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

[RetiredAt55.5]

My OP was clear: stay with the best 5% of MA. In my case, never an HMO = limited.
I can see any doctor, including specialists, directly in/out of network for just $20. Several other MA I like can also see most/all doctors they like directly because most are in their PPO. These plans are inferior to mine because out of network, you will pay a certain percentage. I was on one my first year, but all my doctors were within the network.
So again, several big metros have great MA that cover many doctors. If you checked and they don't, select OM.
These metros likely will continue to have that.

IMO, there is no way more people will switch to MA, which has already happened, and they will get worse every year, while OM will stay great and premiums will stay the same. At some point, after lots of complaints, they may change the system and kick out the bad apples.

Maybe it's not the same, but someone who looks for a great, reliable vehicle starts at Toyota. Do I care about the bottom 5? No. I never looked at the bottom 5. The key is to educate yourself.

To be honest, IF I had the option of switching from a MA plan back to a OM plan each open season, without having to pass underwriting, I'd be much more comfortable going with a MA plan. I'm not talking about just during the first year, but anytime during the next 20-30 years.

I'm just not willing to bet that even if I find a great MA plan in my area, that I can count on that plan being available and maintaining the same rules and benefits for the next 20-30 years, or that there will be other great plans available in my area if something happens to the first one.

Historically, the CMS has added and closed OM plans, but the rules and benefits for each plan tend to be fixed from what I've read. The same can't be said for MA plans.

But that's just me. I do tend to be overly cautious at times, and I'm a "the glass is half empty" guy, so I'm always looking out for the worst case scenarios.

 

[sengsational]

Not sure about who he contracts with, but he is in a small specialty group... 4 Drs total... I think my big problem is I am a new patient...

Ok, that doesn't sound like a corporate owned monstrosity. There are two huge corporations in my geography that bought up practically every practice. I guess the corporations make really lucrative offers, and the doctors get to step away from the forms, compliance, and money side of things. I wonder if they restrict admitting privileges to the hospital unless you join. I don't really know the details, I just see very few that aren't sitting under one of those two corporate logos.

 

[RetMD21]

My OP was clear: stay with the best 5% of MA. In my case, never an HMO = limited.
I can see any doctor, including specialists, directly in/out of network for just $20. Several other MA I like can also see most/all doctors they like directly because most are in their PPO. These plans are inferior to mine because out of network, you will pay a certain percentage. I was on one my first year, but all my doctors were within the network.
So again, several big metros have great MA that cover many doctors. If you checked and they don't, select OM.
These metros likely will continue to have that.

Right, you have a plan with good out of network access and you haven't had any serious health problems. Many practices will limit the MA they accept the a list. Mayo clinic was doing this. I don't think they care if your plan says it will pay. You aren't personally facing care limits or prior approval problems. You have accepted that an insurance company may impose limits that aren't inherent to Medicare. Not everyone likes that idea. Many people will be fine with MA but there are circumstances where traditional is better.

Why are you seeing the approval of strangers for your choice?

 

[Texas Proud]

Ok, that doesn't sound like a corporate owned monstrosity. There are two huge corporations in my geography that bought up practically every practice. I guess the corporations make really lucrative offers, and the doctors get to step away from the forms, compliance, and money side of things. I wonder if they restrict admitting privileges to the hospital unless you join. I don't really know the details, I just see very few that aren't sitting under one of those two corporate logos.

Oh yea... almost all my other Drs are under a corp structure... or at least it appears that was as they fall under St. Lukes or Methodists....

 

[Tracer]

I'm 76 and have been on Humana Gold since 65. It has worked for me. Referrals and Pre-approvals are a hassle but I have never been turned down for anything. I haven't calculated the savings over the years but it has to be in the 10's of thousands. Free gym membership, free OTC stuff that I normally would buy, almost all prescriptions I've gotten have been free or very low cost, Maximum $1250 annually out of pocket, free annual eye exam and glasses, free hearing tests, free chiropractic adjustments, free Urgent Care visits, included dental insurance, it all adds up. Just this month they paid $5000 for a dental bridge I needed to replace. Free hospital stays, Last year I had my gall bladder removed. Cost $0. Both primary and specialist are $0 copay. I see my PCP every 3 months for exam and blood tests. I see my urologist twice per year and my foot doctor every 2 months. No cost for either. Except for what they take from my SS, Premiums to Humana are $0. Their network of primary doctors and specialist in my area is very large. It seems to depend where you live whether these plans are more beneficial.

 

[Teacher Terry]

Two months ago, my GP made referrals within the medical system that she is a part of for me to see a cardiologist and a pulmonologist. When I talked to the scheduling person, both of those type of doctors were booked out for 6.5 months.

That type of wait when you’re experiencing shortness of breath is ridiculous. So I did my own research and then texted my doctor and told her I did not have to stay within that medical system and had found two providers that could get me an appointment within 2.5 months.

Even though my insurance doesn’t require a referral, the specialists won’t see you without one. Luckily my GP was fine with sending a referral to both of them. This is why I pay for a regular Medicare and a supplement, even though it’s pricey and goes up every year.

 

[FD1000]

Right, you have a plan with good out of network access and you haven't had any serious health problems. Many practices will limit the MA they accept the a list. Mayo clinic was doing this. I don't think they care if your plan says it will pay. You aren't personally facing care limits or prior approval problems. You have accepted that an insurance company may impose limits that aren't inherent to Medicare. Not everyone likes that idea. Many people will be fine with MA but there are circumstances where traditional is better.

Why are you seeing the approval of strangers for your choice?

I don't need any approval, and I'm not trying to convince anyone. But I also don't agree that OM is always better. All I'm saying is do your research.
In my case, saving $6K annually is enough to take the risk while my moop is $6700..

This is not the only time I have looked at insurance. LTC is another example of why I don't have it. The premiums are too expensive. They are all invested and have already made much more.

 

[RetiredHappy]

When we had Kaiser, they only subcontracted with the worst Skilled Nursing/Rehab Facilities in the area and patients didn't have the option of picking better SNF/Rehab Facilities. I was in the elder care industry and got direct feedback from hospital discharge planners. That itself is enough for me to not want to be on MA plans.

 

[zaqxsw]

You do not know your health care needs until they happen. You can be healthy and active today and tomorrow you can get into a whole different situation or diagnosis.

If you have the money, insure for the max you can afford. That insurance needs to be without corporate interference. It's your life.

This not an expenditure to cheap out on in your senior years.

 

[teejayevans]

Not all advantage plans are HMOs that require approvals, some are PPOs which generally don’t. For those with substantial HSA balances, they can use it to pay the copayments. You can goto YouTube and see videos of breakdowns of what different options will cost you, here’s a good one:

Advantage is less money unless you have chronic health problems. But other factors are whether there is a good health network, travel coverage, etc.

 

[Dranoel]

OM + a Plan G supplement is undoubtedly the best insurance. And I'd say it's the best choice if you can afford it and especially if you want to avoid billing hassles.



It's not surgeries that cause people to hit the OOP max on Advantage plans--it's cancer. In a lot of Advantage plans, cancer treatment is covered by the member paying 20% coinsurance instead of a copay. Those people can meet their max OOP with a quickness.

The benefit summary you posted doesn't address cancer treatment (chemotherapy/radiation), and maybe it depends on whether it's inpatient or outpatient or maybe under the prescription drug coverage. I'm blessedly ignorant on how cancer treatment is billed.

But I have a friend whose husband was on an Advantage plan, much to her chagrin because they're rich. He had cancer and he hit his OOP max every year, paying more than what OM + supplement would have cost.

That's why it's important to know exactly how cancer treatment is covered under an Advantage plan.



In every state you can switch from Advantage to Original Medicare during the Medicare open enrollment period at the end of the year and during the Advantage open enrollment period at the beginning of the year.

What you might not be able to do is buy a supplement to cover the 20% OM doesn't cover--that will depend on your state and your health status.

I had a Humana Advantage plan in Florida. I was happy with the plan and it's premium savings until I got cancer and began hitting the Max OOP for the last two years. That killed the savings big time. We recently moved to Delaware and, using the Guaranteed Issue rule (no underwriting), I switched to OM and supplemental Plan F. The premium is hefty but, nowhere near the OOP with Advantage. I have the added benefit of seeing any doc that accepts OM - not the case with most Advantage plans.

 

[Dranoel]

That was less than crystal clear, but I did some more reading and I came away with my suspicion confirmed: moving to somewhere where your current Part C does not operate triggers a "Special Enrollment Period", at which point, you can choose traditional Medicare. You have guaranteed issue rights for up to 63 days after your old policy ends. BUT you don't get to buy the most comprehensive Medigap plans under this guaranteed issue scenario. Specifically, you can't get G or N plans as a guaranteed issue. You can get L, covering 75% of what Part B doesn't pay, or K, covering 50% of what Part B doesn't pay. Those have max out of pocket, so you still are protected from really bad financial outcomes, but not protected as well as G or N.

On moving to Delaware in April, I got UHC Plan F

 

[VanWinkle]

There is "treatment" and then there is finding the best surgeon or practitioner in the field of medicine you need the specialized care from. Don't think that anyone on the doctor "list" is the same as the next guy!

My BIL needed a heart transplant at age 74 and I doubt very much if an MA plan would have authorized that at his age. Good thing he had traditional Medicare with a Sup plan. He got the best surgeons in Houston to do the transplant and is doing well 9 years later.

Again, are you 100% sure an MA would not have covered the heart transplant? There is no proof of your claim unless you can supply the proof.

 

[VanWinkle]

I had a Humana Advantage plan in Florida. I was happy with the plan and it's premium savings until I got cancer and began hitting the Max OOP for the last two years. That killed the savings big time. We recently moved to Delaware and, using the Guaranteed Issue rule (no underwriting), I switched to OM and supplemental Plan F. The premium is hefty but, nowhere near the OOP with Advantage. I have the added benefit of seeing any doc that accepts OM - not the case with most Advantage plans.

Curious what the Max OOP was for your MA plan?

 

[RetMD21]

Not all advantage plans are HMOs that require approvals, some are PPOs which generally don’t. For those with substantial HSA balances, they can use it to pay the copayments. You can goto YouTube and see videos of breakdowns of what different options will cost you, here’s a good one:

MA can potentially save you money but as your video indicates there are prior approval issues. This is different than something like getting an approval for a specialist visit.

..... But I also don't agree that OM is always better. All I'm saying is do your research.
In my case, saving $6K annually is enough to take the risk while my moop is $6700......

Did someone say that OM is always better?

 

[RetiredHappy]

MA can potentially save you money but as your video indicates there are prior approval issues. This is different than something like getting an approval for a specialist visit.

Did someone say that OM is always better?

I don't think we should compred OM with MA. We need to compare OM plus a Medigap plan with MA. In my books, OM plus Medigap always wins...

 

[VanWinkle]

MA can potentially save you money but as your video indicates there are prior approval issues. This is different than something like getting an approval for a specialist visit.

Did someone say that OM is always better?

see the post above mine. OM plus medigap is always better even if the expense and treatment are ignored.

 

[Pluperfect]

I had a Humana Advantage plan in Florida. I was happy with the plan and it's premium savings until I got cancer and began hitting the Max OOP for the last two years. That killed the savings big time.

Yeah, that's what happened to my friend who had colon cancer for several years. Every year he paid more than he would have with Original Medicare plus a supplement. And he was rich--he could definitely afford Original Medicare plus a supplement.

I've never found out how he got on an Advantage plan in the first place; all I know is his wife would disparage his "crappy" Advantage plan and when her turn came, she jumped on Original Medicare plus a supplement.

A supplement from Mutual of Omaha (on the advice of her financial advisor). Maybe they'll close the book on her plan and maybe they won't, but fortunately it doesn't matter because she's rich.

I'm just curious--did you know when you picked your Advantage plan that cancer was covered differently, and would likely hit the maximum OOP? That information seems not very obvious in the plan documents I've looked at.

I switched to OM and supplemental Plan F.

What led you to choose Plan F over, say, Plan G?

I have a friend in Plan F whose premiums are going up and up, and he would save money by switching to Plan G, even if he has to pay his own Part B deductible. But he can't pass underwriting.

 

[Dranoel]

Curious what the Max OOP was for your MA plan?

I think it was $8,500

 

[Z3Dreamer]

OP (FD 1000), I wish to applaud you for starting this thread. You did your research and presented it well. You also put in a number of caveats such as "only in some zip codes", "not for everyone" and "only the top MA plans". You have also responded in a respectful way to those who disagree.

When I read your original thread, it looked exactly like something I could have written. I am in my fourth year on MA. I see the best doctors in town. No problems with pre-approval. I take advantage of all those extra benefits -gym, glasses, hearing aids, OTC money, dental and rewards. I have a PPO, so when I am snow birding, I can easily find in-network care.

I realize some would rather pay extra and not manage their care. That is fine. I am comfortable reading the fine print and following the rules. I understand that my having many years in risk management is not the normal thing.

 

[Tracer]

OP (FD 1000), I wish to applaud you for starting this thread. You did your research and presented it well. You also put in a number of caveats such as "only in some zip codes", "not for everyone" and "only the top MA plans". You have also responded in a respectful way to those who disagree.

When I read your original thread, it looked exactly like something I could have written. I am in my fourth year on MA. I see the best doctors in town. No problems with pre-approval. I take advantage of all those extra benefits -gym, glasses, hearing aids, OTC money, dental and rewards. I have a PPO, so when I am snow birding, I can easily find in-network care.

I realize some would rather pay extra and not manage their care. That is fine. I am comfortable reading the fine print and following the rules. I understand that my having many years in risk management is not the normal thing.

I second your analysis of the OP's post.

Location, location, location... It's a huge factor. So yea, not an 'advantage' for everyone.

Something that I don't believe has been addressed... My particular MA goes above and beyond in offering ways to KEEP YOU HEALTHY such as incentives (free gift cards) to get screenings, free gym membership, etc. They have a financial incentive to keep you from getting sick and staying out of the hospital.

I'm on my 12th year of an MA. I've gotten quality medical care from top doctors and facilities and have saved 10's of thousands over that period. My dad was 33 years on an HMO MA before he passed at 98. When it came time for hospice care, he was provided with a hospital bed, wheelchair, walker and 2 hospice nurses who were amazing.

MA's are not for everyone. If you live in the wrong area or your choices of MA's where you live are not the best, you're probably better off staying clear of them.

 

[RetiredHappy]

I second your analysis of the OP's post.

Location, location, location... It's a huge factor. So yea, not an 'advantage' for everyone.

Something that I don't believe has been addressed... My particular MA goes above and beyond in offering ways to KEEP YOU HEALTHY such as incentives (free gift cards) to get screenings, free gym membership, etc. They have a financial incentive to keep you from getting sick and staying out of the hospital.

I'm on my 12th year of an MA. I've gotten quality medical care from top doctors and facilities and have saved 10's of thousands over that period. My dad was 33 years on an HMO MA before he passed at 98. When it came time for hospice care, he was provided with a hospital bed, wheelchair, walker and 2 hospice nurses who were amazing.

MA's are not for everyone. If you live in the wrong area or your choices of MA's where you live are not the best, you're probably better off staying clear of them.

Hospice care is paid directly by Original Medicare and costs MA insurer $0.

 

[audreyh1]

I realize some would rather pay extra and not manage their care. That is fine. I am comfortable reading the fine print and following the rules. I understand that my having many years in risk management is not the normal thing.

The issue is that at some point you may not be able to read the fine print and switch plans annually.

 

[Z3Dreamer]

The issue is that at some point you may not be able to read the fine print and switch plans annually.

I have a plan for that.

 

[Gotadimple]

I don't get this. Isn't there a MOOP associated even with MA plans?

Flieger

Yes there is. Every insurer sets the MOOP value, it is approved by CMS.