MediCare Advantage PPO’s

[Z3Dreamer]

I will be eligible for Medicare July 1, so I thought I would look into this. The safe, conventional, easy wisdom in my area is a Plan G Supplemental with a Part D added. I began researching MA PPO's. I read all of the posts on here in the last few years. I did all of the homework including some cost scenarios. I am the kind of guy who has a high deductible on my home and car insurance because I don't want to pay premiums for little things and am ok with some financial risk. So, I am comfortable with the co-pays. All of the local doctors and facilities are in-network with the 3 nationwide MA PPO's I am looking at.

In my scenarios, MA PPO savings over a Plan G with a Part D added run $1,300 to $1,800. Of course, there is no certainty with future sicknesses. In a year with outpatient surgery and a bunch of tests, I am still $800 to $1,200 ahead.

I also read both sides of the recent OIG sample of 250 payment denials.

In reading the posts, my logic seems to coincide mostly with VanWinkle. I also have done some SHIIP consulting but none since 2020.

Anything new?

 

[Dash man]

I will be eligible for Medicare July 1, so I thought I would look into this. The safe, conventional, easy wisdom in my area is a Plan G Supplemental with a Part D added. I began researching MA PPO's. I read all of the posts on here in the last few years. I did all of the homework including some cost scenarios. I am the kind of guy who has a high deductible on my home and car insurance because I don't want to pay premiums for little things and am ok with some financial risk. So, I am comfortable with the co-pays. All of the local doctors and facilities are in-network with the 3 nationwide MA PPO's I am looking at.



In my scenarios, MA PPO savings over a Plan G with a Part D added run $1,300 to $1,800. Of course, there is no certainty with future sicknesses. In a year with outpatient surgery and a bunch of tests, I am still $800 to $1,200 ahead.



I also read both sides of the recent OIG sample of 250 payment denials.



In reading the posts, my logic seems to coincide mostly with VanWinkle. I also have done some SHIIP consulting but none since 2020.



Anything new?

MA plans often change providers, so because a doctor or hospital may be in the plan now, doesn’t mean they will be later.
MA means turning your healthcare over to an insurance company and giving up original Medicare. They often require approval for scans or procedures that can result in delays even if you have an aggressive disease.
Do you want to spend time fighting insurance companies over denied claims?
Don’t you want the best healthcare when you’re sick? You can go to most doctors with Medicare and a supplement, but you have to stay within network with MA.
Search YouTube for Medicare supplement vs Medicare Advantage.

ETA: Consider a Plan N supplement if you want to save a few bucks. We have it, and the difference with Plan G is minimal.

 

[VanWinkle]

MA plans often change providers, so because a doctor or hospital may be in the plan now, doesn’t mean they will be later.
MA means turning your healthcare over to an insurance company and giving up original Medicare. They often require approval for scans or procedures that can result in delays even if you have an aggressive disease.
Do you want to spend time fighting insurance companies over denied claims?
Don’t you want the best healthcare when you’re sick? You can go to most doctors with Medicare and a supplement, but you have to stay within network with MA.
Search YouTube for Medicare supplement vs Medicare Advantage.

ETA: Consider a Plan N supplement if you want to save a few bucks. We have it, and the difference with Plan G is minimal.

Medicare is very strict about Insurance companies covering the same procedures, scans, treatments that are medicare approved for the situation. If you insure with an established large insurer, they will cover the same things as Medicare. If you use a company just breaking into the business with little experience with Medicare, you could face the trials you describe. Fear alone is not a sound way to make a decision. Your medical situation, ability to pay, and nature of handling risk is the best way to make the decision.

VW

 

[VanWinkle]

I have Plan G HD, $55 per month here in CT. I reason I did this is because being a cancer survivor you always wonder, what if...


Some top cancer hospitals accept medicare but do not accept Advantage plans and if I get cancer again I want to be able to go to the doctor and hospital I want no matter where they are in the country.

You made a smart choice for your situation it seems to me. Good luck on not having to undergo additional treatment. Best to you!!

VW

 

[Dash man]

Your medical situation, ability to pay, and nature of handling risk is the best way to make the decision.



VW

Medical situations change, that’s the point. The things that are required by Medicare are sometimes paid up to 80%, but leave you responsible for 20% and can be unlimited if not covered by the plan. Read the fine print. People need to be aware of the problems with Medicare Advantage because the marketing by insurance is so strong, and insurance agents get a higher commission selling Medicare Advantage.

 

[VanWinkle]

Medical situations change, that’s the point. The things that are required by Medicare are sometimes paid up to 80%, but leave you responsible for 20% and can be unlimited if not covered by the plan. Read the fine print. People need to be aware of the problems with Medicare Advantage because the marketing by insurance is so strong, and insurance agents get a higher commission selling Medicare Advantage.

I read the "fine print" every day..... I see Medigap as the solution more often
than Medicare Advantage, but there are choices for a reason. You don't have to enlist an agent to get either plan. You have a different view, and I respect that.

VW

 

[RetMD21]

Medicare is very strict about Insurance companies covering the same procedures, scans, treatments that are medicare approved for the situation. If you insure with an established large insurer, they will cover the same things as Medicare. If you use a company just breaking into the business with little experience with Medicare, you could face the trials you describe. Fear alone is not a sound way to make a decision. Your medical situation, ability to pay, and nature of handling risk is the best way to make the decision.

VW

That's the dream. The reality differs:


Every year, tens of thousands of people enrolled in private Medicare Advantage plans are denied necessary care that should be covered under the program, federal investigators concluded in a report published on Thursday.

from last week

https://www.nytimes.com/2022/04/28/health/medicare-advantage-plans-report.html

 

[Z3Dreamer]

That's the dream. The reality differs:


Every year, tens of thousands of people enrolled in private Medicare Advantage plans are denied necessary care that should be covered under the program, federal investigators concluded in a report published on Thursday.

from last week

https://www.nytimes.com/2022/04/28/health/medicare-advantage-plans-report.html

I saw that. Here is a link to the original report from the OIG: https://oig.hhs.gov/oei/reports/OEI-09-18-00260.asp

Insurance companies denying without fully reading has always been there. Or denying because the medical facility codes it wrong. That is a factor in my deciding whether to go with MA or Supplement.

The plans that I am looking at have fewer and fewer instances where prior approval is required. I will look at MRI's and other tests.

Thanks for adding to this discussion.

 

[RetMD21]

The doc can do an appeal, but it isn't necessarily cost effective for them

 

[ncbill]

It's clear from what I've read (well before the recent NYT article) that MA companies are consistently denying claims for things like rehab to maximize their bottom line.

After all, they only get a fixed payment monthly for an enrollee, so why shouldn't their claims personnel (with no medical training) just decide that the two weeks of rehab your personal doctor prescribed really only needs to be two days?

There are exceptions (e.g. Kaiser) but given the above I plan to choose a traditional Medigap supplement (at a higher monthly premium) if that's still an option when I'm eligible for Medicare.

 

[Rianne]

I start Medicare in Sept and already signed up for Medicare + G. My broker said you can change insurance companies every year but you might be subject to approval due to current health conditions (I forgot the term). I went with Mutual of Omaha, G plan $92/month + $172 part B then will add drug plan in August. We'll get the 12% discount as DH will go on in December. International travel is included, to an extent.

I would never want to be caught traveling anywhere in the U.S. and be worried if the Medicare HMO plan would cover the costs. The extra premium cost is worth Medicare + medigap plan.

 

[youbet]

I would never want to be caught traveling anywhere in the U.S. and be worried if the Medicare HMO plan would cover the costs. The extra premium cost is worth Medicare + medigap plan.

I've never heard of a Medicare HMO Rianne. What is that?

This thread has been about Medicare Advantage PPO's with comparisons to traditional Medicare plus an optional supplement and optional drug coverage.

 

[PaunchyPirate]

I've never heard of a Medicare HMO Rianne. What is that?

This thread has been about Medicare Advantage PPO's with comparisons to traditional Medicare plus an optional supplement and optional drug coverage.

I believe they are referring to Medicare Advantage HMO plans, which are definitely a thing. One large Medicare Advantage provider in my region sells 9 MA plans in my zip code. Two of them are PPOs and 7 of them are HMOs. The HMOs start at $0 per month and require you to use the insurance company’s sister company healthcare provider and their doctors.

 

[youbet]

Anyone using a "Select" version of their medigap plan?

I decided on BCBS F Select. Seems to work fine and I've had it and used it for almost a decade. The premium is lower and the selection of hospitals I can use for non-emergency issues is very adequate. In an emergency, you can use any hospital of course. And you can change to a non-Select version of the plan for elective procedures with a month's notice.

Any wrinkles I haven't tripped over yet to watch out for?