Employer pushing retirees to Medicare Advantage

[travelover]

I'm following this as DW just turned 65 and gets a BCBS PPO Advantage plan which includes drug coverage as part of her retirement package. She pays $100/month and her former employer pays $300 / month for the Advantage plan. I'd think this means it is a premium plan, but we've not really gotten into it. Tentatively, her plan is to see if she likes it in the first year trial and if not skip to traditional Medicare like I have. Seems like money left on the table to not take it, but perhaps not in the big picture.

 

[Katsmeow]

The Medicare Advantage plans have HMO and PPO versions. With PPO versions, there is a list of doctors. My husband had not gone to a specialist outside of the list of doctors on the PPO. We had gotten flat out rejection the phone when we tried to set an appointment up with these doctors. None of them had said that our share of cost would be higher, it was a flat out no.

This is the verbiage on Humana's website: Out-of-network/non-contracted providers are under no obligation to treat Humana plan members, except in emergency situations.

I don't know how Medicare Advantage PPO's handle out of network doctors. Back before I was on Medicare and had PPO plans, you could see out of network doctors and they could charge you whatever they wanted to charge you. The insurer paid what it would have paid a contracted doctor (one in network) and then I was subject to balance billing by the out of network doctor for whatever they charged.

I'm following this as DW just turned 65 and gets a BCBS PPO Advantage plan which includes drug coverage as part of her retirement package. She pays $100/month and her former employer pays $300 / month for the Advantage plan. I'd think this means it is a premium plan, but we've not really gotten into it. Tentatively, her plan is to see if she likes it in the first year trial and if not skip to traditional Medicare like I have. Seems like money left on the table to not take it, but perhaps not in the big picture.

That is annoying if they don't offer anything for a non-Medicare Advantage plan. Be sure to check if there are any other options that you can use the employer's money for. I would hate to leave that money. On the other hand, if it was me I probably would because I wouldn't want the limitations of the Medicare Advantage plan. I worry about the scenario RetiredHappy describes.


How do Medicare Advantage plans pay out of network doctors and are you subject to balance billing? If the MA plan pays the out of network doctor as if was a contracted doctor and those doctors can't bill you for the difference (or worry about you paying) then I could see them just refusing service. In that case, the "PPO" isn't much better than an HMO.

 

[eytonxav]

That there is little competition among gap supplements as the government requires specific coverage.

Actually, I think there is less competition and pushing of gap plans because the chance for an insurance company to make more $s off an advantage plan is greater. My main reason for selecting a gap plan was the ability to see whoever I wanted due to health issues.

 

[travelover]

...........How do Medicare Advantage plans pay out of network doctors and are you subject to balance billing? If the MA plan pays the out of network doctor as if was a contracted doctor and those doctors can't bill you for the difference (or worry about you paying) then I could see them just refusing service. In that case, the "PPO" isn't much better than an HMO.

The booklet says no balance billing is allowed, higher copay for out of network and DW can go to any doctor that she would under standard Medicare. But that begs the question as to whether out of network docs are paid more or can refuse to render service.

 

[youbet]

Well, I did. I pointed out that I did know that PPO plans exist but may cost more and may not be an option. I was also talking more generally about MA.

Gotcha! I'm probably a bit sensitive because this seems to be a subject where anecdotal examples are frequently being given with numerous posters seeming to imply all MAPs are the same.

 

[MichaelB]

How do Medicare Advantage plans pay out of network doctors and are you subject to balance billing? If the MA plan pays the out of network doctor as if was a contracted doctor and those doctors can't bill you for the difference (or worry about you paying) then I could see them just refusing service. In that case, the "PPO" isn't much better than an HMO.

There is no standard way an insurance plan covers out of network care, it depends on the specific policy and insurer. A typical way to set an out of pocket maximum that is separate from the in network OOP. The patient pays the entire out of network charge, the insurance company determines the “usual and customary” amount for that service and applies that toward the out of network OOP. Once the max OOP has been satisfied, the insurer covers or reimburses the additional charges, but only the usual and customary amounts. Anything over that is the responsibility of the patient and not part of the deductible or out of pocket max.

 

[youbet]

How do Medicare Advantage plans pay out of network doctors and are you subject to balance billing?

With my DW's plan, any doc or other provider that accepts traditional Medicare is in the network, so when I opened her book to get the answer to your question, it wasn't there. There are no out-of-network docs to pay unless it is a doc that does not accept Medicare.

BTW, I chose to go with traditional Medicare and a BCBS type F supplement for some of the reasons you've brought up. DW chose to do the MAP her former employer offered. I was skeptical. But, she has used it a lot (breast cancer, colon resection, rotator cuff surgery, female issue surgery and spinal surgery). She's had no issues including shopping very selectively for the best providers at teaching hospitals, etc. So, so far so good I guess.


Oh, and BTW, I believe you can be subject to balance billing with traditional Medicare. I think it happens when your provider accepts Medicare but does not accept Medicare Assignment.

 

[CardsFan]

Gotcha! I'm probably a bit sensitive because this seems to be a subject where anecdotal examples are frequently being given with numerous posters seeming to imply all MAPs are the same.

Bold by me, and that is really the crux of the differences between a MAP and a Medigap policy. You really DO need to do your homework with MAP's, as they can be all over the place with what they cover. They ARE all different.

With a Medigap plan the insurer is required to provide very specific coverage, the same for everyone, for a particular plan type (F, G, N, etc). Some do add a few extended benefits, but the base requirements must be met.

Now, you still need to do your home work deciding which Medigap plan to get, but you can be assured every supplier for a plan is providing the same base requirements.

 

[Katsmeow]

There is no standard way an insurance plan covers out of network care, it depends on the specific policy and insurer. A typical way to set an out of pocket maximum that is separate from the in network OOP. The patient pays the entire out of network charge, the insurance company determines the “usual and customary” amount for that service and applies that toward the out of network OOP. Once the max OOP has been satisfied, the insurer covers or reimburses the additional charges, but only the usual and customary amounts. Anything over that is the responsibility of the patient and not part of the deductible or out of pocket max.

Is this for non-Medicare Advantage PPOs (i.e. those before Medicare age) or is this for Medicare Advantage PPOs. I am curious if there is any Medicare or CMS rule that governs whether Medicare Advantage plans can allow balance billing. If balance billing is allowed, I am curious why RetiredHappy's spouse couldn't find out of network coverage. Why wouldn't the out of network doctors see him? On the other hand, if balance billing is prohibited and they have to just accept whatever the plan wants to pay then I could why out of network doctors might not want to accept.

Oh, and BTW, I believe you can be subject to balance billing with traditional Medicare. I think it happens when your provider accepts Medicare but does not accept Medicare Assignment.

Sort of. There are excess charges that potentially exist as you mention. However, the amount of these are limited in amount (I think it may be 15% but not sure). Also Plans F and G will cover those charges so you aren't exposed to them as the patient. (There may be other supplements that cover the excess charges...I just know F and G do cover them).

 

[MissMolly]

Bold by me, and that is really the crux of the differences between a MAP and a Medigap policy. You really DO need to do your homework with MAP's, as they can be all over the place with what they cover. They ARE all different.

With a Medigap plan the insurer is required to provide very specific coverage, the same for everyone, for a particular plan type (F, G, N, etc). Some do add a few extended benefits, but the base requirements must be met.

Now, you still need to do your home work deciding which Medigap plan to get, but you can be assured every supplier for a plan is providing the same base requirements.

MAPs are not all over the place with what they cover. They are required by Federal law to cover exactly the same services and supplies as Medicare. Where they differ is in premiums, deductibles, MOOP, in/out of network, HMO/PPO, possible addons, etc.

 

[CardsFan]

MAPs are not all over the place with what they cover. They are required by Federal law to cover exactly the same services and supplies as Medicare. Where they differ is in premiums, deductibles, MOOP, in/out of network, HMO/PPO, possible addons, etc.

Poor choice of words, maybe HOW they cover it, and how much you pay, and where you can go would have been better.

But, on second thought, WHAT they cover beyond the absolute requirements DOES vary widely, and if you listen to the ads, that is their selling point. So you DO need to look at each and everyone.

 

[MichaelB]

Is this for non-Medicare Advantage PPOs (i.e. those before Medicare age) or is this for Medicare Advantage PPOs. I am curious if there is any Medicare or CMS rule that governs whether Medicare Advantage plans can allow balance billing. If balance billing is allowed, I am curious why RetiredHappy's spouse couldn't find out of network coverage. Why wouldn't the out of network doctors see him? On the other hand, if balance billing is prohibited and they have to just accept whatever the plan wants to pay then I could why out of network doctors might not want to accept.

Only RH can provide the details for the situation she describes. I understood her post to mean they couldn’t find an out of network doctor willing to take their insurance.

Balance billing rules changed earlier this year, and we should expect to see much less as a result. In the case of a MA PPO, if the provider is not in network, makes that clear upfront, communicates the price for the service, and the patient goes ahead with that provider, they will be liable for the entire amount billed.

The MA PPO may cover some cost based on the policy language, but typically that would be the “usual and customary amount” and only once the insured had satisfied the total out of pocket.

There is some language in the recent regulatory change that may limit the total amount that can be billed by out of network providers in all cases, but it isn’t clear how that affects situations where the patient is informed beforehand and authorizes treatment. In any case, it applies equally to all private insurance, including MA.

One thing to keep in mind is with traditional Medicare all enrolled providers are required to accept the amount Medicare has agree. There is no balance billing with Medicare.

 

[VanWinkle]

MAPs are not all over the place with what they cover. They are required by Federal law to cover exactly the same services and supplies as Medicare. Where they differ is in premiums, deductibles, MOOP, in/out of network, HMO/PPO, possible addons, etc.

+100 Good Golly MissMolly!!!

You are exactly right- from another SHIP counselor.

 

[John Galt III]

I have a MA plan, but I admit I am afraid of it. SO far it has been good for the limited medical I have used it for, which has been annual wellness visit, and annual blood tests. Wellness was free, blood tests only cost $10 copay for the whole shebang. I also have dental with my MA plan, and that was OK for cleanings and fillings. Free cleanings, and one free XRAy per side, and 50% coverage for fillings. Crowns were supposed to covered at 50%, but Blue Cross Dental gave my dentist a very hard time with that claim. Deny, deny, lie, postpone, etc. That stressed me out for 8 months, then they finally approved the crown claim, after I wrote a letter to Appeals at Capital Blue Cross. But what a PITA it was.

 

[athena53]

Crowns were supposed to covered at 50%, but Blue Cross Dental gave my dentist a very hard time with that claim. Deny, deny, lie, postpone, etc. That stressed me out for 8 months, then they finally approved the crown claim, after I wrote a letter to Appeals at Capital Blue Cross. But what a PITA it was.

Threats to file a complaint with your state Insurance Commissioner can be very effective in cases such as this. That was what finally got an insurer (I forget which one) to pay up for DH's hearing aids, which were clearly covered by my employer's plan up to a fixed amount, had clearly been purchased for more than that amount but they kept delaying and asking for more information.

 

[ncbill]

MAPs are not all over the place with what they cover. They are required by Federal law to cover exactly the same services and supplies as Medicare. Where they differ is in premiums, deductibles, MOOP, in/out of network, HMO/PPO, possible addons, etc.

So you don't think they have an incentive (versus traditional Medigap plans) to deny or postpone approving treatments to keep more of their annual capitation payment?

 

[MissMolly]

So you don't think they have an incentive (versus traditional Medigap plans) to deny or postpone approving treatments to keep more of their annual capitation payment?

That hasn't been my experience.

 

[RetiredHappy]

Our good friends are on MA HMO plan because their plan has zero premium. While they get approved for needed treatments and surgeries, the issue is the schedule. Their surgeons had to schedule shoulder surgery for wife another 6 months out when she had suffered for more than a year before with PT and exploratory procedure which did not address her shoulder issue. The husband's gallblader surgery was scheduled 3 months out and by then, it had become septic and the poor guy had a bag to let the yucky stuff drain out for a couple of weeks after his surgery. Heck no way I will go with a MA HMO. MA PPO is better but Medicare Supplement is the way to go.

 

[FargoI]

All Medicare Advantage plans are required to offer the same coverage as traditional Medicare.

If this Advantage plan is a PPO there is no requirement for pre-authorization, and network is all providers that accept Medicare.

The two big differences between this Medicare Advantage and traditional Medicare + Medigap are 1) the MA plan has more cost sharing and total out of pocket, and 2) The MA plan also covers prescription drug, while the traditional Medicare / MediGap requires a separate Plan D drug plan.

The cost impact of the drug coverage may be substantial but differs for each individual.

In this case, from a distance it looks like the biggest impact is not coverage, it’s greater cost sharing.

To clarify, the group MAP will require preauthorizations for essentially anytime expensive ( CAT scans,MRIs, therapist, etc.) and will include co-pays ($15) for most provider and ancillary services.

 

[FargoI]

To clarify, the group MAP will require preauthorizations for essentially any expensive ( CAT scans,MRIs, therapist, etc.) and will include co-pays ($15) for most provider and ancillary services.

 

[LA_Newsboy]

My wife and I have Medicare Advantage through SCAN. We're in Southern California. Very happy with the plan. Same excellent doctor we were seeing under traditional Medicare, easy referrals/authorizations. Studies seem to show that increasing acceptance of Medicare Advantage is lowering medical costs across the board. For us, for now, it's fine.

 

[ivinsfan]

My wife and I have Medicare Advantage through SCAN. We're in Southern California. Very happy with the plan. Same excellent doctor we were seeing under traditional Medicare, easy referrals/authorizations. Studies seem to show that increasing acceptance of Medicare Advantage is lowering medical costs across the board. For us, for now, it's fine.

Across the board not really, the government pays through the nose to the insurance companies who squeeze each penny for more profits.

 

[Gearhead Jim]

My former employer (United Airlines) transitioned all or nearly all of their retirees from a traditional retirement Medicare plan to an Aetna Medicare Advantage, about two years ago. The change was done with little notice and little in the way of viable alternatives.

My wife and I have a moderate number of typical mid-70's medical issues, not big and complicated but not trivial.

So far, the only difference we've noticed is that our premiums have gone down by about 25%.

 

[REWahoo]

Studies seem to show that increasing acceptance of Medicare Advantage is lowering medical costs across the board.

Here is a recent article from the Houston Chronicle with a dissenting view:

There's a big problem with Medicare Advantage

Medicare Advantage almost always offers more benefits to healthy seniors, but it fails to save taxpayer money, according to the Medicare Payment Advisory Commission’s report to Congress.

“The Commission estimates that Medicare currently spends 4 percent more per capita for beneficiaries enrolled in MA (Medicare Advantage) than it spends for similar enrollees in traditional fee-for-service (FFS) Medicare,” the commission found.

 

[Vacation4us]

HMO’s are great when your healthy. God forbid you get sick. I worked for the biggest name in HMO for 10 plus years. It was cheap and easy for me and my kids.
BUT, never again.
I know of too many people who died because their complaints went ignored and untreated. Next thing you know stage 4.
My BFF still works for that HMO got breast cancer and a mastectomy. She found the care so sub par she paid out of pocket for her reconstruction at 30k. Her DH has a fit if she spends 35.00 on lunch with their son but paid the 30 k without much complaint.

My Brother is a diabetic while on said HMO his premiums were cheaper and his A1C was 11. Off the HMO and on newer meds ie more than just Regular and NPH insulin and his A1C is now 6.5.

So if you only want the option of generic medication and no new technology, go for it.


PS Good luck Robbie, hope you don’t regret your choice someday as a former insider you may be caught dead do to your choice. Love it now but what if?