Help on medicare

[Texas Proud]

There have been many threads on medicare and I read them off and on trying to pick up some info for when I have to purchase in a few years... so, I am far from an expert in the plans...


BUT, I need to learn as much as I can quickly... some background... my mom is on a medicare advantage plan that is offered through the Texas teacher retirement system.... she has had many problems this year...


Early in the year she fell and broke a small piece of her pelvis... was in the hospital for a number of days and then moved to skilled nursing... there for (not sure) 8 to 10 weeks... at the very end she had her arm dislocated and went to the hospital again... they kept her a couple of days because her salts (or something) was out of whack and they were worried...


We have since moved her to a memory care facility that is pretty good, but she has swelling and other issues... OH, forgot to tell that she went into AFIB sometime last year and is in and out of that.... she has had home nursing care off and on the past 4 or so months...



The problem is that the insurance is starting to refuse her home nursing care... the nurse and facility people say they keep working to get her help, but so far not much is happening...


SOOO, the memory care had said that regular medicare is 'better' in getting home health care since all it takes it the Dr. order...



Without going into much more detail as this is already getting long... is there a good website where I can read about what it might cost me if we go that way? I am pretty sure I will not be able to get her supplemental insurance with her age and condition... and I do not want to go regular medicare if there is no limit to what I would have to pay in case she has to do some more hospital visits...


Any other thoughts that you might be able to give me if you or someone you know has gone through this?

 

[wmc1000]

Sorry to about your moms' issues. However, unless her MA provider ceases its coverage in your area your mother can only go on regular medicare if she is accepted after medical underwriting. Given her medical issues that may prove hard to do.

However, during open enrollment she can choose a different MA provider effective 1-1-19 that may provide better coverage at a higher monthly cost.

 

[spncity]

As I recall, we easily got our mom a great Medicare supplemental plan when we moved her near my sister.

Got advice from the SHIP counselor. State Health Insurance Plan counselor. Just google it or call the office on aging, health department, or Medicaid office to find out how to get in touch with the SHIP counselor. Free service.

You should also consult the SHIP counselor each year with her list of medications to choose the right prescription plan during open enrollment (many plans change their formularies, so just because they covered a prescription this year doesn't mean they will cover it the next.)

 

[ivinsfan]

You can run up unlimited co pays on plain Medicare..there in no cap to your OOP. You Mom has run into the big downside of a n advantage plan.

 

[MissMolly]

Regular does not require underwriting. Medicare is always available to switch to during open enrollment. It’s the Medigap policies that require the underwriting. Due to your mother’s health problems it is doubtful you can get her insured under a Medigap supplemental policy but Medicare is always a choice. But as Ininsfan says you would be on the hook for the 20% not covered by Medicare.

 

[Another Reader]

Medicare Advantage = rationed health care. It's why these plans are less expensive.

 

[winger]

Medicare Advantage = rationed health care. It's why these plans are less expensive.

Not in all cases. We have a United Advantage plan through a former employer. While they do recommend their nationwide network, we can go to any provider that hasn't opted out of Medicare. United pays the same to either.

There are many thousands of us.

 

[Texas Proud]

Regular does not require underwriting. Medicare is always available to switch to during open enrollment. It’s the Medigap policies that require the underwriting. Due to your mother’s health problems it is doubtful you can get her insured under a Medigap supplemental policy but Medicare is always a choice. But as Ininsfan says you would be on the hook for the 20% not covered by Medicare.

Yes, it is the medigap that is the problem... I knew there was underwriting and I knew she would never qualify with her condition and age...


I was not sure if regular without gap insurance had a maximum OOP per year... I do not want to take a chance on some long hospital stay as I think she will be needing it next year... maybe a couple of times...


Her plan is pretty decent as they have covered everything that has occurred so far this year... it is only recently that in home nursing has become an issue... so far they are still approving, but when they used to approve 6 sessions it now seems to be 2 or 4... not sure if they have actually refused outright yet...

 

[Texas Proud]

You can run up unlimited co pays on plain Medicare..there in no cap to your OOP. You Mom has run into the big downside of a n advantage plan.

This is what I was afraid of... so we will be keeping what she has...


Thanks for the feedback...

 

[Texas Proud]

Not in all cases. We have a United Advantage plan through a former employer. While they do recommend their nationwide network, we can go to any provider that hasn't opted out of Medicare. United pays the same to either.

There are many thousands of us.

The TRS used to provide a supplement and that is what my sister was on... but they changed starting this year to only advantaged... it was to save money for the plan...

 

[Another Reader]

Not in all cases. We have a United Advantage plan through a former employer. While they do recommend their nationwide network, we can go to any provider that hasn't opted out of Medicare. United pays the same to either.

There are many thousands of us.

You can go to anyone but the insurance company might not approve the recommended care.

 

[MBSC]

I reviewed the Texas Teachers retiree benefits. MA is their only option so there is no opportunity to switch to a traditional retiree plan with secondary Medicare coverage.

https://www.trs.texas.gov/Pages/healthcare_trs_care_medicare.aspx

It is highly unlikely moving from a retiree MA plan to an individual market MA plan will produce better results. Retiree MA plans are almost always more generous than individual MA plans. People like to say MA must cover the same services as original Medicare but it is situations like this when they learn MA is not required to cover the service as comprehensively as original Medicare.

...is there a good website where I can read about what it might cost me if we go that way?

This site shows original Medicare cost sharing amounts. For inpatient hospital admissions, facility fees are billed to Part A and professional services (surgeon, anesthesiologist, etc.) are billed to Part B resulting in both A/B cost sharing. There is no limit to the 20% Part B coinsurance.

https://www.medicare.gov/your-medicare-costs/medicare-costs-at-a-glance

I am pretty sure I will not be able to get her supplemental insurance with her age and condition... and I do not want to go regular medicare if there is no limit to what I would have to pay in case she has to do some more hospital visits.

She would be exempt from supplement (Medigap) underwriting if she moved out of the MA plan's service area as indicated by spncity in post #3.

 

[MBSC]

We have a United Advantage plan through a former employer. While they do recommend their nationwide network, we can go to any provider that hasn't opted out of Medicare.

You need to read your policy again. You can go to any provider in an emergency. For non-emergencies, PPO members can go to any provider that hasn't opted out of Medicare AND takes the MA PPO (aka accepts the plan's terms).

UnitedHealthcare® Group Medicare Advantage (PPO)

Out-of-network/non-contracted providers are under no obligation to treat Plan members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information.

Reference (page 9): https://www.uhcretiree.com/content/...peehip/2018_PEEHIP_Summary_Benefits_15500.pdf

A UHC Medicare Advantage Preferred Provider Organization, or PPO, plan is an appealing option for Medicare beneficiaries who want more flexibility in choosing health-care providers. Members enrolled in a UnitedHealthcare Medicare Advantage PPO can see any doctor and use any hospital they like(*).

(*) Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations.

Reference: https://medicare.com/unitedhealthcare/what-medicare-advantage-plans-does-united-healthcare-have/

Preferred Provider Organizations (PPOs). PPOs let you see any provider or doctor who accepts your Medicare Advantage plan, but you may pay less when you use providers in the plan’s preferred provider network.

Reference: https://medicare.com/medicare-advan...doctor-that-takes-my-medicare-advantage-plan/

MD Anderson Cancer Center in Houston:

Medicare Part C, also known as the Medicare Advantage Plan, replaces traditional Medicare. Kelsey-Care Medicare Advantage is the only Medicare Advantage plan with which MD Anderson is contracted. However, we have a working relationship with some Medicare Advantage HMO and PPO plans. Please contact your plan to determine if they will work with MD Anderson.

Reference: https://www.mdanderson.org/patients...ling-financial-support/medicare-medicaid.html

Mayo Clinic - Arizona campus:

Mayo Clinic's campus in Arizona. Patients covered by any types of Medicare Advantage Plans (exception Cost share/HCPP) that are not contracted may not be seen. Patients cannot be seen on a self-pay basis.

Reference: https://www.mayoclinic.org/patient-.../accepted-insurance/medicare/more-on-medicare

 

[Another Reader]

You need to read your policy again. You can go to any provider in an emergency. For non-emergencies, PPO members can go to any provider that hasn't opted out of Medicare AND takes the MA PPO (aka accepts the plan's terms).

MD Anderson Cancer Center in Houston:

My guess is that most people that buy these policies as an "upgrade" to the HMO have the same misunderstanding. The wording appears to be a deliberate attempt to confuse and mislead the consumer.

My impression is that traditional Medigap supplements are more consistent and more easily understood because of the rules imposed by Medicare. Am I missing something?

The Part D plans are a nightmare. The only assistance in buying these seems to be the programs that take the prescription drugs you use today and run an estimate of your total annual cost of the premium and the co-pays. The insurance company can change the formulary at will with a sixty day notice to the customers. There is no way for the average consumer to evaluate the insurance company's behavioral history. You probably have to be inside the industry to have any real understanding of whose product is best.

 

[MichaelB]

My guess is that most people that buy these policies as an "upgrade" to the HMO have the same misunderstanding. The wording appears to be a deliberate attempt to confuse and mislead the consumer.

My impression is that traditional Medigap supplements are more consistent and more easily understood because of the rules imposed by Medicare. Am I missing something?

The Part D plans are a nightmare. The only assistance in buying these seems to be the programs that take the prescription drugs you use today and run an estimate of your total annual cost of the premium and the co-pays. The insurance company can change the formulary at will with a sixty day notice to the customers. There is no way for the average consumer to evaluate the insurance company's behavioral history. You probably have to be inside the industry to have any real understanding of whose product is best.

I don't think you're missing anything. Employer provided - and administered - health insurance leads to many people never understanding fundamentals about cost, coverage, or even how health insurance works. Their first exposure is either an ACA policy or Medicare, they are simply unprepared and overwhelmed at the cost and complexity. A perfect opportunity to make a poor choice with lasting consequences.

 

[ivinsfan]

Not in all cases. We have a United Advantage plan through a former employer. While they do recommend their nationwide network, we can go to any provider that hasn't opted out of Medicare. United pays the same to either.

There are many thousands of us.

This would not help the OP's DM with her situation. When you use Medigap all Medicare standards don't apply. You deal with the MA company only and go by all their rules for nursing home situations, home health care and rehab. Medicare is no longer primary or even in the picture.

 

[Another Reader]

I don't think you're missing anything. Employer provided - and administered - health insurance leads to many people never understanding fundamentals about cost, coverage, or even how health insurance works. Their first exposure is either an ACA policy or Medicare, they are simply unprepared and overwhelmed at the cost and complexity. A perfect opportunity to make a poor choice with lasting consequences.

What's scary is that the people trained to provide assistance through SHIP that are supposed to be knowledgeable and unbiased, aren't. The training provided in Santa Clara County is incomplete and out dated. The counselor, who was very pleasant and tried to be helpful, had never heard of Plan F Extra/ Innovative Plan F and they were not covered in their written materials. She was not really knowledgeable about the drug plans. She had been trained to run your prescription list through the cost estimator. She mentioned that she had Kaiser Medicare Advantage and "didn't have to worry about any of this."

Those of us stuck with SHIP and the low end call center salespeople of Via Benefits are at a real disadvantage to people that can work with a knowledgeable insurance agent that deals with these companies day in and day out and can advise the customer appropriately. I think I'm a reasonably intelligent person and have spent a lot of time over the last 60 days looking into this. I'm not comfortable with my knowledge level and I have to make decisions in the next couple of weeks.

The one thing I have concluded is "Caveat Emptor" applies to Medicare and all its' moving parts. That really sucks for the consumer.

 

[audreyh1]

What's scary is that the people trained to provide assistance through SHIP that are supposed to be knowledgeable and unbiased, aren't. The training provided in Santa Clara County is incomplete and out dated. The counselor, who was very pleasant and tried to be helpful, had never heard of Plan F Extra/ Innovative Plan F and they were not covered in their written materials. She was not really knowledgeable about the drug plans. She had been trained to run your prescription list through the cost estimator. She mentioned that she had Kaiser Medicare Advantage and "didn't have to worry about any of this."

I wouldn’t expect a SHIP counselor to know anything about non-standard Medigap plans.

 

[Another Reader]

I wouldn’t expect a SHIP counselor to know anything about non-standard Medigap plans.

They are standard plans, at least in California. The other person there had heard of them, but they did not have any information about them.

https://www.blueshieldca.com/sites/medicare/supplement-plans/plan-extras.sp

 

[winger]

You can go to anyone but the insurance company might not approve the recommended care.

And this is different from other insurance?

 

[audreyh1]

They are standard plans, at least in California. The other person there had heard of them, but they did not have any information about them.

https://www.blueshieldca.com/sites/medicare/supplement-plans/plan-extras.sp

If Medicare.gov does not list or explain these plans, then how can they be standard?

 

[MichaelB]

I wouldn’t expect a SHIP counselor to know anything about non-standard Medigap plans.

I would expect a SHIP counselor to be familiar with all Medicare options, including non-standard state specific offerings, Medicare Select, Plan D, and Medicaid for Medicare options.

 

[winger]

You need to read your policy again. You can go to any provider in an emergency. For non-emergencies, PPO members can go to any provider that hasn't opted out of Medicare AND takes the MA PPO (aka accepts the plan's terms).

MD Anderson Cancer Center in Houston:


Mayo Clinic - Arizona campus:

Perhaps YOU need to read my policy.

 

[audreyh1]

I would expect a SHIP counselor to be familiar with all Medicare options, including non-standard state specific offerings, Medicare Select, Plan D, and Medicaid for Medicare options.

What obligations does an insurance company have to stand behind any non standard Medigap offering? I would be very concerned about a bait and switch, as well as constant stream of new non-standard plans to confuse the customer. So I guess it’s hard to see how someone would keep abreast of nonstandardized offerings if they aren’t guaranteed like the standard ones are.

 

[MBSC]

Perhaps YOU need to read my policy.

It would be my pleasure.