Sick Patients switching to traditional Medicare near end of life

[EastWest Gal]

Medicare Advantage isn't Medicare. It's private insurance companies taking profit from denying services. It also costs the government (and taxpayers significantly more) than straight Medicare. Why do you think we are bombarded with ads for Medicare Advantage every fall? Taxpayer dollars are going to the insurance companies rather than the to the doctors and hospitals. Medicare Advantage puts the Medicare system at greater risk for insolvency in the future. No thank you.

 

[Koolau]

I started a thread a few weeks ago about changing from my employer sponsored MA plan to medicare/gap. The MA plan is costly-with the employer contributing less than 10% of the cost but money wasn't the driving reason I thought about and am now leaving the MA plan. I was paying for what someone else referred to as "window dressing". When you dig down into these plans the majority of the plan is covering exactly what Medicare covers. The rest is more "perks" you might use someday but probably you won't. I just didn't see the value and was concerned about being stuck in the MA plan.
I can tell you from talking to people I used to work with (I live in a small town and most of us live and worked here) people have no idea that these MA plans are mostly covering Medicare approved services. Very little is over and above Medicare. But they think it is the MA plan covering.
I guess those years I spent as an analyst early in my career are serving me well!

The advertising for MA plans is really slick! Lots of people have been sucked in. Of course, if you never get sick, MA w*rks out pretty well. It's a crap shoot at best IMHO (and I'm not an expert on the subject.)

 

[stedmakr]

I am surprised by how many of my acquaintances who can afford Medigap plans instead opted for Medicare advantage.
It makes me question my decision to get a Medigap plan when I'm eligible next year, but then I read articles like this one and believe I'm making the right decision. We do not live in a state that allows a change from MA to Medigap without underwriting.

Your friends did not do their due diligence.

 

[audreyh1]

Seems like slick deal promises abound with Medicare Advantage. Insurance companies push these hard. Many companies sent me Medicare Advantage brochures shortly before I reached 65.

 

[youbet]

Everyone loves a deal.. and MA sounds like a deal in the beginning.

For us, we can get MA for FREE, from employer, instead we pay for regular Medicare + Sup, an extra expense of ~$3,500 each.

Are we stupid or smart, ask in 25 yrs and I'll have an answer.

It depends on the employer MA plan. Many employer sponsored MA plans (not to be confused with MA plans offered/sold to individuals) are equal or superior to Medicare + supplement. My DW is on a MA plan sponsored by a Illinois public pension system. The network consists of any provider that accepts traditional Medicare. I think it stacks up very well vs my traditional Medicare plus Plan F.

But, again, this is not the MA that is sold to individuals. What is your employer offering?

 

[RetMD21]

Good article. MIL is currently in post-hospital skilled care covered by Medicare Part A we expect her MA plan to recommend discharge before the staff recommends. It is true that you can appeal these decisions but it you lose, you pay cash for the extra days of care. The MA plan has an incentive to discharge early and even if they lose on appeal they just end up paying for care that was needed. I think many people just can't afford to fight.

Her plan is a state sponsored retiree MA plan which has a wide network but seems similar to other MA when it comes to approvals for care.

 

[SecondCor521]

I'm a bit mystified about my Dad's situation with this.

He switched (or "got switched" more likely) from traditional Medicare to a Medicare Advantage plan about four years ago. I think it was a "helpful" phone rep from his insurance company.

What little I understand about MA is that it is similar to an HMO - the federal government gives my Dad's insurer $X per year, and the insurer is supposed to administer his health insurance for the government. Obviously with this structure, the insurer is incentivized to try to deny claims or offer a limited network.

Neither of those has happened with my Dad AFAICT. He has had several expensive surgeries, several hospital visits (with the attendant imaging and lab bills), several ambulance rides, some durable medical equipment, a two week stint in a SNF for intensive PT, a fair amount of home health care visits and physical therapy, as well as several maintenance meds during the past four years.

In all cases, there were no unreasonable delays in care, all the providers have been in network and are not the "fresh out of med school" types, coverage has not been denied for anything, and my Dad's OOP portion has been, in my opinion, ridiculously small: $300 copay on a solid five figure surgical procedure this summer, $103.04 copay for an ER visit, $15 copay per visit for his home health FNP.

We haven't needed to do much pre-auth or gateway visits at all. ne exception was trying to get him a power chair which was like pulling teeth and took 3 months, but that seemed to be the Medicare rules and not his particular insurance situation because it was driven by the DME provider. And all that work didn't really save the insurer much, because he only rented the powerchair for about five months.

He does also get a "window dressing" benefit of $50 to $100 per quarter to buy medical supplies, which I order for him on a website and gets shipped to my door.

I'm sort of waiting for some shoe to drop based on what everyone else has said about Medicare Advantage, but so far it hasn't. He's sort of in a palliative care mode now and may go on hospice sometime in the near future, so maybe he just dodged a bullet or somehow his particular Medicare Advantage plan in our state is somehow good or something.

 

[athena53]

What little I understand about MA is that it is similar to an HMO - the federal government gives my Dad's insurer $X per year, and the insurer is supposed to administer his health insurance for the government. Obviously with this structure, the insurer is incentivized to try to deny claims or offer a limited network.

Neither of those has happened with my Dad AFAICT. He has had several expensive surgeries, several hospital visits (with the attendant imaging and lab bills), several ambulance rides, some durable medical equipment, a two week stint in a SNF for intensive PT, a fair amount of home health care visits and physical therapy, as well as several maintenance meds during the past four years.

I have heard/read that Advantage plans vary widely, I'm glad your Dad got one of the good ones. My Dad also got aggressively sold an Advantage plan even though we tried to talk him out of it. Fortunately he realized during the trial period (3 months? 6 months?) in which he was allowed to switch back that it wasn't for him and he spent the rest of his life on traditional Medicare. This was in SC.

Right now my mail box is stuffed with two things: solicitations from every charity to which I've ever donated a dime (plus the ones that bought their mailing lists) and Medicare mailings, mostly for Advantage plans.

 

[audreyh1]

I think you have 6 months. Glad your Dad was able to figure things out in time and switch back.

 

[athena53]

I think you have 6 months. Glad your Dad was able to figure things out in time and switch back.

I agree. My friend who answers calls from Medicare beneficiaries was able to help someone just a couple of days ago when he called with this issue. He was within the time frame when he could change back and was grateful to know he had that option.

 

[youbet]

Good article. MIL is currently in post-hospital skilled care covered by Medicare Part A we expect her MA plan to recommend discharge before the staff recommends. It is true that you can appeal these decisions but it you lose, you pay cash for the extra days of care. The MA plan has an incentive to discharge early and even if they lose on appeal they just end up paying for care that was needed. I think many people just can't afford to fight.

Her plan is a state sponsored retiree MA plan which has a wide network but seems similar to other MA when it comes to approvals for care.

Since the recommendation for early discharge is only an expectation on your part it will be interesting to see if that actually happens. Additionally, I hope her discharge is recommended by her doc and not the skilled care facility staff. Their mission is to keep 'em 'til cob webs cover the bed!

DW's state pension plan sponsored MA plan works well, at least so far. Unfortunately, she's used it a lot (breast cancer, shattered ankle bone, colon re-section, rotator cuff, etc.) And she's never had any issues with the insurance. She's shopped carefully for docs and facilities and never had one of them say they'd like to do something but her insurance won't pay. They seem to just cover whatever Medicare covers plus some additional.

I would just as soon have her on traditional Medicare plus Part F, like me, so I don't need to understand two different systems. But, so far, her MA plan has worked out fine.

 

[Pluperfect]

my Dad's OOP portion has been, in my opinion, ridiculously small: $300 copay on a solid five figure surgical procedure this summer, $103.04 copay for an ER visit, $15 copay per visit for his home health FNP.

Has your dad had cancer? It's my general impression that cancer treatments are what will cause Advantage plan members to hit their out-of-pocket max with a quickness.

Obviously there are plenty of people whose Advantage plans work well for them, and it sounds like your dad is one of them. The problem is predicting whether a given Advantage plan will work well for a given person whose future health is uncertain.

 

[SecondCor521]

Has your dad had cancer? It's my general impression that cancer treatments are what will cause Advantage plan members to hit their out-of-pocket max with a quickness.

Technically yes (the minor skin cancer kind), but practically speaking no.

 

[JBTX]

Serious question. What does it mean when upper and lower case are intermixed this way?

It is mocking the statement (and the people that say such things ) as uninformed and stupid.

iF tHeRe iS gLoBaL wArMiNg tHeN wHy is iT coLd oUtSiDe?

 

[flyoverstate]

Wow, what a timely post. My spouse is in the Colorado state employee retirement system (PERA). Up until this year, they had a Medicare supplement program that was pretty good, that they subsidized to the tune of about $200/mo. Now, just this year, they dropped the supplement, and the only choice she has is one, single, solitary Medicare Advantage program that has none of our doctors.

We were assuming we would be able to choose the supplement once we are on Medicare. This one change is going to cost us hundreds per month, there is no way we are going to get roped into a MA program, especially when there is no competition for them. I guarantee there will be some unhappy former teachers, firefighters, police, etc. over this.

 

[Pluperfect]

Technically yes (the minor skin cancer kind), but practically speaking no.

I'm no expert on Advantage plans, but I gather that it's not uncommon for them to cover 80% of chemotherapy costs, with the member responsible for 20% coinsurance. That can really add up (although capped at the member's out-of-pocket maximum).

Whether someone has hit his MOOP because of the way cancer treatment is covered under his Advantage plan could have a big effect on how happy he is with the plan.

I have a friend who's rich but somehow (to his wife's great chagrin) signed up for an Advantage plan. He's been getting cancer treatments for the last five years or so, and every year hits his MOOP, which is more than his supplement premiums would have been. He's not happy with his plan.

 

[pb4uski]

It is mocking the statement (and the people that say such things ) as uninformed and stupid.

iF tHeRe iS gLoBaL wArMiNg tHeN wHy is iT coLd oUtSiDe?

Well, they got the stoopid part right.

 

[walkinwood]

Everyone loves a deal.. and MA sounds like a deal in the beginning.

For us, we can get MA for FREE, from employer, instead we pay for regular Medicare + Sup, an extra expense of ~$3,500 each.

Are we stupid or smart, ask in 25 yrs and I'll have an answer.

We have been paying for an ACA Bronze plan since they became available, so paying for it will not be an extra burden - the big differences will be the very low deductible & max out of pocket, and most importantly, doctor choice.

I'm hopeful, we won't have to wait as long for appointments as we do now. Though, with a call and some cajoling, we can usually get in to see someone pretty quickly. However, if we want to see our PCP or a specific doctor, the wait is often way too long. Luckily, we haven't had any serious illnesses so far.

 

[MichaelB]

I'm a bit mystified about my Dad's situation with this.

He switched (or "got switched" more likely) from traditional Medicare to a Medicare Advantage plan about four years ago. I think it was a "helpful" phone rep from his insurance company.

What little I understand about MA is that it is similar to an HMO - the federal government gives my Dad's insurer $X per year, and the insurer is supposed to administer his health insurance for the government. Obviously with this structure, the insurer is incentivized to try to deny claims or offer a limited network.

Neither of those has happened with my Dad AFAICT. He has had several expensive surgeries, several hospital visits (with the attendant imaging and lab bills), several ambulance rides, some durable medical equipment, a two week stint in a SNF for intensive PT, a fair amount of home health care visits and physical therapy, as well as several maintenance meds during the past four years.

In all cases, there were no unreasonable delays in care, all the providers have been in network and are not the "fresh out of med school" types, coverage has not been denied for anything, and my Dad's OOP portion has been, in my opinion, ridiculously small: $300 copay on a solid five figure surgical procedure this summer, $103.04 copay for an ER visit, $15 copay per visit for his home health FNP.

We haven't needed to do much pre-auth or gateway visits at all. ne exception was trying to get him a power chair which was like pulling teeth and took 3 months, but that seemed to be the Medicare rules and not his particular insurance situation because it was driven by the DME provider. And all that work didn't really save the insurer much, because he only rented the powerchair for about five months.

He does also get a "window dressing" benefit of $50 to $100 per quarter to buy medical supplies, which I order for him on a website and gets shipped to my door.

I'm sort of waiting for some shoe to drop based on what everyone else has said about Medicare Advantage, but so far it hasn't. He's sort of in a palliative care mode now and may go on hospice sometime in the near future, so maybe he just dodged a bullet or somehow his particular Medicare Advantage plan in our state is somehow good or something.

Some MA plans are PPOs, some are HMO. They are all different, and that’s one reason for the confusion. My mum has MA, like your pops she has had her share of medical care and then some, and so far she hasn’t had any serious issues.

I’m not a fan of MA, and the article in the OP does show some bad behavior by insurers, but IMO it’s not correct to paint all MA with the same broad brush. Traditional Medicare + MediGap is my preference but just isn’t an option for many due to the cost. My brother has an MA HMO, he’s well aware of the tradeoff he makes.

 

[RetMD21]

Since the recommendation for early discharge is only an expectation on your part it will be interesting to see if that actually happens. Additionally, I hope her discharge is recommended by her doc and not the skilled care facility staff. Their mission is to keep 'em 'til cob webs cover the bed!

....

Well they discharged her early last time she had a fall and fracture so it doesn't seem to be far fetched to think it would happen again. You might think that the decision to discharged would be based on the doctor's recommendation. The insurance has no interest in physician recommendations. The interaction to justify the extension or therapy services is entirely between the provider of those services and the insurer. There are criteria to ensure that the patient is progressing and they they still have needs to be addressed.

 

[Retired2016]

We didn’t do my homework when we signed up for Advantage. We will be signing up for plan N this week. We live in a state where we will need to go through underwriting.

We have no ‘yes’ answers on the online survey concerning health issues so I am hopeful we will not have any problems getting back in. It will cost much more as we may have made money this year with Advantage since our premium was zero and they kept giving us money. But the limitation of selecting a preferred health care provider is not worth the savings to us. We are fortunate to be able to have the finances to make that decision however.

Hope it works out for you. My husband had no “yes” answers and couldn’t pass underwriting for a different Medigap policy excluding one company that would have more than double what he was currently paying. Unfortunately they based their decision off of prescription medications he had been on for years (that was prescribed for a secondary use) versus the common primary reason for the medication.

 

[Lstansbury]

Good article. MIL is currently in post-hospital skilled care covered by Medicare Part A we expect her MA plan to recommend discharge before the staff recommends. It is true that you can appeal these decisions but it you lose, you pay cash for the extra days of care. The MA plan has an incentive to discharge early and even if they lose on appeal they just end up paying for care that was needed. I think many people just can't afford to fight.

Her plan is a state sponsored retiree MA plan which has a wide network but seems similar to other MA when it comes to approvals for care.

You have the right to one appeal without having to pay of you lose. It's the second appeal that might cost. (Formerly with Medicare QIO that reviewed these case) look up discharge appeal rights, BFCC-QIO for your area

 

[Lstansbury]

I worked for Medicare QIO for almost a decade, did managed care ed care contracting for a hospital system for another three years, credentialing providers with networks. Now I am a Medicare focused insurance agent. Just signed a 75 year old and 80 + year old up for a medigap plan. They were approved. So glad to get them both off an advantage plan. I've seen the denials first hand.

 

[old_swimmer]

plenty of good advice but no one has mentioned SHIP counselors. Volunteers providing Medicare advice at no cost. Some good, some great, some.... well..... if reaching 65 and just enrolling or thinking of switching, find your local state SHIP program and reach out.

 

[Anchors Aweigh1]

Medicare Advantage isn't Medicare. It's private insurance companies taking profit from denying services. It also costs the government (and taxpayers significantly more) than straight Medicare. Why do you think we are bombarded with ads for Medicare Advantage every fall? Taxpayer dollars are going to the insurance companies rather than the to the doctors and hospitals. Medicare Advantage puts the Medicare system at greater risk for insolvency in the future. No thank you.

Very difficult to switch from advantage back to Medicare especially as you get older will never make it through underwriting