If you have a Medicare Advantage plan........

Ed1937

You might want to read this: https://finance.yahoo.com/news/retirees-may-face-this-hassle-with-medicare-advantage-survey-finds-140959662.html  

Jo C.

What is important to understand is that when one decides to enroll in an Advantage Plan instead of open Medicare, it is important to realize that MANY different independent medical group entities are contracted to the specific insurance companies that offer Advantage Plans; there is not one single insurance coverage alone.  A person when enrolling must pick which MD group contracted to the large insurance company they will be assigned to and that is the only group one will receive services from within their "plan."   Any specialists needed will require the patient to see only those specialists who have a contract with the MD group one is assigned to. One can go to someone outside the group, but then that care is not covered and must be the responsibility of the patient.  The MD Group will also have a contracted hospital which will be the "in plan" hospital for their enrolled patients.

So; if one has SCAN, United Health Care Advantage Plan, Humana, Aetna, Cigna, and ALL others, those insurance companies are only an umbrella, so to speak.

Under that umbrella are a plethora of many different physician contracted groups to  provide that care AND one is not the same as the other and some are far more patient oriented and beneficent re their patients than are others.

Those contracted physician groups are NOT in it to lose money; they are profit making businesses. Basically; the way it more or less works, they get paid so many dollars per month for each person signed on in their group as a patient in their practice.  Out of this, the costs of patient care must come. So; if a person has a lot of needs and hospital admission is necessary, then the payment comes out of that physician group's money . . . IF there are many high risk, high cost patients, the group can actually take a hit and some can even lose money, but they are very careful and intense utilization review is important to the groups. This is why they are so concentrated on keeping the number of "bed days" in a hospital low; this is why the smart groups work at preventive care; this is why so many have strict prior approval mandates for certain care, certain tests and certain needs such as DME, Home Health, and necessity to see a consultant, etc.  Also, in many if not most of these, at the end of the year, those MDs including consultants contracted to the group receive bonus incentives for having performed well and met numbers for having held down costs; those MDs who did not do well on that front of holding down costs are not gifted.

It is amazing how the groups will contract with gyms (the MD group gets very low rates with them); this is part of trying to keep members healthier.  The MD groups will also give more incentive with offering eye glasses and some even dental care, and some now even hearing aides - those are amongst the seductive advertising. One must also realize that these are not the cadillac items; they will be lesser items and limited for frequency in many cases, and as for dentists, one must also go to a contract dentist to get services; it is not going to be an open plan.

NOTE: It is of interest that when an Advantage Plan patient goes on Hospice, the Advantage Plan MD group is NOT reponsible for the cost of that care.  The patient's Hospice costs are absorbed by regular Medicare.

Each MD Advantage Plan Group also has highly varying "Tiers" of costs to the patient for prescription drugs - and that can change within any month during the year.  Certain drugs can be moved from one Tier to another. 

Just a little bit of input.

J.

gampiano

To think that aging , and sometimes ill seniors have to navigate through this BS  is disgusting.

What a mess .

Jo C.

From Medicare FAQs:

"How Much Does the Government Pay Medicare Advantage Plans?

The federal government pays out over $1,000 each month for each enrollment for every individual. $1,000 is a substantial amount when considering the number of enrollees they see, and bonus payments received through the bonus system.

Sometimes the Medicare Advantage plan will get over $9,000 from the government to handle the claims of a “high risk” patient. High risk can include patients with heart disease, diabetes, or other chronic condition. "

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Quilting brings calm

These types of things are the reasons why my spouse and I moved him from my retiree insurance to straight Medicare plus a prescription plan plus a supplement.  My retiree insurance turns into a Medicare Advantage plan when I turn 65 later this year  I agonized about it and even felt like I made a mistake when the prescriptions costs hit home.  Dexcom sensors/ transmitters aren’t covered by Medicare unless you take insulin several times a day. (That’s expected to change later to once a day  this year).  

I talked to several people in the medical field along with reading various things and we just didn’t want to deal with all the Medicare Advantage headaches. My spouse has a lot of medical issues and I anticipate increased complications as he ages.  In addition my retiree coverage eligibility is because I’m a state worker retiree.  Health insurance contracts are negotiated by the state change every few years and retirees have no control over any of it. There is only one retiree plan offered.   Every year we see articles where large medical clinics and or hospitals drop out of the state insurance plan network.   

Now, bringing  this back to my PWD.  My mom is on straight Medicare, and there hasn’t been a glitch in her coverage since I started dealing with her stuff over 3 years ago. A month long rehab was covered at 100%.   My step-dads retiree coverage was unilaterally changed from a Medicare supplement to a Medicare Advantage a couple years ago.  It’s a group plan overseen  by a large blue collar union. At the time, I didn’t know enough to make any decisions - plus I don’t have his financial power of attorney. He wouldn’t  tolerate me making any changes anyway.   So far there have been no hiccups - but you never know.   We’ve not needed to have him sent to rehab yet to find out 

Victoria - my thoughts are that the Medicare part D plans should be changed from private insurance companies to being handled like the part A and B coverage,  in other words, prescriptions claims  paid  by Medicare with premiums going directly  to Medicare.   There should not be all this variation of prescription coverage.  Even the Medicare supplements are all the same for a plan ( part G for example) regardless of who you buy it through- but part D isn’t. 

Ed1937

I've been on Medicare for 20 years. We had an Advantage plan for one year, and dropped it as soon as we could. No problems with Medicare. Someone had an article recently about Medicare Advantage plans being anything but an advantage. I didn't read it because I don't have one.

harshedbuzz

I feel like it's as hard to make generalizations around MAPs as it is any other insurance plan.

My mom's teacher retiree coverage switched to a MAP 2 years ago. I was not happy about this. And yet, I have seen zero difference in the quality or administration of her care.

FTR, she is 85 and has various medical issues-- she has 11 doctors we've seen in the last year and an additional 6 we've seen in the last 5 who are now on an "as needed" basis. She's had a hospitalization for pneumonia with bronchoscopy, 2 MOHS procedures, ambulatory surgery for a lipoma near her ear and TAVR since the change and it has been seamless. Her particular plan has picked up any medication her doctor's prescribe including 2 newer meds (Trelegy and Trintellix). 

My husband and I got switch to one this year. So far DH had to get a pre-authorization for a CT scan which stressed him out. It was done and dusted in a couple of hours.

HB

Bob in LW

I have had a Medicare Advantage plan with Kaiser Permanente for nearly 20 years and am quite pleased with it.  Kaiser is not an insurance company.  They are a medical provider with their own hospitals, medical offices, doctors and pharmacies.  One good thing about Kaiser is that all medical decisions are made by doctors, not someone at an insurance company.  They are also proactive in keeping their members healthy.

Joydean

Dh and I have been on Medicare for 10 years and have had no problems. Several of our friends did try advantage plans and hated it, and switched back. My dh mainly uses the VA.

Callie in Boston

A couple of other things to consider with MAP (we are both on them).

Because they are paid more when you are more sick, they call us constantly for FREE home visits from a diff company.  I read up on this and it is because this company (Optum) specializes in "upcoding" you to more serious health issues so the MAP can be paid more.  This is because our doctors are "coding" us correctly.  They call my husband weekly, me less often.  

Also, if you need to take an expensive drug (I do), the pharma companies often consider MAPs to be "private insurance" so you cannot ever qualify for discounted medication, no matter how much it costs, or how much income you have.  If I was on straight medicare, I would have qualified.

I wanted to change this year, but I had a hard time getting my PCP and did not want to change and risk that.  I may change next year.

There are good things though.  Things that are not covered by medicare are sometimes covered by MAPs.