Medicare Advantage PPO plans

[Pluperfect]

Anybody have any experience with Medicare Advantage PPO plans? A couple of people on another forum have said they have either Humana or United Healthcare, and they sound pretty good.

I was looking them up on Medicare.gov and noticed that Aetna and Blue Cross also offer Medicare Advantage PPO plans.

But I looked specifically at Humana and United Healthcare, and you have access to their nationwide network of providers, and pay a copay for most services. You can go to out-of-network providers for a higher copay or some percentage coinsurance, but there's an out-of-pocket limit on out-of-network charges, so the coinsurance isn't terrifying.

And some of them have Medicare Advantage benefits like hearing, vision, and dental coverage, etc.

There are lots of horror stories about the HMO-type Medicare Advantage plans, but what about the PPO ones?

 

[RobbieB]

I have no horror stories about my HMO MA plan.

Always remember that bad news is good. It's interesting when people die.

 

[Car-Guy]

I've got mine with Aetna "only because" my previous employer uses Aetna for the claims processing. Basically I can go to any doctor/facility that accepts Medicare, so there are really no networks. Pretty good coverage too (actually really good) but dealing with Aetna can be a real PIA. When I can't get something resolved with Aetna, my past employer has a retiree advocacy group that will help out...

If I were buying a Medicare Advantage plan on my own, it would not be with Aetna.

 

[GoBears]

I have no horror stories about my HMO MA plan.

Always remember that bad news is good. It's interesting when people die.

Kaiser?

 

[jollystomper]

I am interested in this as well, as when I go onto Medicare next year, this will be one of my options.

 

[VanWinkle]

I have a UnitedHealthcare PPO through AARP. No problems, but no major medical problems either. They have paid as advertised on the minor medicare I have needed. I was with UHC for 40 years through work, so I have a level of trust for them.

VW

 

[mpeirce]

Anybody have any experience with Medicare Advantage PPO plans?

DW has an Anthem MA PPO plan. She picked it because it’s very similar to the Anthem PPO she had before (and I still have). Nothing really changed - same doctors, etc. - except she has more coverage for things like hearing aids, vision, and dental.

 

[MissMolly]

We have Medicare PPO plans (employer provided as a retirement benefit). No complaints. Have had several surgeries. Multiple PT sessions. Colonoscopes, CTs, MRIs, X-rays, etc, etc. No problems. Go to specialists without referrals. All covered without any hassles. No issues finding doctors, hospitals, clinics.

 

[Dash man]

My DFIL has a Cadillac Medicare Advantage plan from his union that is currently run by Aetna, but was Blue Cross for years. He’s never had a problem seeing providers and them getting paid.
However, two years ago he was diagnosed with urothelial cancer. This meant pre-approvals for tests and procedures, which delayed his scans and surgeries. He ended up having the surgery followed by Keytruda and is doing fine now. He started chemo because approval for the test to see if Keytruda was suitable for him took a while to get approved, but once approved he got the test that showed he was a candidate.
I don’t like Medicare Advantage because the insurance company uses delay tactics by requiring pre-approval or denying approval forcing an appeal.

 

[VanWinkle]

My DFIL has a Cadillac Medicare Advantage plan from his union that is currently run by Aetna, but was Blue Cross for years. He’s never had a problem seeing providers and them getting paid.
However, two years ago he was diagnosed with urothelial cancer. This meant pre-approvals for tests and procedures, which delayed his scans and surgeries. He ended up having the surgery followed by Keytruda and is doing fine now. He started chemo because approval for the test to see if Keytruda was suitable for him took a while to get approved, but once approved he got the test that showed he was a candidate.
I don’t like Medicare Advantage because the insurance company uses delay tactics by requiring pre-approval or denying approval forcing an appeal.

Just curious if original Medicare always approves every treatment or do they sometimes also delay treatments while an appeal is under way?

 

[Dash man]

Just curious if original Medicare always approves every treatment or do they sometimes also delay treatments while an appeal is under way?

In my case (Supplement Plan N), I’m only allowed one nerve ablation per year per location. When I had regular insurance it allowed two. That’s the only thing I’ve run into.

 

[REWahoo]

In my case (Supplement Plan N), I’m only allowed one nerve ablation per year per location. When I had regular insurance it allowed two. That’s the only thing I’ve run into.

Isn't it Medicare, not your supplement that imposes this limit?

 

[Dash man]

Isn't it Medicare, not your supplement that imposes this limit?

Yes, it’s Medicare. Insurance companies have to pay if Medicare pays.

 

[ShokWaveRider]

We have Medicare PPO plans (employer provided as a retirement benefit). No complaints. Have had several surgeries. Multiple PT sessions. Colonoscopes, CTs, MRIs, X-rays, etc, etc. No problems. Go to specialists without referrals. All covered without any hassles. No issues finding doctors, hospitals, clinics.

One of my neighbors has a similar plan from his employer, they are negotiated and drastically different from the plans us poor punters are being coerced into buying. The AARP UHC plan offered is also a lot better.

 

[jollystomper]

We have Medicare PPO plans (employer provided as a retirement benefit). No complaints. Have had several surgeries. Multiple PT sessions. Colonoscopes, CTs, MRIs, X-rays, etc, etc. No problems. Go to specialists without referrals. All covered without any hassles. No issues finding doctors, hospitals, clinics.

Thanks for this information.How have the premiums changed over the years you have been on the plan?


Edited to add: Also, did you need anything "pre-approved", if so were there any issues?

 

[Gotadimple]

Thanks for this information.How have the premiums changed over the years you have been on the plan?


Edited to add: Also, did you need anything "pre-approved", if so were there any issues?

I don't have UHC but I do have a PPO MA plan. Premiums quite frankly are based on the insurance company's competitors in that market place. They only have to prove to CMS that they are not bankrupting the company by providing a lower premium or $0 premium. In some places UHC does offer a PPO with a $0 premium.

In theory with a PPO you don't need a referral. But some specialists prefer you have one because it gives them some of your medical background.

- Rita

 

[MissMolly]

Thanks for this information. How have the premiums changed over the years you have been on the plan?


Edited to add: Also, did you need anything "pre-approved", if so were there any issues?

It's a retirement benefit so I have zero premiums for myself. I pay my husband's premium which for the past 5 years he's been on it has not changed. The Retirement Board live-streams their Board meetings on Facebook. The meeting the other week was regarding the insurance for 2023. It was reported that the premiums being charged by Humana are actually going down. However, the Board decided to keep the cost to retirees unchanged to offset any future increases in order to help level out any changes to retirees.

Yes, we did need preapproval for the surgeries and PT. The preapprovals were granted within a day or two of the requests from the surgeons.

 

[Pluperfect]

My DFIL has a Cadillac Medicare Advantage plan from his union that is currently run by Aetna, but was Blue Cross for years.

Is it a PPO Medicare Advantage or an HMO Medicare Advantage plan?

You mentioned getting pre-approvals for tests and procedures, and it's my understanding that they're not required in PPO plans, which is what makes a MA PPO plan uniquely attractive, if it cuts out the gatekeeper that many Advantage plans have but provides the additional benefits like hearing and vision.

 

[Dash man]

Is it a PPO Medicare Advantage or an HMO Medicare Advantage plan?

You mentioned getting pre-approvals for tests and procedures, and it's my understanding that they're not required in PPO plans, which is what makes a MA PPO plan uniquely attractive, if it cuts out the gatekeeper that many Advantage plans have but provides the additional benefits like hearing and vision.

It’s a PPO plan. It’s a good plan, but still required some approvals. He didn’t need any referrals.

 

[Pluperfect]

It’s a PPO plan. It’s a good plan, but still required some approvals. He didn’t need any referrals.

I'm new to Medicare and have almost no experience with how it actually works when getting treatment.

VanWinkle asked something I'm curious about: Does traditional Medicare ever involve approvals? Like if I'm getting a test done or surgery, I just schedule it with a provider who accepts Medicare and the first Medicare hears about it when they get the bill?

But with a Medicare Advantage PPO, I have to let them know I'm planning to have a test or surgery, and they get a say in whether it will be covered? Do I have to stay in contact with them about everything I'm doing?

In the case of Medicare's restriction on Dash man's nerve ablation, how would a person know there is a restriction? Is this something doctors know and factor into their treatment plan?

 

[braumeister]

Does traditional Medicare ever involve approvals? Like if I'm getting a test done or surgery, I just schedule it with a provider who accepts Medicare and the first Medicare hears about it when they get the bill?

I've not had anything overly complicated while using traditional Medicare, just normal care and a couple of surgeries. I've never had to get advance approval for anything.

There was one incident a few years ago where my doc wanted me to have a slightly unusual test and he asked his front office people if it was "covered" for me. They came back and said no. He didn't want me to have to pay for it so he told them to keep looking and find a way to code it. A few phone calls, some computer research, and ten minutes later they told him they found a good code. I got scheduled and had the test, and never a peep from Medicare. So I've been quite pleased.

 

[Dash man]

I'm new to Medicare and have almost no experience with how it actually works when getting treatment.

VanWinkle asked something I'm curious about: Does traditional Medicare ever involve approvals? Like if I'm getting a test done or surgery, I just schedule it with a provider who accepts Medicare and the first Medicare hears about it when they get the bill?

But with a Medicare Advantage PPO, I have to let them know I'm planning to have a test or surgery, and they get a say in whether it will be covered? Do I have to stay in contact with them about everything I'm doing?

In the case of Medicare's restriction on Dash man's nerve ablation, how would a person know there is a restriction? Is this something doctors know and factor into their treatment plan?

The doctors take care of any needed approvals. In the case of my nerve ablation, he knows the Medicare rules. My doctor told me.

 

[MissMolly]

There is essentially no requirement for pre-approval for traditional Medicare except in very limited circumstance (like Hospice). For Medicare Advantage pre-approval is usually required but it is not something you do, it's something your doctor does. Even then, it's more a formality than anything in my experience. We've had several surgeries with our MA plan. The doctors would schedule the surgery and I would ask about pre-approval. They just waved their hands and said "won't be a problem". And it wasn't. I would watch on my health insurance portal and sure enough, a day or two later I could see the approval. We have never been denied or delayed care due to pre-approval. For us, it's a non-issue.

 

[youbet]

There is essentially no requirement for pre-approval for traditional Medicare except in very limited circumstance (like Hospice).

Doc gave me an order for a "sleep test" because of symptoms I've been experiencing. When I called to schedule the test, they gave me a tentative date but said it would require approval by Medicare which could take up to two weeks. So, I'm waiting for the approval phone call so I know my appointment date is firm.

In ten years on Medicare, I've only had a handful of delays to get approval like this, but, as you say, they do occur.

 

[athena53]

There is essentially no requirement for pre-approval for traditional Medicare except in very limited circumstance (like Hospice).

Pre-approval? No, but your doc better know what codes Medicare will approve. Braumeister's doc got it right. I've told this story before but my first gyno exam after Medicare kicked in she ordered the usual bloodwork. It included a lipids panel because my total cholesterol runs high, and an a1c because my fasting glucose is usually a bit over 100 and a1c is in the high end of normal. The lab sent me a bill for $800 because Medicare kicked it back as "not medically necessary." I tried to get the office to re-code it. No success. A technicality saved me- they hadn't had me sign the waiver form agreeing to be responsible for whatever Medicare didn't pay.

Goodbye, Doc (even though I really liked her). Hello, requestatest.com. Just had blood drawn this AM. Medicare doesn't cover but there will be no surprise bills.