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

[TickTock]

MIchaelB,

Was the family member's insurance Medicare Advantage, Traditional Medicare, or something else?

 

[FD1000]

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.

First, what you have done was incredible.
Second, just because most counties don't have great options, it doesn't mean ALL don't. I have been saying this for months and why this thread started.
Third, it's far from winning the lottery based on my experience and hundreds of others.

 

[jimbee]

MichaelB is always a class act. Your relative is fortunate to have you.

 

[RetMD21]

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.

Exactly, the fact that you haven't had a PA denial doesn't mean that it doesn't happen to others or that it can't happen to you. Generally people aren't aware of how physicians may alter recommendations based on their knowledge about prior approvals.

The fact that a MA plan will allow out of network care doesn't matter much if the physician or hospital won't accept it. For them it is partly about the reimbursement and partly the PA process itself.

Undoubtedly most people can save with MA if they are relatively healthy. They may not may not be able to switch later depending on circumstances.

My observation is that people don't necesarily retain the ability to re-shop their MA plans when circumstances or plans change.

MIL's "unicorn" MA plan denied extension of her post hospital rehab. As others has pointed out you can appeal but it you lose you pay a lot and if you win they can deny again the next week. She never really recovered fully from her hip surgery.

Some people do great with MA and never have a problem. I'm not willing to take a chance and I can easily afford traditional Medicare. If I end up on some expensive medication and can't find a part D plan that covers it I might change.

 

[FD1000]

Exactly, the fact that you haven't had a PA denial doesn't mean that it doesn't happen to others or that it can't happen to you. Generally people aren't aware of how physicians may alter recommendations based on their knowledge about prior approvals.

The fact that a MA plan will allow out of network care doesn't matter much if the physician or hospital won't accept it. For them it is partly about the reimbursement and partly the PA process itself.

Let me repeat. MA depends on your county.

RetMD21; Undoubtedly most people can save with MA if they are relatively healthy. They may not may not be able to switch later depending on circumstances.

I already posted about the 2 possibilities you can

My observation is that people don't necesarily retain the ability to re-shop their MA plans when circumstances or plans change.

I'm not others

MIL's "unicorn" MA plan denied extension of her post hospital rehab. As others has pointed out you can appeal but it you lose you pay a lot and if you win they can deny again the next week. She never really recovered fully from her hip surgery.

I know hundreds that didn't have this problem. Let me repeat. MA depends on your county.

Some people do great with MA and never have a problem. I'm not willing to take a chance and I can easily afford traditional Medicare. If I end up on some expensive medication and can't find a part D plan that covers it I might change.

I have plenty of money, but I think I made the right choice based on my research.
What? You may change?

Do you buy the highest insurance for any possible bad outcome? I don't
Do you have the highest or even a small LTC + life insurance? I don't. If you have one, why?

 

[MichaelB]

MIchaelB,

Was the family member's insurance Medicare Advantage, Traditional Medicare, or something else?

His was a Medicare Advantage plan. During the recent open enrollment we changed to a different plan.

 

[RetMD21]

FD1000 I think you still don't understand the issue. Your MA hasn't denied care but it can. My Mil's state retiree employer based MA shortchanged her on rehab. Didn't depend on the couunty. Teacher Terry's friend with the brain tumor would have died with MA. Didn't depend on the county. Getting out of network care is a gamble. I hope something like this doesn't happen to you but it's fine to take a risk to save money. Harder to understand for men if money isn't a problem but different strokes for different folks.

I don't really care if you want to roll the dice about optimizing your MA plans if you have decline in cognition with age. I have seen it happen. I hope you are lucky.

You are saving money with MA and doing fine as are dozens of people you know. You don't understand or don't care about the risks. That's fine. I think you are being cheap but that's fine with me. You seem to have a need for approval that I don't understand.

 

[TrvlBug]

Last night's news had a segment on a retired firefighter with terminal cancer who's insurance carrier denied coverage for any sort of treatment. Wife went 'public' and it was discovered that 2 other retired firefighters were in the same situation. The insurer was BCBS Medicare ADVANTAGE. The segment included the San Francisco mayor as well as reps from his union. I assume that the insurance plan was provided through the union and was a good one.

DH and I are both on original Medicare with Plan F for reasons of possible denial of care on Advantage as well as being able to see any doctor anywhere on original Medicare. We sleep well at night.

 

[youbet]

DH and I are both on original Medicare with Plan F for reasons of possible denial of care on Advantage as well as being able to see any doctor anywhere on original Medicare. We sleep well at night.

That's (see bold) slowly becoming an issue and you need to manage it or at least understand it and have contingencies if you're moving to a new area or seeking a new doctor. While the vast majority of doctors accept original Medicare (98%) for existing patients, only 89% of doctors are accepting new patients with original Medicare.

 

[Pluperfect]

The fact that a MA plan will allow out of network care doesn't matter much if the physician or hospital won't accept it. For them it is partly about the reimbursement and partly the PA process itself.

I find this aspect of PPO Advantage plans intriguing, and rarely discussed.

It seems to me that if a provider wanted to work with a given insurance plan, it would choose to do so. And if it chooses not to, there must be a reason, and if I were a provider, I wouldn't be too happy about being forced to participate in the plan by one-off people who are using the plan's out-of-network provision.

But as I said, people don't talk about much, so I don't really understand how it works. Surely providers can refuse to take on a patient who doesn't have insurance the provider is willing to work with. Just from a billing angle alone, but you also have the possible prior authorization issues, with an insurer the provider has no relationship with.

I wonder if the "you can see any provider that takes Medicare" is one of those things that's great in theory, and definitely sounds great, but in actuality might not work like one would be led to believe.

Then again, they're cancelling a lot of these Advantage PPO plans, so maybe lots of providers were accepting them as out-of-network providers, and dealing with insurance companies they don't actually contract with, and it's hurting the plans' bottom line.

 

[TrvlBug]

That's (see bold) slowly becoming an issue and you need to manage it or at least understand it and have contingencies if you're moving to a new area or seeking a new doctor. While the vast majority of doctors accept original Medicare (98%) for existing patients, only 89% of doctors are accepting new patients with original Medicare.

Yes, I do understand the limitations...there always are some!

 

[teejayevans]

I’ve had PPO plans for 40 years, never had a problem with multiple surgeries, cancer.
But I’ve always gone to bigger facilities, the ones with a back office of PAs, receptionist, and etc. Normally patients don’t need to do anything, it’s the provider who does all the paperwork, and having dedicated staff to do it, so it’s done correctly, all the right boxes are checked and the wrong ones aren’t. If they don’t take an insurance policy it’s because they’re hard to work with, and a doctor won’t put up with them. A insurance company with no customers is not going to be good for the company.

I know a friend who had stage 4 pancreatic cancer, they gave him 6-12 months with basically no treatment, and 12-18 with very expensive treatments, he chose the latter and lasted about 10 months. Complete waste of money and I don’t know if they ever got the insurance company to pay for it. Do you blame the insurance company for not wanting to pay?

Devil is in the details, I would need to know more about these MA cases, why they were refused, did they appeal, what was the prognosis, do the doctors still take insurance, and if they’re still are, why?

 

[CaptTom]

I always say we shouldn't call them "Advantage"

Agreed. Why should we participate in their marketing campaign? My doctor calls them "Disadvatage" plans.

Another one I won't repeat marketing BS for is vinyl plank flooring. There's absolutely nothing "luxurious" about it, so stop calling it "LVP."

Any time someone is trying to sell you something, assume using this kind of hyperbole is deliberately misleading.

 

[FD1000]

FD1000 I think you still don't understand the issue. Your MA hasn't denied care but it can. My Mil's state retiree employer based MA shortchanged her on rehab. Didn't depend on the couunty. Teacher Terry's friend with the brain tumor would have died with MA. Didn't depend on the county. Getting out of network care is a gamble. I hope something like this doesn't happen to you but it's fine to take a risk to save money. Harder to understand for men if money isn't a problem but different strokes for different folks.

I don't really care if you want to roll the dice about optimizing your MA plans if you have decline in cognition with age. I have seen it happen. I hope you are lucky.

You are saving money with MA and doing fine as are dozens of people you know. You don't understand or don't care about the risks. That's fine. I think you are being cheap but that's fine with me. You seem to have a need for approval that I don't understand.

I do understand it, but you chose not to accept it based on your own experience.
Mine has been different.
If you’ve followed my posts, you know I don’t roll the dice , I never have.
I don’t need anyone’s approval. I was simply responding to the same narrative I’ve been reading for years.
I started this thread for anyone interested in learning about MA. From the very first post, I made it clear that Original is the best choice for most people, while MA may be a good option for some.

Read teejayevans, just 2 posts above.

 

[Flieger]

I do understand it, but you chose not to accept it based on your own experience.
Mine has been different.
If you’ve followed my posts, you know I don’t roll the dice , I never have.
I don’t need anyone’s approval. I was simply responding to the same narrative I’ve been reading for years.
I started this thread for anyone interested in learning about MA. From the very first post, I made it clear that Original is the best choice for most people, while MA may be a good option for some.

Read teejayevans, just 2 posts above.

While I have yet to make a decision (and still have a good bit of time) I appreciate your thread. There are plenty of threads warning of the pitfalls that a lot of these posts can be put in. I read the thread title as for those that have had good experience to opine. I think some just can't help but impart their "overwhelming intelligence" to those less fortunate in IQ.

Flieger

 

[ShadowBloom]

The fact that a MA plan will allow out of network care doesn't matter much if the physician or hospital won't accept it. For them it is partly about the reimbursement and partly the PA process itself.

Are you able to pay the doctor directly and then submit a claim yourself for reimbursement? The doctor just produces some paperwork with the codes insurance needs for the patient to upload to the insurance company. That's what I've done with my current (non-Medicare) plan when seeing someone out of network.

 

[Turbo29]

Agreed. Why should we participate in their marketing campaign? My doctor calls them "Disadvatage" plans.

Another one I won't repeat marketing BS for is vinyl plank flooring. There's absolutely nothing "luxurious" about it, so stop calling it "LVP."

Any time someone is trying to sell you something, assume using this kind of hyperbole is deliberately misleading.

It is called "Medicare Advantage" in the Code of Federal Regulations, 42 CFR Part 422. (Of course, getting that name into the CFRs might have been helped along by some lobbying.)

 

[FD1000]

Are you able to pay the doctor directly and then submit a claim yourself for reimbursement? The doctor just produces some paperwork with the codes insurance needs for the patient to upload to the insurance company. That's what I've done with my current (non-Medicare) plan when seeing someone out of network.

I saw a doctor out of network and did nothing special.
I called his office directly. The one who scheduled the appointment asked for my insurance and verified my insurance. I saw the specialist and his back office did the rest.
The above is what I have done for decades before Medicare, on my employer private insurance.

 

[Ian S]

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.

Wait a minute, don't Part D plans have an annual maximum out of pocket of $2000? Why are we talking $91K a year for Humira?

 

[RetiredHappy]

Wait a minute, don't Part D plans have an annual maximum out of pocket of $2000? Why are we talking $91K a year for Humira?

The issue with Medicare is that many of the biologics like Humira are not covered, so they don't fall under the $2K maximum. Same thing with biologics like Skyrizi. Many of these pharmaceuticals have a "charity" program for those who meet the income criteria and they will cover for free.