Top 5 Things your Medicare Advantage salesman won't tell you

[yakers]

DW & I have Kaiser HMO MA, has worked fairly well, nothing perfect with them or any alternatives. DW & I had serious cancer issues, nothing out of pocket. Never searched deeply into alternatives as we had Kaiser before medicare so it was working and just stayed with them.

[SecondAttempt]

You folks are much smarter about all this than me. I am trying to learn as much as I can so I can make good decisions in 8 years when I am eligible for Medicare. The discussion here caused me to do some research today. I personally would not sign up for anything that required me to give up a governemnet guaranteed plan and premium for a plan subject to a for-profit company's decisions. I have always been fairly healthy but there will come a time when I am not as there is for all of us. I don't think that is a time when I want to try to switch back to medicare and have preexisting conditions excluded.

[SecondAttempt]

I have a related question. My partner has a pension from the State of Hawaii she is eligible in a few years. She gets health insurance paid for life, which is of course good. But once she gets on Medicare it looks like the only plan offered is a MA plan. Obviously she could buy a Part G/K/L/N plan on her own but this seems like another incidence of a MA scam/influence. My understanding is she can opt out of their plan but would give up the premium supplement they provide. Doesn't seem very fair that the state government only provides a MA plan. I could be wrong about this but that is how it seems.

[Irishgirlyc58]

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Originally Posted by SecondAttempt I have a related question. My partner has a pension from the State of Hawaii she is eligible in a few years. She gets health insurance paid for life, which is of course good. But once she gets on Medicare it looks like the only plan offered is a MA plan. Obviously she could buy a Part G/K/L/N plan on her own but this seems like another incidence of a MA scam/influence. My understanding is she can opt out of their plan but would give up the premium supplement they provide. Doesn't seem very fair that the state government only provides a MA plan. I could be wrong about this but that is how it seems.

I actually have the same type of decision except I’ll be 65 next September so I have to decide by June.
What I did was request the information on the Medicare Advantage plan that they offer.
MA plans from an employer are typically different from what is offered in the wild.
The plan from my former employer has no co pays for any medical services in or out of network, effective throughout the U.S., max out of pocket is 0. So really the only cost will be for prescriptions.
There are some additional services such as hearing aids, routine eye exam, and others.
Prescriptions have additional medications covered in addition to the normal list.

You don’t give up your government provided Medicare which are parts A and B. They must cover the same services that Medicare covers.
The private insurance part is what is covered over and above Medicare.
Medigap coverage is also provided by private insurance.

I plan to develop a spreadsheet of coverages etc and hopefully that will help me make a decision.

[Scuba]

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Originally Posted by SecondAttempt You folks are much smarter about all this than me. I am trying to learn as much as I can so I can make good decisions in 8 years when I am eligible for Medicare. The discussion here caused me to do some research today. I personally would not sign up for anything that required me to give up a governemnet guaranteed plan and premium for a plan subject to a for-profit company's decisions. I have always been fairly healthy but there will come a time when I am not as there is for all of us. I don't think that is a time when I want to try to switch back to medicare and have preexisting conditions excluded.

I agree 100%. We are planning to go for traditional Medicare plus supplemental. We want the maximum choice possible and are willing to pay for that, just as we’ve paid for a PPO plan all these years.

DH turns 65 in 2024. Is any underwriting required when initially signing up, and are pre-existing conditions used as a basis for supplemental policy rates or denial of eligibility? Since he had quadruple bypass surgery at age 63, I hope we will be able to get him good coverage.

[athena53]

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Originally Posted by Scuba DH turns 65 in 2024. Is any underwriting required when initially signing up, and are pre-existing conditions used as a basis for supplemental policy rates or denial of eligibility? Since he had quadruple bypass surgery at age 63, I hope we will be able to get him good coverage.

Pre-existing conditions are not considered when initially signing up for traditional Medicare. They are considered only by the supplement carrier if you're switching from Medicare Advantage. I retired at 61 and DH was 75. He had cardiac stents and polycythemia (bone marrow churning out too many red blood cells- eventually morphed into acute myeloid leukemia, which is a common result). No problem at all getting him traditional Medicare coverage and no major out-of-pocket expenses, even through his final months.

[ncbill]

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Originally Posted by Z3Dreamer OK, you ask for Medigap disadvantages. The whole Medigap theory is a reactive approach. My MA is a proactive approach. My MA has preventative things. So this is a big disadvantage of Medigap. I can give a whole bunch of examples of how they try to get/keep you healthy, if you want. A second advantage of my MA is the speed at which they process claims. My MA is within a few days. DW's Medigap is lengthy. A recent misbilling took her two months to clear up. I have more but I will address the "However if you get sick, that disadvantage can disappear very quick." Yes, my MA has co-pays, but no deductibles and no premiums. In some years, you will do better with an MA and some years you will do better with a Medigap. This is the whole concept of risk management. Do want to pay nice regular premiums or only pay when you are sick? Personal choice. Let me ask you this: For your house, would rather pay low premiums but have a higher deductible or pay high premiums and have a low deductible? Again, personal choice. But I hear from people are passionate that a high deductible on a house is bad, stupid, etc. On my MA plan, if I save $2,000 per year for a number of years, but have a number of years where I pay more, is that bad? I don't understand this point: "Another point, clearly the dollars allocated to Advantage plans is to high." I think you are saying that it costs the government too much and is therefore bankrupting Medicare. Is that correct? Your last point is: "The are spending on advertising with thousands of commercials to coerce you into a plan. If it wasn't overly profitable they wouldn't spend so much pushing it." I think you are saying that the massive amount of spending on advertising proves it is too profitable and therefore their product must be bad. I don't see that one follows the other. I could argue that all advertisers must be bad by that logic, but you would say that I was offering a strawman's argument. I could say that they have to advertise to overcome all the negative things about MA, but you would say they are doing a bad job as we are all sick of Joe Namath and JJ Walker. I will just agree that we are all sick of the MA advertisements.

It's not just denying things like physical therapy where you could pay OOP.

But when you develop a form of cancer whose treatments require $60,000 infusions every four weeks (according to your oncologist) but your MA plan will only approve paying for those infusions every eight weeks what will you do then?

It would take weeks for any appeals...the first two levels of which are internal anyway, IIRC.

[Livefree]

I've had a Blue Cross PPO Medicare Advantage Plan for almost 3 years and it's been fine.


It works well for me, as I don't take prescriptions, or any real health problems.



Also, I live in Mass. and there is no medical underwriting, so I can switch to a gap plan if I decide to.

[RetMD21]

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Originally Posted by Irishgirlyc58 I believe page 18 of the report link on his first point contradicts what he is saying regarding admin costs. A 15% admin cap is typical contract language for federal funds/programs. What’s included in admin vs program costs differs by program. I don’t see any side by side comparison of admin costs for MA vs admin costs for CMS/Medicare specific to the administration of Medicare A and B.

from the original link:

If you choose Medicare Advantage, the Centers for Medicare & Medicaid Services (CMS), transfers that average $13,500/year benefit to the private health insurer you select. In turn, the insurer is allowed to skim off up to 15% of that $13,500 in admin expenses (i.e., $2,025/yr) though in many urban areas competition may limit that skim rate to 12% or so. That 15% figure relates to the so-called Medical Loss Ratio or MLR. Medicare demands that Medicare Advantage insurers spend at least 85% of your benefit on actual medical services and no more than 15% on overhead & profit.

For 2021, traditional Medicare had program costs of $887.6 Billion, spent $839.3 Billion on actual medical services for its 63.8 million beneficiaries, and $10.8 Billion for administrative expenses. (See Page 12, 2022 Medicare Trustees Report). That's an admin cost of 1.2%.

[RetMD21]

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Originally Posted by Z3Dreamer Challenge accepted. NYT article is behind a paywall, but the section quoted below the hyperlink discusses the IG report (I think) that found MA plans deny too many legitimate pre-authorization requests. This is true, but the author at retireearlyhomepage then drew the conclusion of "There's a lot of suspected for-profit insurance company fraud in Medicare Advantage." Fraud is a totally different animal. Here is a link to the IG's report. https://oig.hhs.gov/oei/reports/OEI-09-18-00260.asp No where in the IG's report is the term "FRAUD" mentioned. Furthermore, the IG recommends improvement to the system, which is an administrative fix. What the author of the article suggests is a criminal proceeding. Totally different. Furthermore, H.R. 3173 which purports to fix the problem has passed the House. It may never be law, but the issue in the IG report is being looked at, addressed, etc. So, I am refuting point #4 as the facts do not support his conclusion.

‘The Cash Monster Was Insatiable’: How Insurers Exploited Medicare for Billions
By next year, half of Medicare beneficiaries will have a private Medicare Advantage plan. Most large insurers in the program have been accused in court of fraud. https://www.nytimes.com/2022/10/08/u...legations.html

[Z3Dreamer]

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Originally Posted by RetMD21 ‘The Cash Monster Was Insatiable’: How Insurers Exploited Medicare for Billions By next year, half of Medicare beneficiaries will have a private Medicare Advantage plan. Most large insurers in the program have been accused in court of fraud. https://www.nytimes.com/2022/10/08/u...legations.html

Sorry but it is behind a paywall. It is suspect because they use the terms "Most" and "Accused". Something like: MA plan xyz ordered to pay $x billion to CMS because of fraud would be better.

Even if some plans get accused of overbilling, do you want to get into a discussion of the medigap side of this which is medical professionals overbilling Medicare?

[Z3Dreamer]

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Originally Posted by ncbill It's not just denying things like physical therapy where you could pay OOP. But when you develop a form of cancer whose treatments require $60,000 infusions every four weeks (according to your oncologist) but your MA plan will only approve paying for those infusions every eight weeks what will you do then? It would take weeks for any appeals...the first two levels of which are internal anyway, IIRC.

No one would want to be in that situation. If you feel that it is a real possibility and it bothers you greatly, MA's are not for you. The MA denials that I am aware of have been reasonable. YMMV.

[Z3Dreamer]

Quote:

Originally Posted by RetMD21 from the original link: If you choose Medicare Advantage, the Centers for Medicare & Medicaid Services (CMS), transfers that average $13,500/year benefit to the private health insurer you select. In turn, the insurer is allowed to skim off up to 15% of that $13,500 in admin expenses (i.e., $2,025/yr) though in many urban areas competition may limit that skim rate to 12% or so. That 15% figure relates to the so-called Medical Loss Ratio or MLR. Medicare demands that Medicare Advantage insurers spend at least 85% of your benefit on actual medical services and no more than 15% on overhead & profit. For 2021, traditional Medicare had program costs of $887.6 Billion, spent $839.3 Billion on actual medical services for its 63.8 million beneficiaries, and $10.8 Billion for administrative expenses. (See Page 12, 2022 Medicare Trustees Report). That's an admin cost of 1.2%.

There are many reasons why a for-profit insurance company would have higher admin costs than a government agency, but I don't understand the relevance of this discussion as those are "input" numbers. Shouldn't the evaluation of the plan be based on outcomes? Such things as health of patients or cost to customers.

[Z3Dreamer]

OP had a well thought out article by someone he had a lot of respect for. The article happened to agree with his knowledge about MA plans. I am on the opposite end and I had time to kill, so I decided to present the other side, in great detail. I may be wrong, but my points are well researched. As I said in my first post, I doubted that I could convince anyone of my side. But I think that if I post anymore to this thread: I will will be banned. Sent for OCD treatment. Drawn and quartered.

I am stepping out gracefully, not conceding. Please continue to bash MA plans without me responding.

[Irishgirlyc58]

Quote:

Originally Posted by RetMD21 from the original link: If you choose Medicare Advantage, the Centers for Medicare & Medicaid Services (CMS), transfers that average $13,500/year benefit to the private health insurer you select. In turn, the insurer is allowed to skim off up to 15% of that $13,500 in admin expenses (i.e., $2,025/yr) though in many urban areas competition may limit that skim rate to 12% or so. That 15% figure relates to the so-called Medical Loss Ratio or MLR. Medicare demands that Medicare Advantage insurers spend at least 85% of your benefit on actual medical services and no more than 15% on overhead & profit. For 2021, traditional Medicare had program costs of $887.6 Billion, spent $839.3 Billion on actual medical services for its 63.8 million beneficiaries, and $10.8 Billion for administrative expenses. (See Page 12, 2022 Medicare Trustees Report). That's an admin cost of 1.2%.

But right above the chart it states:

For fee-for-service Medicare, the largest category of Part A expenditures is inpatient hospital services, while the largest Part B expenditure category is physician services. Payments to private health plans for providing Part A and Part B services represented roughly 48 percent of total A and B benefit outlays in 2021.

I believe the numbers you quoted include all expenses for part A and B.
Do you read that differently?

[Irishgirlyc58]

Regarding the 15% admin costs that MA plans are allowed in order to compare how do Medigap plans make their money for admin costs? They are private insurance as well. It costs them to process claims, they have overhead. Where is the accounting for their admin costs?

[Gotadimple]

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Originally Posted by Irishgirlyc58 Regarding the 15% admin costs that MA plans are allowed in order to compare how do Medigap plans make their money for admin costs? They are private insurance as well. It costs them to process claims, they have overhead. Where is the accounting for their admin costs?

It's probably built into the premium rate that CMS approved for the plan. Along with the commission costs the plan must pay sales people.

[Irishgirlyc58]

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Originally Posted by Gotadimple It's probably built into the premium rate that CMS approved for the plan. Along with the commission costs the plan must pay sales people.

I assumed this as well but where is the accounting for that amount?
If we know what MA can use for admin costs for all 4 programs- Part A, B, D, and the gap coverage shouldn’t we be able to determine the % insurance companies that provide only the gap coverage charge for admin costs?

I ask because if I were truly analyzing/ comparing these programs I would want to know this.

[Texas Proud]

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Originally Posted by qwerty3656 So where does "Boomer Benefits" fall in the "you can trust what they say" scale? I'm not on Medicare, but probably plan to contact them or someone like them when I do go on Medicare.

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Originally Posted by Ian S I have not used Boomer Benefits but did go to a local agent's seminar and separately, one on one meetings with an agent whom I knew personally. I did my homework though and ultimately went with the AARP supplement which was not the one promoted by my agent friend. I did have him do the paperwork though!

One thing is who you get on the phone... I got someone who seemed that they did not want to talk to me... they recommended a new firm that I wanted to research some before buying... so asked about a plan D... was told they would talk about plan D when I signed up for a plan !!!



I called Senior Savings Network and had someone that was very helpful. Talked about the plans and even a D plan. They were also recommending the same firm BB recommended so wanted to do research. Later I found that UHC was not included by them in the rates given. When given their rate was higher than what UHC was gong to charge but they do not even write UHC plans.


No matter who you call you are dealing with agents that have their opinion and incentives and it might not be the best for you. Like always you need to do your own homework and make an informed decision.


BTW, the guy at BB was not working there a month after I had talked to him as someone else called me to pick up his contacts. Who knows how they would have been if they were my first contact. I would have gone with SSN if the rate for UHC was the same as what I got and they wrote it. They were very helpful and informative.

[CRLLS]

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Originally Posted by Texas Proud .....No matter who you call you are dealing with agents that have their opinion and incentives and it might not be the best for you. Like always you need to do your own homework and make an informed decision.....

^ +100