Part D Frustrations

[Sunset]

We notice that those receiving retiree benefits from their former employer often have very good Medicare Advantage plans, PPOs, extensive networks. But these plans are not available to the general public.

True, we could go with one for free.. But decided to stay with Medicare, I've experienced a few times where some clerk/agent at the insurance company questioned my Doctor's decision.

It was a bit of a hard decision to throw away "free" healthcare.

I don't want to be dependent upon the pre-approval by some unqualified stranger who has never seen me and is possibly getting rewarded base on the savings to the insurance company.

 

[CaptTom]

We notice that those receiving retiree benefits from their former employer often have very good Medicare Advantage plans, PPOs, extensive networks. But these plans are not available to the general public.

The MegaCorp I retired from has a "retiree medical benefits" plan. I finally got the details, and the price. It does include prescription coverage.

I plugged it into the spreadsheet I'm making of all the Medicare plans I'm interested in. It's very hard to find a combination of plans which is more expensive than what the company is offering. About the only way would be to select the most expensive Plan D, which my company plan is nowhere near comparable to. I even called the company health care support number and flat-out asked if the plan they offer is subsidized or fully paid by the retiree. He claimed it's subsidized, but when I wondered out loud whether any retirees found it less expensive than other options, he said he wasn't allowed to answer that question.

They also rolled out a new retiree Advantage plan this year. I sat in on an on-line seminar which was billed as addressing retiree health insurance issues. Pretty early on, they turned it over to a Humana rep who gave a hard-sell sales pitch for that Advantage plan. I was already leaning toward avoiding Advantage plans, but this attempt to shove it down my throat only strengthened that idea.

It's pretty clear to me the company wants no part of retiree health care expenses. They made the "regular" plan unaffordable and are trying to pawn everyone off onto Humana's Advantage plan. I suspect they're getting a cut of the profits from Humana.

 

[1vertical]

This I have first hand experience with using Wellcare due to the low premiums I have had.
They are based in the Phillipines. Annual renual payment experience is abysimal on the telephone.
If you request an "onshore operator" you will wait even longer. My new med Voquenza
is NOT on the formulary and it is $23.80 a tablet. Glad it is a short term application. I endeavour
to keep as slim a digital profile as possible and have no online interface with them.
How can a US Government Medicare Sanctioned Provider be Contracted by a company in ASIA?
Rant over....Good luck OP

 

[RetMD21]

We notice that those receiving retiree benefits from their former employer often have very good Medicare Advantage plans, PPOs, extensive networks. But these plans are not available to the general public.

True but I am not sure that they are any better when it comes to approving care.

 

[audreyh1]

True but I am not sure that they are any better when it comes to approving care.

I wondered about that, although many employer retiree benefit plans are PPOs which implies no gatekeeper.

 

[Lstansbury]

The MegaCorp I retired from has a "retiree medical benefits" plan. I finally got the details, and the price. It does include prescription coverage.

I plugged it into the spreadsheet I'm making of all the Medicare plans I'm interested in. It's very hard to find a combination of plans which is more expensive than what the company is offering. About the only way would be to select the most expensive Plan D, which my company plan is nowhere near comparable to. I even called the company health care support number and flat-out asked if the plan they offer is subsidized or fully paid by the retiree. He claimed it's subsidized, but when I wondered out loud whether any retirees found it less expensive than other options, he said he wasn't allowed to answer that question.

They also rolled out a new retiree Advantage plan this year. I sat in on an on-line seminar which was billed as addressing retiree health insurance issues. Pretty early on, they turned it over to a Humana rep who gave a hard-sell sales pitch for that Advantage plan. I was already leaning toward avoiding Advantage plans, but this attempt to shove it down my throat only strengthened that idea.

It's pretty clear to me the company wants no part of retiree health care expenses. They made the "regular" plan unaffordable and are trying to pawn everyone off onto Humana's Advantage plan. I suspect they're getting a cut of the profits from Humana.

I hear you. I chose to skip out of my big university retiree plan because it was an Advantage plan. (Even though most people really like it). It is very expensive and I didn't want to lose my guaranteed issue right to be enrolled in a Medigap plan without needing to go through underwriting. Some people I have seen do have pretty good retiree plans though. It's just the guaranteed issue right that is in question. The local SHIIP office could not answer my question about the GI issue -- I had to talk to a independent broker to get the info! That was before I got my license.

 

[RetMD21]

I wondered about that, although many employer retiree benefit plans are PPOs which implies no gatekeeper.

No gatekeeper to be seen by a physician but MA plans required prior approval tests and treatments. In Michigan I didn't see a difference in this between the state's MA plan for retirees and the regular ones administered by the same company.

 

[audreyh1]

No gatekeeper to be seen by a physician but MA plans required prior approval tests and treatments. In Michigan I didn't see a difference in this between the state's MA plan for retirees and the regular ones administered by the same company.

Doesn’t traditional Medicare also need approval? Or how do you know your claim will be accepted?

 

[AudiDudi]

Doesn’t traditional Medicare also need approval? Or how do you know your claim will be accepted?

We never had an issue and can see any doctor anywhere that accepts traditional Medicare. No need for a referral for a specialist. (who also accepts Medicare.) If DW wants to see her cardiologist, she calls and makes an appt - no need to see her primary care doc 1st.

 

[audreyh1]

We never had an issue and can see any doctor anywhere that accepts traditional Medicare. No need for a referral for a specialist. (who also accepts Medicare.) If DW wants to see her cardiologist, she calls and makes an appt - no need to see her primary care doc 1st.

I understand that you can go straight to any specialist on traditional Medicare, but what about approval for tests and procedures/treat agents as RetMD21 mentioned above?

 

[Texas Proud]

I understand that you can go straight to any specialist on traditional Medicare, but what about approval for tests and procedures/treat agents as RetMD21 mentioned above?

Well, I am making a guess here but I just went and requested some test on my heart that I saw on a Dr that teaches at Johns Hopkins... he said that we will go with a calcium score and stress test first... his comment was 'we have to check the boxes first'...

So the Drs might now what is easy to get done and what needs something done first...

 

[audreyh1]

Clearly some doctors are much better at coding properly for Medicare than others.

 

[AudiDudi]

I understand that you can go straight to any specialist on traditional Medicare, but what about approval for tests and procedures/treat agents as RetMD21 mentioned above?

Has not been an issue - DW has had several procedures that cost approaching $10k and one at $90k. Medicare and supplement paid 100% after the annual Part B deductible was paid. Everytime she sees the cardiologist she has an EKG. Always paid for. I requested a follow up to an issue 5 yrs later that required an ultrasound - no questions and paid for but I do believe the doc checked with Medicare 1st and I verified it was covered before I proceeded with the check-in.

 

[RetMD21]

Traditional Medicare only requires authorization for a few things. I know blepharoplasty is one. They don't pay for cosmetic but will if it is to improve vision. Cholecystectomy, cataract surgery etc don't require it. A lot of MA approvals are easy but sometimes they deny the procedure or require a lesser one.

If you are a cardiologist and somebody wanders in requesting a heart characterization the medically reasonable thing to do is to do some less invasive tests to see what this issue is and if the other test is needed.

Somebody else might know more about this but if a Medicare beneficiary doesn't sign an "advanced beneficiary notice" the provider of the service is out of luck if Medicare denies payment. The patient would owe 0.