement plans just pick up the difference between 80% and 100%.

If a PPO plans says you can refer yourself to any specialist who accepts Medicare, that means you pick a provider from their provider directory for a lower co-pay, or pick a provider who accepts Medicare for a higher co-pay. It is up to the specialist to contact the MA plan to determine coverage and any restrictions the plan may have about the details of the visit (procedure, drugs, etc.).

As to appeals, if the person who lost the appeal didn't clearly show that both the Welcome to Medicare book wording and Medicare Advantage wording for the same benefit match - and they didn't receive services, then, it has nothing to do with govt Medicare and everything to do with how they presented their case.

 

[mathjak107]

@mathjak:
Obviously you have your opinion. But Medicare Advantage is 'govt Medicare'. A plan who wants to sell it has to be willing to provide ALL the services covered by traditional Medicare.

@dashman Govt Medicare pays at 80% of the approved charges. This means a fee schedule that the provider who accepts assignment agrees to. That does not mean that the Medicare Advantage plan only pays 80%, they pay based on fee schedule from the health plan, and a co-pay system that can result in far less than the 20% that govt Medicare doesn't cover.

@ Pluperfect Accepts assignment means that a provider agrees to accept the Meedicare rates - a fee schedule - plus meet certain requirements regarding being certified to accept Medicare. The physician cannot bill any charges in excess of the fee schedule.

In comparison, Medicare Supplement plans just pick up the difference between 80% and 100%.

If a PPO plans says you can refer yourself to any specialist who accepts Medicare, that means you pick a provider from their provider directory for a lower co-pay, or pick a provider who accepts Medicare for a higher co-pay. It is up to the specialist to contact the MA plan to determine coverage and any restrictions the plan may have about the details of the visit (procedure, drugs, etc.).

As to appeals, if the person who lost the appeal didn't clearly show that both the Welcome to Medicare book wording and Medicare Advantage wording for the same benefit match - and they didn't receive services, then, it has nothing to do with govt Medicare and everything to do with how they presented their case.

if only it was that simple ..and no a private insurance company administering your coverage is not the same as govt medicare who is not for profit administrating it

why do you think so many hospitals don’t want to accept advantage plans and are dropping them breaking their contracts or not renewing them , but they accept medicare

 

[MichaelB]

if only it was that simple ..and no a private insurance company administering your coverage is not the same as govt medicare who is not for profit administrating it

why do you think so many hospitals don’t want to accept advantage plans and are dropping them breaking their contracts or not renewing them , but they accept medicare

You’ve made your point, based on your experience. Others have different, positive experiences with Medicare Advantage. There are MA plans that do work, provide adequate coverage, and fit the needs of policyholders.

 

[mathjak107]

i agree , i wish we had kaiser plans here , but we don’t . they are the only one though i would consider

 

[Teacher Terry]

Mathjak, some of the hospitals locally broke their contracts with MA plans before the year was up. This left my friend unable to get her knee replacement surgery after jumping through many hoops including having both a cardiologist and pulmonary doctor saying she could have surgery. If she still wanted to get it she would need to jump through all the hoops again with new doctors in the new system after spending 9 months previously doing just that. She gave up and that’s what the MA plans count on.

There’s some decent employer retirement plans that have been separately negotiated but they are the exception and not the norm. The government wants people on crappy MA programs so they can get out of the Medicare system.

I suspect the true goal is to have everyone on these plans with long waits for service and denials of surgeries, etc as people age. Seniors are viewed as a drag on the system and the fewer the better. I know it’s a pessimistic view but a realistic one. I worry about the HC my kids will have in retirement.