Medicare Advantage PPO plans

[Telly]

For those who REALLY want to cut to the chase in the SSN video that RASAP linked to, go to 19:15 and listen for just a minute. To me, THAT was the deciding factor for me, before I turned 65.


My research of Medicare, before I turned 65, aided by a good book Get What's Yours for Medicare, by Philip Moeller (Amazon), made my decision to go the Original Medicare route. My health at 65 was very good, no ongoing prescription medication, etc. But even very healthy people should figure out their route to include their health taking a dive. And maybe never getting any better. Seeing people crash around me for years, dispelled any idea that somehow I was and would continue to be a medical marvel. Past health is not indicative of future health. Sounds odd applied to health, but almost all agree with the investment version of that saying! Aging can, and always does, provide surprises. And they ain't good.

 

[RASAP]

Another interesting spot in the video is at 21:05 - Mayo Clinic won't take most MA plans.

 

[Dash man]

Another interesting spot in the video is at 21:05 - Mayo Clinic won't take most MA plans.

That was brought up in post #39.

 

[Pluperfect]

Anyone considering an MA plan should watch this video. I think it will be well worth your 40 minutes.

I went to the part on the Mayo Clinic and...really? People watch a video of a guy reading aloud an article he saw on the internet? Sigh.

So I'm gathering that there ARE three levels of networks: (1) in network, (2) out of network that a MA PPO plan might pay for, and (3) out of network providers who will ask who your insurance is with and might refuse to schedule you even as an out-of-network patient. Does this sound correct?

 

[RetMD21]

My late father had a Medicare Advantage plan.

Once they determined his course, they determined it was too late, that he should go to hospice.

We contacted other providers including UCSF. They were willing to see him but it was up to the Medicare Advantage plan people. They controlled his underlying Medicare benefits so if we wanted a second opinion outside of their facilities, we'd have had to pay fully to have him transported, checked into a hospital outside of the network for examination.

We appealed to their board and they declined. Unless they "release the Medicare funds" we'd have to incur big out of pocket expenses. The appeal process was drawn out and with each day, it was becoming moot.

It was likely the second opinion probably wouldn't have changed the prognosis. But it was clear they were going to stick to what the statistics said about what they deemed to be inoperable brain cancer.

Of course you hear anecdotes of cases of people who survived brain cancer or outlived the prognosis by a lot.

In any event, the experience really alienated us and we moved our mother to a Supplemental F plan, so that we'd always be able to choose whom to see and get second opinions for her.

When I get on Medicare, I may or may not do Medicare Advantage. But I know I will never go on that particular MA plan. Doubt my sisters will either.


So this year, the large provider organization whose doctors we'd been taking our mother to since sent two emails in the last week, touting MA plans. I didn't bother to check but they claimed you could see any doctor including theirs. They cited some study about better results for patients of MA plan. I was thinking about looking into it and then sent another email again pumping up MA plans.

That made me suspicious, probably get a share of the premiums for anyone they sign up through their links. So I didn't follow their links.

I think they get a finders fee. Even solo practice doctors seem to promote particular MA plans

 

[jollystomper]

In a lot of places, insurance carriers only offer an HMO plan. So sometimes it is hard to find a PPO with a broad network and people aren't familiar with the difference.

- Rita

Good point. Perhaps because, it seems. Medicare PPO plans are primarily offered/sponsored by companies, available only to retired employees of the company. A smaller population, with a known (and likely less expensive) medical history, which may contribute to making a PPO plan profitable for the insurer.

 

[JJpop]

If Medicare Advantage plans are not Medicare, then why does Medicare assign star ratings to the different MA plans?
Ok. I went to the official Medicare site and it 100 pct fully explains the difference.
You can get it straight from Medicare instead of watching videos made by whoever on you tube.

 

[Telly]

Although I am very negative on MA plans, there ARE some custom MA plans out there that are a cut above, way above. Our state has one for retired school district employees (Pre-K through Grade 12 schools) who met the state school retirement medical age and years of service formula to get the retiree medical insurance benefit. $500 per year deductible, which includes drugs. No network. Go anywhere that accepts Medicare Assignment. It's ~$138 per month premium, has held at that level for some years.

Set by the state legislature. Loads of people in it, and growing. A carrot for those who go into education, in a rapidly-growing state. Retiree pays Part B, of course, just like everyone. The state every X years goes out with an RFQ, and insurance companies clamor to be the one that wins. No advertising, no marketing, no annual enrollment switching, just take care of the people in it. It is very unlikely that the state legislature will ever jack with it to the detriment of the users. Would be like shooting both feet.

 

[steelyman]

My home (former) state, Illinois, has a retiree program called TRAIL that sounds similar to what Telly describes.

They’re switching in 2023 from United Healthcare to Aetna. One thing I noticed is that they appear to be dropping HMO plans in favor of PPO.

https://cms.illinois.gov/benefits/trail.html

 

[Gotadimple]

I went to the part on the Mayo Clinic and...really? People watch a video of a guy reading aloud an article he saw on the internet? Sigh.

So I'm gathering that there ARE three levels of networks: (1) in network, (2) out of network that a MA PPO plan might pay for, and (3) out of network providers who will ask who your insurance is with and might refuse to schedule you even as an out-of-network patient. Does this sound correct?

That's correct. (1) there is a contract between the plan and the provider, (2) there is no contract but the provider is willing to accept the payment rate the plan pays doctors in #(1), and (3) provider will not accept the plan's reimbursement rate, and the plan will refuse to allow access to the provider because they will bill the beneficiary for the balance due (a CMC no-no).

 

[Gotadimple]

Good point. Perhaps because, it seems. Medicare PPO plans are primarily offered/sponsored by companies, available only to retired employees of the company. A smaller population, with a known (and likely less expensive) medical history, which may contribute to making a PPO plan profitable for the insurer.

In the cases of a large company or government agency who is buying coverage for their retirees, the benefit design is Medicare plus a negotiated set of coverages not offered to the public. Premiums are negotiated as well. They are great (I was on one for a while), until the rates have to go up as the population ages and gets sicker and claims cost rise.

- Rita

 

[Pluperfect]

That's correct. (1) there is a contract between the plan and the provider, (2) there is no contract but the provider is willing to accept the payment rate the plan pays doctors in #(1), and (3) provider will not accept the plan's reimbursement rate, and the plan will refuse to allow access to the provider because they will bill the beneficiary for the balance due (a CMC no-no).

Since we're talking Medicare, might the amount in #2 be Medicare reimbursement, in which case I think it might be likely the provider will be willing to accept it since they accept it for traditional Medicare patients? Which would lean toward broad acceptance by out-of-network providers.

Also, the MA plan might be willing or even happy to provide out-of-network coverage for a procedure (assuming the price is substantially less than the sticker price) because the plan member's financial responsibility is higher than when in network (like a higher copay, or even 50% coinsurance).

I'm still fuzzy on the mechanics of how all this works. I'm assuming that MA enrollees have to get some sort of permission from their plan to see an out-of-network provider; maybe not a referral (or maybe yes a referral?), but some sort of permission?

In other words, are there typical MA HMO-type guardrails still operating even in a PPO plan when it comes to out-of-network providers?

Good point. Perhaps because, it seems. Medicare PPO plans are primarily offered/sponsored by companies, available only to retired employees of the company. A smaller population, with a known (and likely less expensive) medical history, which may contribute to making a PPO plan profitable for the insurer.

I'm doing my research mainly in the realm of fulltime RVers who need access to providers throughout the country, and there are reports of satisfaction with both Humana MA PPO and UnitedHealthcare MA PPO when it comes to finding in-network providers across the country. So it would appear that these two, at least, have a robust network, along with out-of-network coverage (which might simply mean a copay of $75 instead of $35).

I looked on Medicare.gov for MA PPO plans in a few different states and each area I looked at had a bunch of them, and all of them included Humana and UnitedHealthcare.

Here are the breakdowns I saw--the number of Medicare Advantage PPO and HMO plans for a particular zip code in each state:

Illinois (Elgin): 26 PPO, 26 HMO
Texas (Livingston): 22 PPO, 10 HMO
Florida (Green Cove Springs): 21 PPO, 27 HMO
Colorado (Denver): 15 PPO, 21 HMO

Maybe I just happened to hit some outlier states?

Anyway, the MA PPO plans really do seem like they could be the best of both worlds, or at least not terrible to a big swath of the population depending on how involved the MA PPO plan is, and how closely it resembles a MA HMO plan when it comes to inserting itself into your medical care.

But then you have providers that are making it known they accept only certain MA plans, or no MA plans at all, whether in network or out of network, and that's something to think about. But maybe not a dealbreaker because it's possible to get excellent medical care at some place that is not the Mayo Clinic in Florida or Arizona.

For the record, I have traditional Medicare + G supp + Part D, so I'm not cheerleading for MA plans. But it appears that Medicare Advantage isn't necessarily such a bad thing if people understand what they're getting (which is a big if, of course). (And that's why I'm asking these questions--I'm trying to understand how a MA PPO plan works in real life.)

 

[explanade]

How much of a price difference between Medicare and supplement and Part D vs. MA plans?

 

[Dash man]

How much of a price difference between Medicare and supplement and Part D vs. MA plans?

It varies by location and other factors. You need to research. But realize that while MA plans will be less expensive, if/when your health starts to deteriorate, MA will be more expensive with copays and coinsurance, plus the hassles of fighting denials, doctors coming and going from a network, needing pre-approval for procedures, and reviewing plans each year for changes.
You want to select the plan you’ll want when you’re sick, not when you’re healthy.

 

[VanWinkle]

How much of a price difference between Medicare and supplement and Part D vs. MA plans?

Average price of Medigap G is 150.00. Average price of Part D is 33.00. Average price of Dental plan is 30.00. Average price of Vision is 12.00.
Total with part B premium of 4680.00 per year.

Medicare Advantage = 1980.00 for part B.

Without claims, Part C (medicare advantage) looks good

With claims, Medigap is 4680.00 plus 233.00 ded for 4913.00 total.
With claims Part C is 1980.00 plus avg OOP of 5500.00(avg) for 7480.00 total.

Your figures could be different, these are averages only.




.

 

[Doribe]

So far in my research I have not seen a difference in Medicare Advantage PPO plans and non-Medicare PPO plans. We have been on Megacorp and Retiree PPO plans for many years and have never had the issues highlighted for Medicare Advantage non-PPO plans.

We have seen, from other folks, issues with non-Medicare HMO plans that are the same issues that Medicare HMO plans have, in terms of networks and authorizations. I am finding it interesting that those against Medicare Advantage are not making a distinction between the HMO and PPO types of Medicare Advantage plans.

+1

 

[RetMD21]

Since we're talking Medicare, might the amount in #2 be Medicare reimbursement, in which case I think it might be likely the provider will be willing to accept it since they accept it for traditional Medicare patients? Which would lean toward broad acceptance by out-of-network providers.

Also, the MA plan might be willing or even happy to provide out-of-network coverage for a procedure (assuming the price is substantially less than the sticker price) because the plan member's financial responsibility is higher than when in network (like a higher copay, or even 50% coinsurance).

MIL has a state supported employee version of MA. She can see any provider she wants w/o permission but the out of network deductible and max OOP are double. She is quite frail and doesn't travel and the health care system that dominates her city takes her plan. t is hard to imagine a circumstance where she would be flying to the Mayo clinic.

 

[Gotadimple]

Since we're talking Medicare, might the amount in #2 be Medicare reimbursement, in which case I think it might be likely the provider will be willing to accept it since they accept it for traditional Medicare patients? Which would lean toward broad acceptance by out-of-network providers.

Also, the MA plan might be willing or even happy to provide out-of-network coverage for a procedure (assuming the price is substantially less than the sticker price) because the plan member's financial responsibility is higher than when in network (like a higher copay, or even 50% coinsurance).

I'm still fuzzy on the mechanics of how all this works. I'm assuming that MA enrollees have to get some sort of permission from their plan to see an out-of-network provider; maybe not a referral (or maybe yes a referral?), but some sort of permission?

In other words, are there typical MA HMO-type guardrails still operating even in a PPO plan when it comes to out-of-network providers?


I'm doing my research mainly in the realm of fulltime RVers who need access to providers throughout the country, and there are reports of satisfaction with both Humana MA PPO and UnitedHealthcare MA PPO when it comes to finding in-network providers across the country. So it would appear that these two, at least, have a robust network, along with out-of-network coverage (which might simply mean a copay of $75 instead of $35).

I looked on Medicare.gov for MA PPO plans in a few different states and each area I looked at had a bunch of them, and all of them included Humana and UnitedHealthcare.

Here are the breakdowns I saw--the number of Medicare Advantage PPO and HMO plans for a particular zip code in each state:

Illinois (Elgin): 26 PPO, 26 HMO
Texas (Livingston): 22 PPO, 10 HMO
Florida (Green Cove Springs): 21 PPO, 27 HMO
Colorado (Denver): 15 PPO, 21 HMO

Maybe I just happened to hit some outlier states?

Anyway, the MA PPO plans really do seem like they could be the best of both worlds, or at least not terrible to a big swath of the population depending on how involved the MA PPO plan is, and how closely it resembles a MA HMO plan when it comes to inserting itself into your medical care.

But then you have providers that are making it known they accept only certain MA plans, or no MA plans at all, whether in network or out of network, and that's something to think about. But maybe not a dealbreaker because it's possible to get excellent medical care at some place that is not the Mayo Clinic in Florida or Arizona.

For the record, I have traditional Medicare + G supp + Part D, so I'm not cheerleading for MA plans. But it appears that Medicare Advantage isn't necessarily such a bad thing if people understand what they're getting (which is a big if, of course). (And that's why I'm asking these questions--I'm trying to understand how a MA PPO plan works in real life.)

I'd suggest to go to one of the insurer websites, you can download both a summary of benefits (to understand in-network v out of network), and the Evidence of Coverage. In the evidence of coverage look for service area. If you spend most of your time out of the service area you may not qualify for Medicare Advantage. An plan rep (on the phone) or an insurance agent can answer these questions. There is no obligation to buy.

 

[Gotadimple]

How much of a price difference between Medicare and supplement and Part D vs. MA plans?

It depends on where you live and the number of insurers in the marketplace. You can spend $20/month for a supplement + plus another $2 for a Rx plan
or
You can spend anywhere between $0 and $100/month on a MA plan that covers both but has copays for most every service.

You can see the difference for your state on the Medicare.gov site - it really is very helplful.

- Rita

 

[Pluperfect]

That's correct. (1) there is a contract between the plan and the provider, (2) there is no contract but the provider is willing to accept the payment rate the plan pays doctors in #(1), and (3) provider will not accept the plan's reimbursement rate, and the plan will refuse to allow access to the provider because they will bill the beneficiary for the balance due (a CMC no-no).

I thought for #3 that maybe the provider would refuse to see the patient because the provider won't accept the patient's insurance, but you're saying the plan would refuse to allow the patient access to the provider. How would that take place, if it's a PPO plan, where referrals aren't necessary?

 

[youbet]

s avg OOP of 5500.00(avg)

.

That OOP sounds high VW. DW's OOP for her group MA PPO plan is 1100. Monthly premium is $3.20.

EDIT: Googling around while watching Buffalo kick GB's butts, it looks like your number for Medicare Advantage average OOP is pretty close to what I'm seeing. Who knew? Because DW's is only a small fraction of that, your number looked high.

She's exercised her MA plan a lot in the years she's had it (unfortunately). So meeting her OOP is a given. But her total annual costs are still less than my traditional Medicare with Part D and Type F supplement. And she does get some of those highly advertised "extra benefits" the most useful of which is silver sneakers which pays her health club membership.

Frankly, I'd be in favor of her being set up the same way I am: traditional Medicare + Part D + F supplement since the annual costs are similar. But she's had nothing but satisfaction with her MA plan including seeking out and utilizing several specialists. So far, nothing that traditional Medicare covers has been questioned and customer service seems far superior to traditional Medicare.

But I'm sticking to traditional Medicare.

 

[Gotadimple]

I thought for #3 that maybe the provider would refuse to see the patient because the provider won't accept the patient's insurance, but you're saying the plan would refuse to allow the patient access to the provider. How would that take place, if it's a PPO plan, where referrals aren't necessary?

No, the plan would deny the claim, leaving the patient to pay the provider.

 

[RetMD21]

No, the plan would deny the claim, leaving the patient to pay the provider.

I don't know what you are talking about. First, you said provider won't accept reimbursement rate (which isn't possible with Medicare) Now you are saying the plan would deny the claim. Which is it?

 

[Gotadimple]

I don't know what you are talking about. First, you said provider won't accept reimbursement rate (which isn't possible with Medicare) Now you are saying the plan would deny the claim. Which is it?

Both my points are correct. It doesn't matter if Medicare would pay for a procedure, the Medicare Advantage plan is on the hook for the entire cost of the procedure because they receive a flat rate payment from Medicare to provide health coverage and it is up to them to figure out how to do that and not go bankrupt.

The private insurer takes on all the risk, and Traditional Medicare is out of the picture in terms of payment. CMS cares that the insurer provides coverage for everything covered by Traditional Medicare, and that they have a network of contracted providers that is able to service the number of members in the insurer's Medicare Advantage plan. The insurer can have the same or a different fee schedule than Traditional Medicare. If the patient wants to go out of network, then the MA Insurer negotiates with the provider to accept their rate of payment for the service.

If they won't accept the fee schedule, the plan is not required to pay the claim - and neither is Medicare because the cost of care has been passed to the Medicare Advantage plan in exchange for a monthly cut of the Part B premium (read most of it goes to the MA plan).

Medicare Advantage is not Medicare Supplement. It does not pay for that part of a claim not covered by Medicare, it pays for the whole entire claim less any co-pays and deductibles.

 

[RetMD21]

That's correct. (1) there is a contract between the plan and the provider, (2) there is no contract but the provider is willing to accept the payment rate the plan pays doctors in #(1), and (3) provider will not accept the plan's reimbursement rate, and the plan will refuse to allow access to the provider because they will bill the beneficiary for the balance due (a CMC no-no).

MA ppo has no discretion to reject charges and pays non-contract (ie full rates to physicians - not sure about labs etc)