Why I use Medicare Advantage, and I'm happy.

[jollystomper]

One of the benefits of our our Megacorp provided Medicare Advantage PPO plan is that it is self-funded by Megacorp, and the insurance company primarily acts as an administrator. Megacorp has put in place "advocates" that one can contact to appeal the insurance company or providers actions, and they will investigate the situation. This is similar to what they had for employee health insurance, and the few times we had to use an advocate in those times, it always turned out in our favor. We have a minor issue currently where the insurer is saying A and he provider is saying B, we raised this to an advocate, who has contacted both the insurer and the provider and has started an appeal on our behalf.

I believe this is one reason that so far, we have not had any issues getting any specialist or surgical requirements approved quickly. In fact, the same day my urologist practice put me on their surgical schedule, I received a call from the insurance provider saying my surgery (and all the associated stuff for it) was approved.

The year before I turned 65 I looked into all of the options, and we planned to go with Medicare and Supplemental Plans for the flexibility. I am very fortunate that Megacorp provided this Medicare Advantage plan with the same flexibility, wider range of things covered and benefits, and (if I choose) a much lower maximum out of pocket level.

 

[Teacher Terry]

As I stated,


Those three people could have received care from whoever they wanted if on an Advantage plan, nothing would have prevented them. But it would have been at a "high cost" and savings from their premiums wouldn't offset.

And while you have three people as an example, I'm sure there are others who have three people who are example of beneficial on Advantage plan.

So it still comes down to "Risk vs Premium". As with any decision, all seems good, until it's not.

One surgery was for a baseball sized tumor wrapped around her brain stem so very few neurosurgeons can do it without killing or maiming the patient. Plus it cost 1 million. It was also out of state. No local MA plans pay for that.

 

[teejayevans]

There are cases where you can find MA plans cover treatments you won’t get with gap/partD plans. I used the drug Humira as a proxy, with all part D plans cost was $91k+/yr, some MA plans were the same, but some covered it reducing the cost to ~$4k/yr.

 

[youbet]

There are cases where you can find MA plans cover treatments you won’t get with gap/partD plans. I used the drug Humira as a proxy, with all part D plans cost was $91k+/yr, some MA plans were the same, but some covered it reducing the cost to ~$4k/yr.

Yeah………. DW is MA and I’m OM. Every year we plug my meds into her plan and come up with an annual cost. Then I do my annual search for a Part D plan. I never find a Part D plan that beats what she would hypothetically pay for the same drugs here in Illinois. Annoying. The new $2.1k max oop limit with Part D coverage does help.

 

[youbet]

zl55lz,
You are correct. We are enrolled in A and B, but the state reimburses the Part B payments. We are not permitted to enroll in any other parts of Medicare.

What other parts ?

 

[Koolau]

For me, it’s not so much a financial decision as it’s the ability to get the care that I need in a timely manner. As I have stated before I have three people in my life that would be dead if they were not free to seek the best care in another part of the country.

In many cases, especially if you have an aggressive type of cancer time is of the essence and you don’t have time to wait for approvals or to progress through step therapy before getting the treatment that you really need. That for me is the real difference.

Yeah, this sounds like a single reason to go traditional that trumps the other issues in my book. The last thing you want to do when you have cancer is fight with an insurance company and worry about whether something will be covered - eventually.

 

[RetMD21]

......


So any discussion comparing original Medicare and Advantage should include:

(1) the financial considerations (including the "extras" that Advantage plans offer),

(2) acknowledgement of networks (including the issues with "see any provider" provisions that some plans have), and

(3) acknowledgement of pre-authorization practices of Advantage plans.

Good points. Are we sure that those advocating MA understand 2 and 3? Those posting that MA is better because their premium is lower don't inspire confidence.

I agree with you that many MA denials are overturned on appeal but most people don't even appeal. From my perspective some of the prior authorization peer reviews that I did looked like behavior modification. If you recommended the insurance preferred treatment option approval was automatic.

 

[FD1000]

No, it’s not. Create a SS and model it yourself.

Even if you max out on occasion, and most of us will, especially towards the end, you’ll still be ahead with an MA plan. Only if you frequently have high medical expenses will you be ahead with supplemental plans. If you have a chronic illness that requires high spending every year, then yes. But say if you max out say every 7th year for first 21 years, then 4 years in a row, you’ll still probably be ahead. It depends on which state you’re in and future premium increases.
What really hurts financially is to get sick at the end of the year, so an illness expenses are spread over 2 years.
Don’t forget supp plans (lately) are rising faster than inflation, and you need separate drug and dental plans.
Gap plans are better for flexibility, not because they are cheaper.
It really depends on where you live, and what’s available. Some have excellent health care providers, some don’t.

Nailed it.

Pluperfect said​

People usually do (eventually) acknowledge that Advantage plans have networks of providers....
And there are plans that allow you to see any provider who accepts Medicare, perhaps at a higher copay. The problem can occur that the provider won't agree to see you, because they don't contract with your Advantage plan and don't want to hassle with it. That's not generally mentioned when the "see any provider" provisions are discussed.

For us, with no network restrictions, PCP visits are always $0, and specialists anywhere in the country who accept our MA plan are just $20.

My wife joined last year and initially found that her OB-GYN wasn’t listed. She said she goes with Original Medicare. Then she called the office, and they told her the doctor doesn’t accept any Medicare patients, Original or Advantage.

Teacher Terry said
For me, it’s not so much a financial decision as it’s the ability to get the care that I need in a timely manner.
In many cases, especially if you have an aggressive type of cancer time is of the essence and you don’t have time to wait for approvals

So far, almost nothing has required prior approval. Both of my surgeries were approved the same day, and I never saw a bill.
Dozens of people I know, including several in their 80s with 20 years on MA, have had similar experiences. I can see local specialists just as quickly as anyone else, including back when I had employer-sponsored insurance.

bobandsherr said​

As I look over the discussions it seems it boils down to Risk vs. Premium. Supplement users pay for "certainty" upfront to avoid high costs later. Advantage users "self-insure" by keeping their premiums low, betting that their health will remain good enough that their total annual spend (premiums + copays) will remain lower than the cost of a Supplement.

That’s how insurance works, you manage risk, not eliminate it. I know my maximum annual out-of-pocket cost is $6,700.
After three years, the savings plus portfolio performance are over $22K, and that includes two surgeries. My wife joined last year, which will increase our portfolio even more.
When I retired in 2018, I also looked at long-term care insurance and decided against it. Instead, I mentally set aside $500K for that risk. Since then, that amount has grown by over 135%.
LTC is a lot more expensive than the MA vs Original dicussion. We are talking about at least $100K annually.

While I wholeheartedly agree that Original Medicare is the preferred option in most cases, Medicare Advantage can be an excellent choice in specific counties.
In my county, there are over 60 MA plans. More than 90% aren’t good enough, but the top two or three are excellent. There’s no need to discuss the inferior ones at all.

 

[Pluperfect]

In my county, there are over 60 MA plans. More than 90% aren’t good enough, but the top two or three are excellent. There’s no need to discuss the inferior ones at all.

Except for the fact that it sounds like your Advantage plan is a unicorn. The inferior ones are often all that is available to many people, so there is a need to discuss them. And those people likely aren't equipped to take your suggestion that they move to a county 15 miles away in order to change to original Medicare if their Advantage plan blows up in their face.

And while you, and everyone you know, have not had any problems with prior authorization requirements, it's not that it can't happen--it's just that it hasn't happened. As they say, past performance is not a guarantee of future results.

 

[Dtail]

Ah the back and forth, when both sides are right for their situation.
Like stating I don't wish to live in Florida, as their are no mountains but there are in Pennsylvania, while the Florida person doesn't like the cold. Both are correct for their situation.
Some/many parts of Florida have a multitude of good MA plans which are accepted by enough doctors in their area. However, my fiance has a one shot deal when turning 65 this year to switch from her MA plan to Medigap with no underwriting even though on SSDI. She will do it, as she sees doctors quite a bit and the unknown for her in the future is more cloudy.

 

[FD1000]

Most threads and posts about Medicare focus on how bad Medicare Advantage is and emphasize its downsides.

I started this thread to show that Original Medicare should be the default choice, while acknowledging that in some counties a very selective Medicare Advantage plan can be a reasonable option. I also discussed two ways to switch back, noting that neither is guaranteed.
I understand that many people disagree. That’s fine.

My suggestion is simple: start a new thread explaining why you don’t like Medicare Advantage, no matter the circumstances.

That's similar to someone who invests in CEFs. It's not a secret; I don't like them, but I don't post several times daily about it on a CEF thread about it.

Bottom line: people who are interested may gain some useful knowledge.

How about the following: after I save and invest $200K, I'm switching to Original.

 

[Flieger]

I posted earlier showing that in NC, Duke and other key medical areas except MA plans. Looking in SC, that is also true. I still have a couple of years and will review again. I made a copy of who is currently accepted, and will see if that changes over time as part of that analysis.

Flieger

 

[Calico]

In 2018, while I was still w#rking, I underwent 4 rounds of chemo.

Twenty-four hours after each chemo infusion, at the direction/insistence of my oncologist, I was scheduled to receive a Neulasta injection to prevent neutropenia, which could make me vulnerable to life-threatening infections and fevers.

At the time I was covered by a "cadillac" PPO health insurance plan (BC/BS) provided by my employer. My oncologist filed all the correct pre-authorization forms for the injections, and I saw the signed authorizations from the insurance company. I insisted on seeing the approvals because I knew the injections were ridiculously expensive.

A few days after the first injection, I was notified by BC/BS that they were denying the claim, and holding me responsible for the cost of the shots ($20,000 each; a total of $80,000).

I remember being awake at 2:00 am, sick from the chemo, reading the denial email, in tears and filled with fear that even if I lived, I could lose my house because some nameless, faceless idjit sitting at a desk somewhere failed to check the correct box, even though my doctor and I had done everything "right."

The next morning I contacted the billing department at the hospital and told them they needed to fix the error. They said to contact BC/BS. I contacted BC/BS, and they said to contact the hospital. I just threw up my hands and hung up the phone. I was still w#rking from home every day except the days I had chemo, and I had better things to do than deal with insurance idjits.

I told my oncology therapist what had happened, and she said "leave it to me." A day later I got a message from her that she had fixed it. To this day I don't know who she called or how she fixed it. I do know that she is a little bitty Southern woman, who can aptly be described as a steel magnolia, and the look in her eyes when I told her what happened made me glad I wasn't on the receiving end of her call to BC/BS. She was an angel, and she did what she had to do to save my sanity (and probably my house) at that time.

I completed my treatment, and I'm grateful to still be here, alive and kicking.

In 2020 I researched original Medicare and Medicare Advantage before signing up. Once I learned about the percentage of denials Medicare Advantage issues, which are then overturned on appeal, it took me exactly 2.3 seconds to choose original Medicare and a supplement.

I wouldn't wish what I went through at 2:00 am that day on my worst enemy. God willing, I'll never deal with cancer again, or anything else of that magnitude, but there are no guarantees in life. The last thing I want to deal with when I'm 85, in poor health, and losing my marbles, is fighting with insurance idjits. I won't have the energy, and there might not be an angel on my side next time. (Thank you, Pam!!)

I am blessed to be able to afford original Medicare and a supplement, and I realize how lucky I am. Not everyone has the means to make that choice. It's worth every penny I spend on it; you can't put a price on peace of mind.

Edited to add: I sincerely hope that everyone on a Medicare Advantage plan has a good experience, and that they never have to deal with a denial of claims. I simply posted my experience to explain that the decision does not always come down to dollars and cents; there's a lot more that goes into it. Personally I believe that it's a case of "pay now or pay later" and given that choice, I'm happy to pay more upfront. Good luck to everyone, whatever choice they make!

 

[TickTock]

In 2020 I researched original Medicare and Medicare Advantage before signing up. Once I learned about the percentage of denials Medicare Advantage issues, which are then overturned on appeal, it took me exactly 2.3 seconds to choose original Medicare and a supplement.

Do you recall (at least roughly) % of denials overturned on appeal for Medicare Advantage vs. traditional Medicare?

 

[Flieger]

In 2018, while I was still w#rking, I underwent 4 rounds of chemo.

Twenty-four hours after each chemo infusion, at the direction/insistence of my oncologist, I was scheduled to receive a Neulasta injection to prevent neutropenia, which could make me vulnerable to life-threatening infections and fevers.

At the time I was covered by a "cadillac" PPO health insurance plan (BC/BS) provided by my employer. My oncologist filed all the correct pre-authorization forms for the injections, and I saw the signed authorizations from the insurance company. I insisted on seeing the approvals because I knew the injections were ridiculously expensive.

A few days after the first injection, I was notified by BC/BS that they were denying the claim, and holding me responsible for the cost of the shots ($20,000 each; a total of $80,000).

I remember being awake at 2:00 am, sick from the chemo, reading the denial email, in tears and filled with fear that even if I lived, I could lose my house because some nameless, faceless idjit sitting at a desk somewhere failed to check the correct box, even though my doctor and I had done everything "right."

The next morning I contacted the billing department at the hospital and told them they needed to fix the error. They said to contact BC/BS. I contacted BC/BS, and they said to contact the hospital. I just threw up my hands and hung up the phone. I was still w#rking from home every day except the days I had chemo, and I had better things to do than deal with insurance idjits.

I told my oncology therapist what had happened, and she said "leave it to me." A day later I got a message from her that she had fixed it. To this day I don't know who she called or how she fixed it. I do know that she is a little bitty Southern woman, who can aptly be described as a steel magnolia, and the look in her eyes when I told her what happened made me glad I wasn't on the receiving end of her call to BC/BS. She was an angel, and she did what she had to do to save my sanity (and probably my house) at that time.

I completed my treatment, and I'm grateful to still be here, alive and kicking.

In 2020 I researched original Medicare and Medicare Advantage before signing up. Once I learned about the percentage of denials Medicare Advantage issues, which are then overturned on appeal, it took me exactly 2.3 seconds to choose original Medicare and a supplement.

I wouldn't wish what I went through at 2:00 am that day on my worst enemy. God willing, I'll never deal with cancer again, or anything else of that magnitude, but there are no guarantees in life. The last thing I want to deal with when I'm 85, in poor health, and losing my marbles, is fighting with insurance idjits. I won't have the energy, and there might not be an angel on my side next time. (Thank you, Pam!!)

I am blessed to be able to afford original Medicare and a supplement, and I realize how lucky I am. Not everyone has the means to make that choice. It's worth every penny I spend on it; you can't put a price on peace of mind.

Edited to add: I sincerely hope that everyone on a Medicare Advantage plan has a good experience, and that they never have to deal with a denial of claims. I simply posted my experience to explain that the decision does not always come down to dollars and cents; there's a lot more that goes into it. Personally I believe that it's a case of "pay now or pay later" and given that choice, I'm happy to pay more upfront. Good luck to everyone, whatever choice they make!

None of the above says their would be anything beyond the OOP costs for MA.

Flieger

 

[Pluperfect]

Do you recall (at least roughly) % of denials overturned on appeal for Medicare Advantage vs. traditional Medicare?

The prior authorization requirements for traditional Medicare and for Advantage are two completely different animals and don't lend themselves to easy comparison.

Traditional Medicare has only a limited set of services subject to prior authorization requirements:

www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/prior-authorization-and-pre-claim-review-initiatives

There are approximately the same number of people with Advantage plans as traditional Medicare. But in 2023, Advantage plans made almost 50 million prior authorization determinations, while traditional Medicare made just under 400,000. That averages out to 1.8 prior authorization determinations for each Advantage member, and .01 prior authorization requirements for each person with traditional Medicare.

Here's an excellent analysis of prior authorization denial rates, how many are appealed, and how the rate that denials are overturned.

www.kff.org/medicare/nearly-50-million-prior-authorization-requests-were-sent-to-medicare-advantage-insurers-in-2023/

KFF has scads of data on all things Medicare and Medicare Advantage. It's a great resource.

The statistics that point to troubling practices that can affect people's health are that in 2023, only 11.7% of denied Advantage prior authorization determinations were appealed, and that 81.7% of those were overturned. Sure, the Advantage member "won," but how many people are being denied care because they, possibly through ignorance, don't appeal the denial? And every one of these "wins" was associated with a delay in getting the service.

That's why considering an Advantage plan should never be only about the money, or even the networks, but also about the possibility of delayed medically necessary services due to Advantage plans denying prior authorizations requests in such numbers that if you jump through the proper hoops, you have an 80% chance of them admitting they wrongly denied it, at which point you can get the services you should have gotten all along, and hope the delay didn't harm your health.

 

[Cayman]

Why assume that physicians and facilities participating with MA plans will continue to do so? That can change quickly. So ask yourself... do I feel lucky? There are no guarantees your physician or hospital system will continue to participate in MA past their current contracts and there is no guarantee that you will qualify to return to TM once you've left. Who likes those odds?

 

[teejayevans]

Why assume that physicians and facilities participating with MA plans will continue to do so? That can change quickly. So ask yourself... do I feel lucky? There are no guarantees your physician or hospital system will continue to participate in MA past their current contracts and there is no guarantee that you will qualify to return to TM once you've left. Who likes those odds?

Yes, but of course you can switch MA plans during open enrollment with NO medical underwriting, unless they drop ALL MA plans you can just switch, for any reason.
I don’t know any hospital or doctor that only does Medicare. Remember, all the under 65 patients have regular insurance coverage. This assumes you’ve picked a major insurance company (Cigna, Aetna, UHC….) that has personal, business , as well as Medicare.

 

[FD1000]

Pluperfect said There are approximately the same number of people with Advantage plans as traditional Medicare. But in 2023, Advantage plans made almost 50 million prior authorization determinations, while traditional Medicare made just under 400,000. That averages out to 1.8 prior authorization determinations for each Advantage member, and .01 prior authorization requirements for each person with traditional Medicare.

Suppose I want to buy a luxury car. I’m offered ten cars under $30K plus a Lexus LS 500 Heritage Edition, and I’m told they all cost zero/near zero. Which one would I choose? The Lexus, without hesitation. Do I care about the other options? Of course not.
Second scenario: I’m choosing between a Mercedes and a Lexus (think best Advatage options), but my top priority is reliability. Again, I choose the Lexus. The other choices are irrelevant to my decision.
This is a simplified example. Healthcare and vehicles aren’t comparable and vary in far more complex ways, but the point stands.
Healthcare is intentionally complicated. I don’t trust Medicare brokers, and here’s why. A well-known local broker in my county recently moved most of his clients from Aetna to a newcomer called Devoted.
Would I choose Devoted—a company with only a few years of experience and availability in just a handful of states? No.

Did you know how well Medicare brokers are paid?
Medicare Advantage (MA) & Part D (PDP) Commissions (2026):

• National MA: ~$694 initial, ~$347 renewal per member per year
• High-cost states (e.g., CA, NJ): up to ~$864 initial, ~$432 renewal
• National PDP: ~$114 initial, ~$57 renewal per member per year

Medicare Supplement (Medigap) Commissions:

• First year: typically 21–26% of the premium
• Renewals: ongoing commissions, often for at least six years, also percentage-based

How can you fully trust a broker when one plan pays them $400 and another pays $600? I don’t.
That said, there are situations where Medicare Advantage is the only realistic option. For example, a friend’s mother is 92 years old. Her Social Security check is low—but not low enough to qualify for Medicaid. Original Medicare plus Part D would cost her over $500 per month, effectively forcing her into Medicare Advantage.

======

In my case, prior authorizations are required only for the most expensive procedures, and all of mine were approved within a couple of hours. I’m sure many Medicare Advantage plans aren’t nearly as good, but that’s not my concern.

 

[sengsational]

He told me that after decades in the business, the worst out-of-pocket cases he’s seen were in the $2,000–$2,500 range.

LOL! Consider the source.

What stops me from moving 15 miles away to a county that doesn't accept my MA and switch to Original.Medicare?

Admitting that you're thinking about the unicorn becoming a mule.

If one is on a Medicare Advantage plan, then one must also be enrolled in "Original Medicare"--Parts A and B.

A and C, or A and B. I always say we shouldn't call them "Advantage", instead "C" plans, because across all plans of that type, that's the letter grade I'd give them.

Comparing the financial "payout" of Advantage vs. Medigap is certainly warranted, but the two options are not equal otherwise.

Yes. It's interesting to read how the goal posts shift back and forth, depending on the position being defended.

There are approximately the same number of people with Advantage plans as traditional Medicare. But in 2023, Advantage plans made almost 50 million prior authorization determinations, while traditional Medicare made just under 400,000. That averages out to 1.8 prior authorization determinations for each Advantage member, and .01 prior authorization requirements for each person with traditional Medicare.

That says a lot.

If you want to save tons of money while healthy, Part-C is great. Even if you're sick, if you find a plan that hasn't managed to get shut out from your local high quality providers, great! Or at least kind of great, because some idjit will need to approve it. Or if you want internationally recognized treatment providers, you have saved enough, way more, to pay the out of network max out of pocket. But the fact is, you will be in the approval hopper with 50 million other people. In the mean time, the traditional Medicare guy is already in the recovery room.

 

[Pluperfect]

In my case, prior authorizations are required only for the most expensive procedures,

Have you identified what plan you're on, and I missed it? In fact, you mentioned the "top two or three MA options" available. I think it would be helpful for us to see what those plans are. How do you identify the top plans? I've always found comparing Advantage plans to be dizzying.

You've said you're outside Atlanta, but I don't know which direction, and apparently it matters if you could move 15 miles away and your current plan wouldn't be available to you. You could give us a zip code that isn't yours, but has the same plan options. And identify the top ones, and the one you have. I'm wondering if I'd be able to suss out which are the best.

Oh, and I once looked at a friend's Advantage plan documents, and don't remember seeing a list of what procedures are subject to prior authorization. Is there a separate place to find that for each plan?

 

[MichaelB]

A word about prior authorizations. A close family member had an accident and broke his hip. (actually, the femur neck). So, ER, a hemihip replacement. I spoke with the surgeon. She said 5 days in the hospital followed by 4-6 weeks in rehab in a SNF. Then she said “good luck with his insurance”.

2 days later the insurer said no more hospital. Thy gave me 5 hours to find a SNF, which I did. Insurance said transportation was his responsibility.

The preauthorization was open-ended, so no end date. 4 days later, on a friday at 4 PM, they said more more, with immediate effect. The SNF social worker explained the appeal process, gave me a phone number number, and said “good luck”. The person with the broken hip lives on the 3rd floor of a building with no elevator. In other words, unable to walk, no chance of using stairs, so nowhere to go.

She said a couple of other things. The late friday denial was normal, because it was more difficult to get the appeal approved on weekends becasue they were understaffed. She also said the appeal window was 3 days, and the friday counted as a full day even though it happened at the end of the work day, Coldly calculated.

If the appeal was denied we could submit a second appeal. But, this process took 10-14 days, and if unsuccessful, the patient was responsible for the entire cost of the SNF over the appeal process. ($685 per day).

The appeal was approved, again no end date. The following friday it was once again denied. We followed the same process. It was approved Sunday, and denied again on Wednesday.

In total it was denied 5 times, and under appeal reapproved 4 times, all over a period of 3 1/2 weeks, and despite the surgeon ordering rehab for 4-6 weeks.

There’s more, as the whole scenario played out the same for physical therapy and in-home care aid to help him walk up and down stairs. The insurer simply refused to authorize even though these are automatic Medicare approved services. There were no in-network providers in the service area and the insurer refused to make an exception.

A week after he got home the SNF called me to say we owed 12 days of the stay. Even though each appeal win was confirmed in writing and I have copies of the letters, the last 2 were revoked retroactively. I filed a complaint against the insurer and the SNF with the state insurance regulator and Attorney General office. They stopped calling me about 10 days ago, so my guess (or hope) is between them they’ll sort it out.

It’s difficult to describe the stress we experienced over that month, but I can easily see people just giving up and accepting.

i think it’s great that there are some MA plans out there that work well and are affordable. There were none for me, nor are there any for any of my siblings, friends, relatives, or even acquaintances.

Congratulations to FD100 and anyone else with this type of health care insurance option. They should take advantage of it, but also understand it’s like a winning a lottery ticket. It can happen for a fortunate few, but not the rest. When we buy the lotto ticket we all have hope, but only a few win.

 

[Calico]

@MichaelB

What an absolute nightmare for you and your family member. They are fortunate to have you in their corner fighting for them.

 

[MichaelB]

@MichaelB

What an absolute nightmare for you and your family member. They are fortunate to have you in their corner fighting for them.

Thanks for the kind and mostly undeserved words.

 

[Teacher Terry]

Michael B your relative is indeed lucky to have you! It takes so much energy and perseverance to fight insurance companies. 60 Minutes actually did a program on this last year citing difficulties like yours, and one of them led to the person‘s death because he was being denied care.