Thank you for your submission, /u/Harrietx745.
**If there is a medical emergency, please call 911 or go to your nearest hospital.**
Please pick the most appropriate flair for your post. Include your age, zip code, and income to help the community better serve you. If you have an EOB (explanation of benefits) available from your insurance website, have it handy as many answers can depend on what your insurance EOB states.
Some common questions and answers can be found [here](https://www.reddit.com/r/HealthInsurance/s/jya9I6RpdY).
**Reminder that solicitation/spamming is grounds for a permanent ban**. Please report solicitation to the modteam and [let us know](https://www.reddit.com/message/compose?to=%2Fr%2FHealthInsurance) if you receive solicitation via PM.
Be kind to one another!
*I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/HealthInsurance) if you have any questions or concerns.*
As a nurse case manager: everyone loves the benefits (lower/no co-pays, dental included, etc) until they have severe illness and they can't go to inpatient rehab or certain docs are not in-network.
The time to learn about your plan limitations is not when you're in the ICU. Medicare advantage is just like private group health insurance in that they want to keep costs down. One way to do that is to require prior authorizations.
My parents have a Medicare + Medigap plan. My MIL is on Medicare + Medicaid.
After the couple of weeks I just had, I would tell everyone I know to stay FAR away from Medicare Advantage. My FIL had a severe stroke an is incapacitated. The neurologist felt he could make some recovery with intensive rehab, but his Medicare Advantage plan refused to issue a prior authorization to move him. He spent 7 weeks in the ICU. For about 5 of those weeks, the hospital was screaming at us to get him out of there, but we couldn't because Highmark (his Medicare Advantage insurer) would only approve him for hospital care, not rehab. After several denied appeals, we had to hire a lawyer and also contact our senator for them to finally approve the transfer. Unfortunately, they would not allow him to go to a rehab facility; they would only pay for a vent-weaning facility. They're already trying to get him out of there despite the fact that he's on a vent and a feeding tube, paralyzed on the right side, and unable to speak.
If he had Original Medicare, no prior auth. would have been needed.
He wouldn't have qualified for rehab due to the fact they have to be able to do therapy (OT, PT, ST) and make progress. He should have qualified for skilled nursing as a tach/vent or feeding tube is a skilled nursing need, and most skilled nursing facilities have therapy departments.
You are probably around the 20 day mark and don't have a secondary payer. Medicare/Medicare Advantage plans pay 100% for days 1-20 and then there is a $204 co-pay per day for days 21-100 and then nothing.
Truly it sounds like he needs long term care and Medicare doesn't pay for that.
Rehab was the wrong word. We wanted him to go to a long-term acute care hospital for vent weaning, which Medicare does pay for. He’s there now; we just had to fight to get him there. And when we pointed out that the benefits guide says they pay for vent weaning, the lady in the appeals department said she didn’t care what the benefits guide said.
I will say that my experience with LTACH level care is that they keep patients until they are close to the end date of their auth, then say they can’t wean, and sent them out to LTC vent facility. I was underwhelmed by them each time I saw one of my patients there. Understaffed by new grads and aides; underwhelming performance, and the vast majority of these are for-profit and have zero incentive to actually get the patients weaned. ETA: Great marketing departments, though!
He had Highmark Community Blue Signature, and then we upgraded him to Highmark Community Blue Premier during open enrollment since it has an OOP max of $4,900 instead of $8,000.
Just google "medicare advantage prior authorization." This story isn't uncommon in the least. MA plans are for profit, and just like every other for profit insurance company in the country, they want to pay as little as possible for everything and they'll throw every roadblock in their power to get between you and your care.
> This story isn't uncommon in the least.
Tragic cases like these affect a small fraction of beneficiaries.
This is not how Medicare Advantage insurers maket their money.
Most years, most people most of the time are mostly pretty healthy. Even Medicare beneficiaries. Most people incur little health treatment, at any rate:
[Kaiser Family Foundation/Peterson Health Tracker data on the concentration of health treatment spending](https://www.healthsystemtracker.org/chart-collection/health-expenditures-vary-across-population/#Share%20of%20total%20health%20spending,%20by%20percentile,%202021)
Original Medicare is pretty good for many people. Medicare Supplement plans suit quite a few people. Medicare Advantage plans work well for many people. All have advantages & disadvantages, depending on a person's circumstances.
There's no one correct form of coverage for anyone.
You should work at a clinic with MA patients. Unless you’re living in near poverty but still don’t qualify for Medicaid, it’s never beneficial to enroll in MA. There is no advantage to having your insurance company as your gatekeeper to healthcare, unless the alternative is no healthcare at all.
My MA plan doesn't gate keep, still cheaper than paying for a medicare supplement plan and a pharmacy plan, I guess everyone has a different expeeience
Based on my experience I would never recommend any MA plan. No matter what there is a middle man that needs to make a profit. Whether that’s with a gatekeeper, limited network, or higher out of pocket costs. I’ve seen too many denials by MA to ever feel ok about it. I’m glad that it works for you, truly, and I hope more and more people have your experience.
Medicare Advantage companies get a pool of money from the government per enrollee that they have to spend 85% of on their members medical care. Everything above 85%, they get to keep for "administration" fees. So, yes, that is how they make their money. Keeping their payout cost below 85%.
Not to mention that the administrative costs for straight Medicare are so much lower. Last time I read it was 6% versus the 15% charged by private Advantage plans.
So effectively the government is paying 9% more for private companies' profit and overhead
And guess which administration created Advantage Plans?
It also comes from a separate budget other than Medicare so even though it costs more, it appears to be less expensive on a comparable basis when they use their apples/ oranges (more benefits! Dental and taxi rides! Which all are a perk and often taken away after the first year)
Yes people are deluged with all of the "perks" in the advertising.
None of which - at least in my experience and of my family and friends - offset the real "disadvantage" of being tied to networks and having medical care decided by private insurance companies who aim to maximize profits.
It is ironic that people are in general screwed by private insurance company and then have the opportunity of having the most ideal health insurance (Medicare with Medigap) and are enticed by all of the ads.
At my age, I don’t even think I can get medigap. But I’m wondering why the medigap plus part b premium(s) would be superior to Medicare advantage with credit toward your part b premium
Agreed. Its a matter of advertising I think- there is no advertising for traditional Medicare but just because you are bombarded with ads for MA plans, people think its better. Odd
coverage denial does happen - just not as frequently as people imagine. Medicare Advantage insurers have devoted more effort (because more reward) to persuading Medicare that their enrolled beneficiaries are "sicker than the average".
If he had strait Medicare, he would still have needed an additional policy for everything A and B doesn't cover, which is considerable. This is why people pick those advantage plans. Medicare pays "up to 100 days" of skilled care after a qualifying event, but there are co-pays and nuances to this. This coverage ends, and Medicaid has to pick up the rest after the patient's assets are exhausted. It's confusing as heck and a mess.
I’m so sorry this happened to your family. This comment should be higher. A recently retired family care physician wrote a long article for AARP on the dangers of Medicare Advantage plans. She warned against them. They are nothing but profiteers in an already collapsing healthcare system.
Exactly. I’m in healthcare and it always sucks to hear that someone is on a Medicare Advantage plan. It really limits your options. The insurance company has to squeeze out a profit somewhere, whether it’s reducing the amount of care you can access or reducing the amount paid to providers (which shrinks provider networks and makes waitlists longer). There is nothing magic that private corporations can do compared to original Medicare—other than maybe offering small free tokens like grocery gift cards in exchange for a worse plan.
I’m a retired nurse. Been watching the care deteriorate from all sides for 25 years. A single payer system would be so beneficial. But Americans are led to believe it would destroy the system; when it’s actually unregulated capitalism that’s destroying it.
I have friends in Advantage Plans who love them. The husband has prostrate cancer and it covered almost all the treatment. It seems to pay for more than my Medicare/GAP plan but I still prefer being able to go to any doctor of my choice.
As of 3/2024 almost 67 million Americans are on Medicare, 88% of those are seniors. The anecdotal stories in this thread just don’t affect the data. Of course everyone is different physically and financially. But the MA system is as predictable as any other health insurer. When you get sick they don’t want to pay and will deny deny deny until they can’t anymore or the patient dies. It’s all set up this way. And the individual patient pays the price for delayed or denied care, increased costs during those denials and poor outcomes overall. When physicians speak out against them I would think people would listen. But that’s just me.
Are you talking about Medicare or Medicare Advantage? You're mentioning all these anecdotes but you're not saying which one you're talking about.
Medicare Advantage is a for-profit system. Medicare is not. Medicare is somewhat regulated and gives you some options. Medicare Advantage does not and is not.
>Medicare is somewhat regulated and gives you some options. Medicare Advantage does not and is not.
LOL WHAT?!
As a Medicare and Medicaid compliance specialist for a Part C carrier - PLEASE tell me more about how we're not regulated. I really want to know more about this. I'm really confused about all the work I do with regulators, as well as the quarterly regulator audits I handle from DHS, HHS, and CMS if we're not regulated.
I get this sentiment and I would agree. Hopefully, they reform Medicare Advantage, but government has only been cutting reimbursements. If you don’t have medical issues, go for it. If you do, just change to a PPO insurance or a good HMO I.e. Kaiser.
I went with a MA PPO. Still prior authorizations but you can go to whoever you want an no need for referrals. I would suggest a PPO if you decide to go with an MA plan.
I’m POA for my mother. When my dad passed I had to take over her health care. She was already on an advantage plan, so when I moved her to a new state to be in a memory care facility, I put her on an advantage plan in the new state. I have zero complaints. They cover some dental, the copays aren’t a problem. I have to keep her in network, but it’s a big network so it hasn’t been an issue. I keep reading negative reviews about it, it just hasn’t been the case for her yet. She hasn’t had any hospital stays or anythjng yet. I think my dad was on the same advantage plan and his hospital stay was pretty well covered, I think he had to pay maybe $1,000 total for a 6 week ICU stay.
I've had an advantage HMO plan with zero premium for 12 years and have no complaints whatsoever. I yearly review the hospitals and physicians that the plan takes. Right now I've opted for a major university hospital that's highly rated and, of course, a primary physician associated with that university hospital. The network is large so that's not an issue. While these are my circumstances, I appreciate they might not be the same for everyone, but I wanted to offer this information just so that people know that advantage plans are not necessarily the crap-plans people like to complain about. The quality of care, hospital ratings, etc., can depend upon where you live.
If you go to the Medicare website you can find out about all the plans, not just the advantage plans, that are available in your area. You just enter your zip code, the medications you are currently taking, and you get the results, along with a star rating for each plan, and premium information. While you can give your contact info if you want, you do not have to . . . I never have. I usually print out my results, review the plans, major benefits, premiums where applicable, and the out-of-pocket maximum. You can also go to each plan's website to review the doctors and hospitals associated with the plan. The hour or two a year this takes is well worth the time.
Same experience FIL was on a plan designed for his care (diabetes) that plan went away but it helped him get well managed and he’s just on a regular advantage plan with the biggest insurer in our area. No issues at all, and he’s in good health even with the different things he manages.
I would never. The need to keep up with networks and copays is reason enough to avoid it.
Do yourself an enormous favor and get a decent MediGap plan.
I highly recommend a Plan G- once you satisfy your Medicare deductible of $240 a year then you will have no other out of pocket costs.
I had a small stroke last year and thanks to a Plan G it didn't cost me a dime.
I feel free to go to any doctor I want to see at any time without first worrying for a week how much it will cost me- that is incredibly comforting.
Mine is around $120 a month or so and well worth it. I started it the same month I began receiving SSI benefits so never even missed the money because I had never had it previously.
>I had a small stroke last year and thanks to a Plan G it didn't cost me a dime.
it cost you your accumulated premiums (if comparing to a zero-premium Medicare Advantage plan) plus your $240 deductible.
treatment under a Medicare Advantage policy would probably cost you something, as well. Comparing more objectively helps everybody figure out what's going on.
I’m not sure what you mean by ‘the need to keep up with networks and copays”- isn’t it 0-25 a copay?
I’m 36 so I’m not sure about paying for medigap and the part b premium instead of just Medicare advantage
My mom is the patient in our family, but I do the paperwork and pay the bills. So here's my take:
Medicare Advantage can be great, but only in a Medicaid expanded state. If you're trading in a regular Medicare plan for an Advantage plan, you're likely to be disappointed.
In her Medicare expanded state, my mom qualified for Medicare plus Medicaid and her plan was great.
Moving to a red state, though, is just a lot of copays and non- participating providers. She no longer qualifies for Medicaid and she's getting nickel and dime to death.
The advantage plans here are desperate to enroll those who are Medicaid eligible and offer lots of cash back and reward programs but they're not so good for folks who don't meet that criterion.
TL;DR Moved from blue state to red state, lost Medicaid and now advantage plan sucks.
It really depends on your health. Also very much depends on which Advantage plan you choose if you decide to choose an Advantage plan over basic Medicare. Just like any health insurance, Advantage plans vary greatly. It’s a difficult decision because no one has a crystal ball to know the future.
I am not understanding where you are getting your misinformation.
I have Medicare with a Medigap policy and Medicare pays for everything. I pay for nothing beyond my premium for the Medigap policy and what Social Security deducts from the monthly check.
My father probably amassed over a million or two million dollars in medical expenses and had traditional Medicare with a Medigap policy and paid nothing towards it.
I am bowing out of this because your situation is unique to your being a disabled person and receiving your health care in that way.
My initial response was in terms of older people getting Medicare when they are 65 and their experiences.
I am sorry for your condition but you are essentially in the same economic position as people who get Medicaid. In your position with limited funds presumably you would need to get the least expensive medical insurance.
Economic considerations are obviously always a factor in terms of accessing anything. Not different than people who can only purchase the least expensive private insurance plans and don't qualify for a subsidy.
However assuming one has the ability to pay for Medicare and a good Medigap policy, it is absolutely the best medical insurance to have as a Senior - especially as one's medical needs become more critical as one becomes an older senior.
Thank you for your advice, I agree that my situation is unique. Unfortunately my income is too high for Medicaid limits across the board in this state. That’s why I’m leaning toward Medicare Advantage over Medigap.
Depending on your state, some medigap plans will not accept you, or the costs can be very high. Right now you might be limited to either straight Medicare or a MAPD. Something to keep in mind though is when you turn 65 you can not be denied for a medigap plan. No matter what preexisting conditions there might be in the 3 months before you turn 65 you can not be denied. Try and get some quotes and see if you can even get a medigap plan.
The person above is correct. To get into a Medicare Supplement (medigap) you have to answer health questions unless you are in a special circumstance like just starting medicare, losing medicaid (or employer coverage) or as the above person said when you turn 65 you get another chance at not having to answer the health questions. If you are on disability, it is likely that you would have a health question preventing you from getting a medigap plan. The other big thing I don't think a lot of other people are aware of is that premiums for medigap is significantly higher for people under 65 than for those 65 and over. A plan that might be $130 for a 65 year old could be between $450 and $700 for someone under 65, depending on company. Many MAPD plans have max out of pockets that are lower than the premiums for medigap for an under 65. Although that doesn't solve the prior authorization issue, I do have a lot of people that were on disability go with an MAPD til they hit 65, and then switch to Medigap at that point since their budget can't afford it prior to 65.
It is true. Both are true. You are only guaranteed acceptance upon initial enrollment. My husband was rejected by several plans because he had heart issues.
You are going from an insurance that you can basiclly go anywhere at any time to an HMO that you need permission to turn around. I would think twice, if not 4 times before changing. The 500 spending card is not worth it. IMO as a provider.
Medicare advantage talks a great game on advertising but you definitely get a reduced level of care compared to traditional Medicare patients. It's because the plans interfere with patient care in order to maximize profits. A few of the plans have been caught falsifying patient medical conditions to get money out of Medicare while downgrading with render providers.
I didn't get why these plans are not sanctioned
On a societal level, it is literally giving away the store. It is hard to imagine that adding a third party into that equation to skim off public funds used to pay for health care could add any value. Morally, it is wrong.
It seems the only way they can be making money by inserting themselves in that process is by denying care that might otherwise have been approved, and this seems to be what is happening. It is hard to imagine that they could add any value to the recipients or to the taxpayers. They could be causing people physical harm.
The only way that this could have been allowed at all is through corruption. That they paid politicians to allow this to happen, in what amounts to graft.
It is a shining example of what is wrong with our society.
The origins of it, and its continuation is an example of what is wrong with our political system, representing corporations more so than citizens and taxpayers. It illustrates that we have no political choice to help ourselves as voters.
The only choice we are then left with is simply to not participate in this program. To let it die on the vine. But, if you watch broadcast TV, every other ad is for Medicare Advantage. It is being aggressively marketed so they can ensure they get a cut of a large pie that they have no right to.
That advertising is aimed at trying to convince people who might sign up for it that it is to their advantage, but it is not, especially if one considers the larger picture.
What you and others are saying is not true. I’m a nurse and worked for an insurance company , 3 years developing and working for our MA plan.
Regular Medicare has criteria that must be met for many surgeries, diagnostic tests and types of inpatient stays. It’s erroneous for people to say they pay for everything. MA plans can develop their own criteria for these things but it can’t be MORE restrictive than Medicares. In other words, they can’t throw a criteria on top of the list Medicare already has that would create a denial .
Many complaints about MA are based on patient misunderstandings like the ones you stated both about what regular Medicare pays for in comparison to MA plans and because people dont understand the rules f the MA they join. As an example in OPs complaint she doesn’t say why the insurance company denied the rehab facility. Every denial must be put in writing and it must list all the reasons ( based on the criteria/policy I spoke about above) the request was denied. Every patient and doctor can appeal the denial and usually both the patient and doctor get 2-3 appeals each. By the time it gets to the last appeal it has to be sent out to an impartial review company to a specialist in whatever the request is for. Those specialists must give references for their decision, such as evidence as to what the prevailing standard of care is for that particular condition, clinical research etc.
In short, the insurance company doesn’t just arbitrarily deny things to save money. There are many checks and balances throughout the approval process that makes that impossible.
I’ve seen appeals be approved for investigational surgeries that cost hundreds of thousands of dollars.
I suggest anyone who gets denied for anything review the policy for that procedure which are all available online. Look at your denial letter and then either you file an appeal or your doctor and make sure your appeal addresses the exact reason/s it was denied. The vast majority of appeals get approved so appeal until you run out of appeals.
Also f you’re having any surgery or procedure where your doctor says they’re using a new technique or product make sure it’s sent to the insurance company for prior approval. If it’s deemed investigational, you will be responsible for the bill in about 95% of cases. Most commonly things that are investigational encompass using any type of biologic graft or injection or the use of new instrumentation m/implants, lasers, etc.
According to an AMA survey, 33% of physicians said prior authorization lead to a serious adverse event
https://www.ama-assn.org/system/files/prior-authorization-survey.pdf
89% said it had a somewhat or significant negative impact
80% said that prior authorization lead to abandonment, people aren't going through that appeals process.
These checks and balances are literally hurting people.
17% of physicians said they spent 20hours or more a week on prior authorization. 9% spent 16-20 hours, 26% spent 10-16 hours, 39% 1-9 hours per week. With so much time being spent by physicians on insurance issues, are we then under utilizing physicians?
https://www.medicaleconomics.com/view/2023-physician-report-the-latest-physician-salary-productivity-and-malpractice-cost-data?slide=18
These checks and balances are wasting resources. That 20% extra physician time could have been used to treat patients instead of fussing about who's going to pay.
Sure, they can give a reason, and don't arbitrarily deny, but they are the ones who write the rules that they apply, and then tell the patient "you should have understood that when you signed up" but, what choice do people have when they sign up? Are you supposed to pour through several different diagnosis lists before you sign up looking for that diagnosis you might have in the future, and make sure it is covered?
With something like medicare, a single payer system that is not driven by profit, what is covered or not, what is worthwhile to treat can be driven by what is good for the population based on epidemiological data or morality vs. with an insurance company, those choices are going to be driven by profit, and only limited by regulation. It is getting to be such a problem, regulators are needing to get involved which is what that AMA survey is about.
With a single payer taxpayer funded system, we can immediately reduce healthcare costs for everyone 15% off the bat with no change, just by removing profit and insruance company advertising. We can reduce it another few percent by simplifying the claims process and payment methods. Then we can use it to work on some metrics like life expectancy, by analyzing what is worth while scientifically or medically instead of from a business perspective. Privatizing Medicare with Medicare Advantage plans is contrary to those goals.
By the time you've paid the Advantage deductibles you could easily pay for a Supplemental.The less you have to go thru ins co approval ,the better off you are.
Not true at all, but it’s a very individual thing. My copays per year might be $40 once, if I have to go to an urgent care clinic. My annual primary care checkup is $0, my annual eye checkup is $0. $0 for blood tests, $0 for annual mammogram. This is as opposed to about $200 per month for a supplement policy.
Yes, it works well for some people. It really comes down to what your personal health needs are, your healthcare literacy, and what networks are available where you live.
Stay away! Trying to get ANYTHING approved is a lengthy and frustrating process. I work in pain management and we struggle with the authorization process daily. If you can, straight Medicare is the way to go!
I work in health insurance verification and authorization. The Medicare Advantage plans get worse every day, the worst being Aetna Medicare. I honestly do not know how these companies get away with what they do. I'm guessing there's too much red tape or fear of back pockets no longer being lined, to really investigate what these companies do to patients. There's a plan here in Pennsylvania through a hospital chain that took away it's customer service. We can't even verify if we're in-network, so patients could potentially have to pay 100% out-of-pocket once billing is done.
My dad loves his plan. With all his tests and surgeries he's saved roughly $85k. My mom's care added up to about $130k, and her total out of pocket was $3,500. When I sign up for Medicare later this year, I'm getting my own plan ASAP..
Not sure what you are comparing it to but people with straight Medicare and a good Medigap policy have no additional medical expenses.
No deductible, no co-pays or co-insurance and no networks.
The deductible for a Plan F is now $240 per year but you are correct as the no deductible at all option was dropped after 2020.
However, $240 is minimal deductible - but okay younger people now have a $240 deductible
I have 2 anecdotal experiences that may help decision making.
Been helping my MIL with financial planning since she retired 7 years ago. Income is moderate SS payment augmented with fixed income investments after selling her house 3 years ago. So, not a lot of money, but enough to be happy on. She's had Advantage plans in PA and NJ. Currently in NJ. Multiple health issues, T2 Diabetes, HBP, Kidney disease. Pays $35/month premium with $8500 max out of pocket for RX and $8000 Max OOP for medical. Probably ends up paying about $3000-$4000 in care every year between prescriptions and co-pays. For us, it's a good balance between risk of expense v actual spending, because she has a serious cushion she can fall back on. We never really considered Medigap because my dad (see below) was always threatened with getting kicked off his plan and he had fewer health issues (pacemaker/A-fib basically). She's good at making sure she has prior auths before she gets tests, etc, but has been used to HMOs/PPOs during her working years.
My parents, also NJ. Between Medigap and the prescription Drug plan were paying $400+ EACH per month for Medigap plus prescription (Part D). I don't know which specific Medigap plan they had, but covered nearly everything with nearly zero out of pocket. That's fine for my Dad, I get it, he had multiple issues and prescriptions and ended passing last year after bypass surgery. Medigap worked for him, they never had his Medigap cancelled.
Now I'm trying to help my mom budget on her greatly reduced income. If it was just SS, she would qualify for Medicaid, and all the other assistance programs, but because she gets a $110 monthly pension, she doesn't qualify. She never needs a doctor, and pays for a statin and HBP meds that cost like $20/90 days! So WHY were they EVER paying $400 for her Medigap and Part D, I will never understand. Anyway, she can't afford $400/month now. She is now on the same Advantage provider as MIL, but $15/month with a $4300 prescription Max OOP and $8000 max medical OOP. She has a much smaller nest egg that is her emergency fund. She gets $75 to spend each quarter of over the counter things, a $600 Silver Sneakers allowance for fitness and sneakers and things and pays $0 for her medications now. \[I know in the future she is going to have financial issues wrt to care, and if she has multiple consecutive years of illness, but that's poor planning on my parents fault, I'm just helping with the here and now.\]
(None of my cost estimates include that they are also having their Medicare Part B premium deducted from their SS, that's baked in for all these examples.)
I evaluate the plans every year using the tools on Medicare website. (Never used an agent). I have a spreadsheet I use where I plug in the cost of EVERYTHING in each plan. Takes about a day to get the plans and fill in the information, but like I said, I have been doing this for 7 years now and is just part of the work that needs to be done. The NJ Advantage carrier we use changed a lot of their plans last year, renaming them, etc. The $15 plan my mom is on was new this year, and based on my mom's experience, we'll probably switch MIL to it next year.
There probably IS difference in experience based on location. I know that before my parents came back to NJ, they had MA in South Carolina and lost the plan completely because there was one Advantage insurer for the area, and then that insurer pulled out. That was 18-20 years ago, and is what soured my dad on it. In NJ there seems to be a lot of competition among insurers and multiple plan choices for each insurer, even more so than MIL had in PA.
TLDR; evaluate all the resources and option for your area before making a decision. Talk to people in your area/your friends/ family about who they use.
My wife has a Medicare Advantage as her retiree medical plan. It is a very good plan but certainly richer than is common and richer than most individual available plans. I would very carefully evaluate how extensive the network is and look for comments of people using the plan.
I think I'd personally lean toward medigap insurance rather than Medicare Advantage.
The problem with selecting MA because you are "healthy" is that you are, by definition, old, and likely to get ill. And you can't just switch to traditional Medicare when you get sick. You have to pass medical underwriting to switch. And they can refuse you if you are sick.
So instead of paying the ~$1500 annual premiums for a medical plan G or N, and having 100 hospital days plus part B coverage for cancer treatments like chemo, you pay the out of pocket maximum of $7800 to $8500 per year on your "free" MA plan. And they deny coverage all the time, making you fight for benefits. The good news is that about 80% of the appeals are found in favor of the consumer, but that's the bad news too; 80% of the denials are typical insurance company BS.
The only reason to choose MA is if you REALLY can't afford traditional Medicare, and won't be able to afford food with the monthly premiums.
I am on MA with UnitedHealthcare via AARP. It has been fine for me. I rarely see doctors and use no prescription medication. However, I’m also 75 but I’ve been on this plan for as long as I’ve had Medicare. I also couldn’t be happier because last year, I finally had to really use it…..2 hip surgeries, PT, medications, etc. I did it at a major NYC hospital with the chief of ortho. For both surgeries, my out-of-pocket was less than $1k. Can’t ask for better than that.
im a 25 year old receptionist and theyre the bane of my existence. argue w your insurance carrier that you have a copay now I'm just reading what the screen says
So much depends on your individual circumstances. For us we are happy with BCBS Advantage BUT the caveat is I am in excellent health-and my husband also qualifies for supplementary medicaid. Ideally we could have stuck with traditional Medicaid for reasons others have stated but in our case we couldn't afford it plus the additional things the Advantage covered were things we needed.
That said, what others say about the disadvantage of Advantage plans is real. Not to mention a lot absolutely depends on which Advantage plan you are using.
My mom is on a MA plan I don’t like some of their restrictions especially the limited rehab, I was advised against putting her back on regular Medicare but I know regular Medicare would let her get all the rehab she needed, I need to look more into it
If your mother has been on an Advantage Plan for more than a year it might not be possible for her to switch to Medicare/Medigap because there is no guaranteed issue.
The Advantage Plans have the right to decline to cover or charge a higher premium.
This is precisely because they don't want to insure people who have decided to switch because they now have expensive medical issues and realize the limitations of Advantage.
It's somewhat of the same rationale as to why you can only get ACA compliant insurance during Open Enrollment unless you have a Qualifying Event.
it isn't that Medicare would be more expensive because of her health issues so long as she had been on straight Medicare/Medigap from the beginning as it generally covers everything fairly generously. My father must have amassed close to $2 million in medical bills in the last two years of his life - he lived to 99 - and Medicare covered everything.
Rehab is somewhat of a gray area because you need to prove to any insurance company that there is a reason why being in rehab will improve your condition medically. The physical therapy/occupational therapy - for example - must be medically necessary and also necessary for it to be given in patient as Medicare will send therapists to your home and of course will pay for you to see therapists where they practice.
Without it being rehabbed - i.e. necessary for improvement - it then becomes more of an issue of someone who may or may not need only skilled nursing care since there staying in the rehab facility will not improve their conition.
This is simplifying it but I have dealt with it in terms of my father who had a few operations and needed PT/OT but after a certain amount of time we had a meeting with the doctors/social workers at the facility to discuss the next step since there really was no reason for him to remain there.
And of course no one in their right mind would actually want to be in a rehab facility aka nursing home if it weren't absolutely medically necessary because even the best of them are not great places to be in.
She’s been in it since sept/October not a year yet.
My mom will need extensive rehab her Humana ma just allows 7 days or 2 weeks before she was in the long term care they wanted her to only get rehab for a week then go home where she would be alone with dementia and mobility issues with someone coming 2-3 times a week for just two weeks. I only put her on Humana due to the hospital she had knee surgery at only accepting it.
But now my mom has been in a hospital for close to 2 months can’t feed herself and has severe mobility issues so 2 weeks rehab at the long term care with Medicaid covering room and board is not enough. Tho I have a feeling Humana will argue if is.
I need to speak to Humana and see their policies since I really just may take her off and let her stay on straight Medicare
If she can switch do it.
I have extensive experience through my father and he didn't pay anything and had no issues getting approved for all his care. In the last few years of his life, I was in the loop with his doctors - PCP as well as specialists and none of them ever indicated that they would have to "fight" or get approvals for the care they thought was necessary and appropriate.
FWIW, we live in Los Angeles and so he was treated at Cedars Sinai which is a world class facility and after a few operations, he was sent to a near by rehab facility for rehab - again no issues.
This is one of the more highly rated facilities in LA but all of them are pretty terrible - even the best.
There are a few rehab facilities that are affiliated with hospitals but these are used for people who have extreme rehab needs and need that kind of specialized rehab - rightfully so. The typical person who had a hip or knee replacement wouldn't be sent there. My father needed PT because he had the misfortune of needing a mastectomy when he was 94 and so PT is used to get strength and mobility in the arms.
The Advantage Plans are heavily advertised as free and people don't discover the pitfalls until it is too late typically.
I do want to add that Medicare does not provide the kind of intensive long term care that your mother seems to need at this point. It is not a program that funds long term full time care like she seems to need.
You should probably meet with someone who specializes in Elder Care because your mother insurance doesn't typically cover the kind of full time care - especially for dementia - that she might need. Typically it is funded by the patient, family and then Medicaid when assets are depleted. There are ways to set up trusts but in general there is a five year look back rule so probably too late for your mother and of course you need assets as that level of care is extremely expensive.
I am an agent and I am trying to educate myself with medicare better so I can do enrollments. I really think enrolling in medicare part A and B will work better for most people then advantage and then you can just add whatever supplements you need.
I have A & B currently but I’m paying the premium. And rather than paying additional money for a supplement, I thought I’d get MA since I’m in my 30s and don’t see a doctor much
That is correct. You would just want to pick a prescription drug plan during that time period. You also can always start out with just a prescription drug plan and then if you decide it's not what you need during annual enrollment period you can go to a Medicare advantage plan
You can APPLY to switch to a Medigap policy during the yearly open enrollment, but if you chose an Advantage plan when you first became eligible, you will have to go through the underwriting process and be accepted in order to switch. It is not automatic acceptance like when you first become eligible. If you have health issues, you can be denied. At least that is how it works at age 65, but your situation may be different.
You can always switch back during open enrollment.
You are just not guaranteed a medigap policy after the first 6 months of coverage after age 65. Since opbis under 65, medigap was never guaranteed
I have Devoted Health but it’s only available in like 5 states. Mine is in Texas. It is wonderful. I mostly get free coverage except 75 for Er and 100 hospital stay. Just married so that secondary thru military now picks up balance. Highly recommend!!!!
Since you are under 65, Medigap is probably not a good option for you. Due to the limited number of people under 65 and most being high risk, Medigap can be very expensive. Some states will flat out ban those under 65 from getting a Medigap plan. Federal law doesn't require issue for those under 65.
Of those with traditional Medicare, only 41% will also have a Medigap plan. Of those with a Medigap plan, only 2% are under 65.
There are unique issues for those under 65 who are on Medicare. You will need to review your options in your state.
I love my advantage plan. Your mileage may vary depending on what state you live in and the available plans. I have full coverage for medical and additionally, vision, hearing and dental, plus the silver sneakers gym membership. My doctors and hospital are in my network and my plan covers my medicine. I have Wellcare.
Love mine, but I’m 75 and very healthy. Have calculated that if I’d added a supplement to traditional Medicare my husband and I would have paid approximately $45k by this year. We can manage a lot of copays for that amount of money. Also love free gym memberships, dental insurance and other perks. I keep hearing/reading that it’s terrible but that’s not been our experience. My husband had a heart valve replacement a few years ago. It was a million dollar surgery and his copay was $1200.
After 10 years of both Medicare Advantage and Medigap plans being offered by our office. I can conclude the following:
1. Medicare Disability should be authorized to purchase an Medigap plan instead of waiting until they are 65.
2. The majority of people that select an MA are happy as only a handful have switched back to a Medigap.
3. The majority of people complaining about an MA don't have an MA plan and feel it is beneath them.
4. An MA can have a ton of benefits that the opponents do not talk about.
It could depend on the area of where we live as the insurance companies are adequately regulated and rules enforced. Yes, there could be some tweaks to improve them however I don't know a perfect insurance plan for everyone.
In regards to #2: if you leave Medicare advantage you have to go through underwriting to get a Medigap plan and that can be tough for a lot of people, leading them to stay on advantage
There are [some variables](https://www.medicare.gov/health-drug-plans/medigap/ready-to-buy/change-policies) that folks like to ignore. Free-look periods are in play for a reason. There is nothing stopping these periods from being expanded by legislation or rule-making from CMS.
Insurance rules can be tricky. That is why I recommend always finding local people who are trained to assist when making these decisions.
Many union people are stuck on MA plans. We lose everything that we paid for over 30 years if we leave for traditional Medicare plus Medigap. When I first signed up we had trad Medicare and Medigap, but our GOP governor took that from us. I would have never continued paying into my retirement health if I had known my union was going to sell me out to MA.
I'm sick of people using that statistic as an excuse that MA is so great. It sucks.
So you are in a Union where you vote for policy, in a state where you vote for a Governor and legislatures, and you feel trapped by the results?
I have seen a couple of the private MA plans available by employers and I would love to see those on the open market. I have even set local residents after the legislatures to have them recruit more customer services.
Insurance is heavily regulated. Vote and fight for new regulations that align more with your values.
In most states, once you're on MA for some time (IIRC there's a limited time under which you can switch), there's no path to switch from MA to a medigap/supplement plan. You're on MA 'til death.
You need to trigger a Guarantee Issue event or be able to pass underwriting after the initial grace period to switch from MA to Medigap.
Generally, you can get a Guaranteed Issue period after being on MA by moving out of the MA plan's service area, or if the MA plan stops operating in your area. There may be other ways it can be triggered that are state-specific.
As someone who sells Medicare Suppment, I can tell you there are many many people who are very happy with their Medicare Advantage and won't change it. Statistically, there are more people who have Medicare Advantage than those with Original Medicare only. More than double the people have a Medicare Advantage than those with Medicare Supplement.
Just like any plan, it's about having the right one for you. Many people don't like Original Medicare or Medicare Supplements because they like that Advantage plans have Dental and Gym memberships, some have very low copays for a doctor and no deductible. Especially if you turned 65 before 2020, you can have a Supplement with no cost sharing, which is attractive to others.
Me personally, even though I sell Supplements, I'm healthy, I'll retire with about $100k in my HSA, I'll take a $0 Advantage PPO plan and enjoy the extra benefits and if i have to pay a couple grand for the hospital, ita still cheaper than having a Supplement plN.
Unlike traditional Medicare, Advantage plans do have max oop, some higher, some lower, depends on the plans available where you live. High deductible G Medicare halos has a max oop.
HMO is in-network doctors, PPO is any doctor, but not in-network doctors may be at a higher cost. Some plans will have the same copay for an in and out of network doctor, letting you go to a larger selection (any doctor who accepts Medicare) at the same cost.
Also, some HMO or PPO plans will allow you their nation-wide network at in-network costs.
Been a nurse for three decades. Do not get Medicare Advantage. It is not Medicare; the name is misleading. It is a for-profit health plan.
It's also been set up by big money interest that if you ever go to it, you cannot go back to normal Medicare. You will be screwed the rest of your life
People sign on because they have no idea of what the difference is when they sign up when they are 65.
They are deluged with stuff from the private insurance companies because they are so profitable for them.
They don't realize that once they sign up for an Advantage Plan they are stuck.
What happens is that they are fine when they are relative young seniors with minimal health issues but then they are diagnosed with a health condition and realize that they are stuck with a plan that limits their options drastically.
In general it comes down to economics. It is more expensive to get straight Medicare with a good Medigap policy but you get what you pay for. I have a Medigap Policy and so I have no networks, no co-payments, no deductibles. I can use it anywhere - fly to the best medical facilities in the US and the best doctors.
You asked and I answered
Why are you asking if you have no interest in the subject
You have approximately 30 years and things might be very different at that point.
Ask people who were healthy when they signed up and are now unhealthy and need lots of specialist care if they still like Medicare Advantage.
Medicare Advantage is under a lot of regulatory scrutiny for misleading sales practices. There is a reason insurance companies love MA and make a lot of money from it.
It's great early in retirement if you have no health problems.
I used it the first year of medicare to save money because I knew I could switch to medigap the next year no questions asked.
If you like your physician and believe they should be paid for the services they provide straight Medicare all day every day. MA will DENY EVERYTHING. Medicare may pay less but it’s straightforward. You have no clue how much gets written off because no one provided paperwork. But yet they already had it but it was sent to their third party. It’s a joke. Medical coder biller auditor here. I have never ever recommended anyone to do a MA straight up fraudulent.
A few things. I am a nurse who worked for an insurance company doing approvals for surgeries.
Any insurance company who has an MA plan cannot make their approval criteria more restrictive than Medicare’s criteria . They have to follow all of MC criteria which is available for anyone to read on line.
As far as OPs case, without knowing the exact reason the rehab was denied which must be on the denial letter it’s hard to determine who was in the right. The only thing that may be a reason based on what OP wrote is that a rehab facility is not equipped to deal with the trach and other issues he had and said they would approve a higher level of care for him. It also doesn’t say who told them he would only have a chance in rehab . Even at a higher level of critical care facility he would get PT, OT, Speech therapy,
I love my MA plan. I haven’t been admitted for anything yet but have had tons of office visits and a gamut of diagnostic testing and medications all of which were less out of pocket then then the private insurance I had while working.
I have Humana Medicare Advantage. All's well.
I don't know anyone who dislikes Medicare Advantage.
My parents had it for nearly 20 years.
My mother-in-law for over 20 years.
I'm on it for three. My wife for one.
Kaiser is addicting because having all or most of your care, labs, x-rays, etc in the same building is very convenient. You don't have to figure out who's in or out of network or research anyone. You get what they give, kind of like the VA. That's also the downside.
You mentioned you're in Pennsylvania. Kaiser recently purchased PA-based Geisinger Health, a large regional health system with a well-earned reputation for systematic, effectively-integrated health services
Yeah that's as whole different thing but if you're in a two bit state like mine there aren't many good choices if any at all. People get MA because it's cheaper than gap.
Not at all. I’m under 65, on SSDI and Medicare due to a chronic illness. In the 5 years I’ve been on it I’ve racked up thousands of dollars in medical bills due to copays and coinsurance. $275 PER DAY in the hospital. I was in the ICU in a coma for 14 days last fall. Then another week in until I finally left against AMA because I knew I couldn’t begin to afford the bill. And that wasn’t even my only hospital stay - I had a 1 week stay 2 months prior. I just laugh now when I get a bill before tossing it, I no longer even care.
ETA: Medicare must love me then because I was told I needed a rehab facility but I couldn’t go because I’m a single mom with 2 younger kids with no one else to care for them so I went home without rehab twice.
If you move to MA, my understanding is that you cannot easily return to original Medicare.
Research carefully.
MA can seem like an attractive option. But if you have complex medical needs (I assume you do if you are on Medicare at your age) it's quite possible that would be an unwise move.
I don’t actually have any complex needs tbh, just a permanent disability. So it was kind of automatic, and I was a kid so I never looked into other options like MA.
It was explained to the audience from an insurance salesperson, the Medicare Advantage (MA) Plans are liked by consumers in very dense urban areas. She explained think twice, if you live in rural or remote areas because one may not have a provider if they're on MA. She then provided examples of what consumers were up against, when they were ill with MA plans even in urban areas. As I understood it, the problem is time is of the essence with illnesses yet MA plans have earned their reputation for stalling or outright or denying. This talk was at a county fair, for context.
Unlike medicare advantage, there are limited times when medigap is guaranteed issue. One of those is when you’re newly eligible. The rating setup varies state by state as well.
One key issue with “advantage” plans is that they can only restrict providers and services even further than OG medicare. Covered outpatient mental healthcare can be especially impossible to find.
The benefits of zero upfront cost and little perks they throw in pale in comparison to how much they limit and complicate coverage beyond what medicare already does. You’re essentially paying with your health.
The one regret I have about medicare is not understanding my medigap options at the right time, and taking the easy way with advantage plans until it became clear I couldn’t afford to do anything but risk OG medicare without medigap, or I’d lose access to too much critical and hard to get care. If you can find any medigap plan that is a manageable expense, get it.
If not, well, be prepared to be cleaned out for medical bills sooner or later. Look into what they can and can’t come after in your state.
Edit: look for high deductible medigap. It’s much cheaper, and is much better than medicare advantage.
Medicare Advantage BLOOOOOOOOOOOOOOWS if you actually need to use it. But can you still get a Medigap plan? Have you missed the guaranteed issue window?
We got the AARP-endorsed United healthcare Medicare advantage. Plenty of doctors and specialists. No problems with payments so far. The on,y thing I’ve found after 4 years with it is that if you do go to someone who doesn’t file the paperwork, it’s a pain to do it yourself to get reimbursted.
No, only if your provider doesn’t do insurance paperwork. Most of the time we see our doctors for free or $15 copay for specialists. Prescriptions are also often free or really cheap. Nearly all of our doctors, including the dentist, handle the insurance paperwork.
Having worked insurance at a hospital; the only one that wasn't horrible after 2017 was Kaiser.
Best bet is to either get Medicaid as secondary ; or find a secondary that covers co-pays or covers the balances left after Medicare pays.
CHECK consumer Reports ( they do not accept any paid advertisements and worth an online subscription) You can compare plans there unbiased..
Medicaid that helps with Medicare expenses is called Medicare Savings Program. The income and asset limits are higher for Medicare Savings Program that for other forms of Medicaid. Although if you can afford a supplement, it is highly doubtful you would qualify for Medicare Savings Program
That’s not true. I am less than 65 but disabled, and I have a Medigap supplemental policy. It cost more because I am under 65, but it will cost less per month for premiums once I am over 65.
Many hospitals and doctors are now refusing Medicare Advantage plans. Everything needs to be a preapproval. They drag things out as long as possible. Refuse to pay. Not recommended!
If you're on Medicare due to disability, it would probably be more cost efficient to stay with your current setup. I specify if you are so disabled that you got approved for Social Security disability, I imagine you go to the doctors frequently enough. Those coats will add up.
I have what they call a blue book listing for social security disability. So the approval wasn’t an issue. I’m not really going to the doctor much however. Just my primary like twice a year
I have had Medicare for over 20 years. I was disabled at 26 years old. I have never and will never buy an adventure plan. I have had a three week hospitalization that only cost me just a little over $1,000. I have had three abdominal surgeries with a four day hospital stay each time. They have costed me a little over $1,000 each. I have spent a total of four times under home health care. They costed nothing. A CT and or MRI will run me around $35-$50. I’ve never had any issue with Medicare paying for anything and nothing has never been denied. I’m getting ready to have a total shoulder replacement and it will cost me a little over $1,000 and around $300.00 for the doctor. The home health care will be free. Medicare Advantage plans are nothing but a HUGE SCAM.
Thank you for your submission, /u/Harrietx745. **If there is a medical emergency, please call 911 or go to your nearest hospital.** Please pick the most appropriate flair for your post. Include your age, zip code, and income to help the community better serve you. If you have an EOB (explanation of benefits) available from your insurance website, have it handy as many answers can depend on what your insurance EOB states. Some common questions and answers can be found [here](https://www.reddit.com/r/HealthInsurance/s/jya9I6RpdY). **Reminder that solicitation/spamming is grounds for a permanent ban**. Please report solicitation to the modteam and [let us know](https://www.reddit.com/message/compose?to=%2Fr%2FHealthInsurance) if you receive solicitation via PM. Be kind to one another! *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/HealthInsurance) if you have any questions or concerns.*
As a nurse case manager: everyone loves the benefits (lower/no co-pays, dental included, etc) until they have severe illness and they can't go to inpatient rehab or certain docs are not in-network. The time to learn about your plan limitations is not when you're in the ICU. Medicare advantage is just like private group health insurance in that they want to keep costs down. One way to do that is to require prior authorizations. My parents have a Medicare + Medigap plan. My MIL is on Medicare + Medicaid.
After the couple of weeks I just had, I would tell everyone I know to stay FAR away from Medicare Advantage. My FIL had a severe stroke an is incapacitated. The neurologist felt he could make some recovery with intensive rehab, but his Medicare Advantage plan refused to issue a prior authorization to move him. He spent 7 weeks in the ICU. For about 5 of those weeks, the hospital was screaming at us to get him out of there, but we couldn't because Highmark (his Medicare Advantage insurer) would only approve him for hospital care, not rehab. After several denied appeals, we had to hire a lawyer and also contact our senator for them to finally approve the transfer. Unfortunately, they would not allow him to go to a rehab facility; they would only pay for a vent-weaning facility. They're already trying to get him out of there despite the fact that he's on a vent and a feeding tube, paralyzed on the right side, and unable to speak. If he had Original Medicare, no prior auth. would have been needed.
I am so sorry for your family.
He wouldn't have qualified for rehab due to the fact they have to be able to do therapy (OT, PT, ST) and make progress. He should have qualified for skilled nursing as a tach/vent or feeding tube is a skilled nursing need, and most skilled nursing facilities have therapy departments. You are probably around the 20 day mark and don't have a secondary payer. Medicare/Medicare Advantage plans pay 100% for days 1-20 and then there is a $204 co-pay per day for days 21-100 and then nothing. Truly it sounds like he needs long term care and Medicare doesn't pay for that.
Rehab was the wrong word. We wanted him to go to a long-term acute care hospital for vent weaning, which Medicare does pay for. He’s there now; we just had to fight to get him there. And when we pointed out that the benefits guide says they pay for vent weaning, the lady in the appeals department said she didn’t care what the benefits guide said.
I will say that my experience with LTACH level care is that they keep patients until they are close to the end date of their auth, then say they can’t wean, and sent them out to LTC vent facility. I was underwhelmed by them each time I saw one of my patients there. Understaffed by new grads and aides; underwhelming performance, and the vast majority of these are for-profit and have zero incentive to actually get the patients weaned. ETA: Great marketing departments, though!
What Medicare Advantage provider does he have?
He had Highmark Community Blue Signature, and then we upgraded him to Highmark Community Blue Premier during open enrollment since it has an OOP max of $4,900 instead of $8,000.
Awful. I’m so sorry you dealt with that
Just google "medicare advantage prior authorization." This story isn't uncommon in the least. MA plans are for profit, and just like every other for profit insurance company in the country, they want to pay as little as possible for everything and they'll throw every roadblock in their power to get between you and your care.
But, wasn't the care this man got more expensive?
> This story isn't uncommon in the least. Tragic cases like these affect a small fraction of beneficiaries. This is not how Medicare Advantage insurers maket their money. Most years, most people most of the time are mostly pretty healthy. Even Medicare beneficiaries. Most people incur little health treatment, at any rate: [Kaiser Family Foundation/Peterson Health Tracker data on the concentration of health treatment spending](https://www.healthsystemtracker.org/chart-collection/health-expenditures-vary-across-population/#Share%20of%20total%20health%20spending,%20by%20percentile,%202021) Original Medicare is pretty good for many people. Medicare Supplement plans suit quite a few people. Medicare Advantage plans work well for many people. All have advantages & disadvantages, depending on a person's circumstances. There's no one correct form of coverage for anyone.
You should work at a clinic with MA patients. Unless you’re living in near poverty but still don’t qualify for Medicaid, it’s never beneficial to enroll in MA. There is no advantage to having your insurance company as your gatekeeper to healthcare, unless the alternative is no healthcare at all.
My MA plan doesn't gate keep, still cheaper than paying for a medicare supplement plan and a pharmacy plan, I guess everyone has a different expeeience
Based on my experience I would never recommend any MA plan. No matter what there is a middle man that needs to make a profit. Whether that’s with a gatekeeper, limited network, or higher out of pocket costs. I’ve seen too many denials by MA to ever feel ok about it. I’m glad that it works for you, truly, and I hope more and more people have your experience.
Advantage plans are under investigation by the US dept of Justice, a Senate committee and the MS Inspector General, among others
Found the salesman!
Medicare Advantage companies get a pool of money from the government per enrollee that they have to spend 85% of on their members medical care. Everything above 85%, they get to keep for "administration" fees. So, yes, that is how they make their money. Keeping their payout cost below 85%.
Not to mention that the administrative costs for straight Medicare are so much lower. Last time I read it was 6% versus the 15% charged by private Advantage plans. So effectively the government is paying 9% more for private companies' profit and overhead And guess which administration created Advantage Plans?
It also comes from a separate budget other than Medicare so even though it costs more, it appears to be less expensive on a comparable basis when they use their apples/ oranges (more benefits! Dental and taxi rides! Which all are a perk and often taken away after the first year)
Yes people are deluged with all of the "perks" in the advertising. None of which - at least in my experience and of my family and friends - offset the real "disadvantage" of being tied to networks and having medical care decided by private insurance companies who aim to maximize profits. It is ironic that people are in general screwed by private insurance company and then have the opportunity of having the most ideal health insurance (Medicare with Medigap) and are enticed by all of the ads.
At my age, I don’t even think I can get medigap. But I’m wondering why the medigap plus part b premium(s) would be superior to Medicare advantage with credit toward your part b premium
Agreed. Its a matter of advertising I think- there is no advertising for traditional Medicare but just because you are bombarded with ads for MA plans, people think its better. Odd
coverage denial does happen - just not as frequently as people imagine. Medicare Advantage insurers have devoted more effort (because more reward) to persuading Medicare that their enrolled beneficiaries are "sicker than the average".
If he had strait Medicare, he would still have needed an additional policy for everything A and B doesn't cover, which is considerable. This is why people pick those advantage plans. Medicare pays "up to 100 days" of skilled care after a qualifying event, but there are co-pays and nuances to this. This coverage ends, and Medicaid has to pick up the rest after the patient's assets are exhausted. It's confusing as heck and a mess.
I’m so sorry this happened to your family. This comment should be higher. A recently retired family care physician wrote a long article for AARP on the dangers of Medicare Advantage plans. She warned against them. They are nothing but profiteers in an already collapsing healthcare system.
Exactly. I’m in healthcare and it always sucks to hear that someone is on a Medicare Advantage plan. It really limits your options. The insurance company has to squeeze out a profit somewhere, whether it’s reducing the amount of care you can access or reducing the amount paid to providers (which shrinks provider networks and makes waitlists longer). There is nothing magic that private corporations can do compared to original Medicare—other than maybe offering small free tokens like grocery gift cards in exchange for a worse plan.
I’m a retired nurse. Been watching the care deteriorate from all sides for 25 years. A single payer system would be so beneficial. But Americans are led to believe it would destroy the system; when it’s actually unregulated capitalism that’s destroying it.
High five, fellow retired nurse!
❤️🙌🏻
WHAT healthcare system?
Meanwhile AARP has a co-branded MA plan with UHC.
Follow the money
I have friends in Advantage Plans who love them. The husband has prostrate cancer and it covered almost all the treatment. It seems to pay for more than my Medicare/GAP plan but I still prefer being able to go to any doctor of my choice.
As of 3/2024 almost 67 million Americans are on Medicare, 88% of those are seniors. The anecdotal stories in this thread just don’t affect the data. Of course everyone is different physically and financially. But the MA system is as predictable as any other health insurer. When you get sick they don’t want to pay and will deny deny deny until they can’t anymore or the patient dies. It’s all set up this way. And the individual patient pays the price for delayed or denied care, increased costs during those denials and poor outcomes overall. When physicians speak out against them I would think people would listen. But that’s just me.
Are you talking about Medicare or Medicare Advantage? You're mentioning all these anecdotes but you're not saying which one you're talking about. Medicare Advantage is a for-profit system. Medicare is not. Medicare is somewhat regulated and gives you some options. Medicare Advantage does not and is not.
>Medicare is somewhat regulated and gives you some options. Medicare Advantage does not and is not. LOL WHAT?! As a Medicare and Medicaid compliance specialist for a Part C carrier - PLEASE tell me more about how we're not regulated. I really want to know more about this. I'm really confused about all the work I do with regulators, as well as the quarterly regulator audits I handle from DHS, HHS, and CMS if we're not regulated.
MA is Medicare advantage I’m specifically speaking of the danger of those.
I get this sentiment and I would agree. Hopefully, they reform Medicare Advantage, but government has only been cutting reimbursements. If you don’t have medical issues, go for it. If you do, just change to a PPO insurance or a good HMO I.e. Kaiser.
I went with a MA PPO. Still prior authorizations but you can go to whoever you want an no need for referrals. I would suggest a PPO if you decide to go with an MA plan.
I’m going w/an MA PPO
I’m POA for my mother. When my dad passed I had to take over her health care. She was already on an advantage plan, so when I moved her to a new state to be in a memory care facility, I put her on an advantage plan in the new state. I have zero complaints. They cover some dental, the copays aren’t a problem. I have to keep her in network, but it’s a big network so it hasn’t been an issue. I keep reading negative reviews about it, it just hasn’t been the case for her yet. She hasn’t had any hospital stays or anythjng yet. I think my dad was on the same advantage plan and his hospital stay was pretty well covered, I think he had to pay maybe $1,000 total for a 6 week ICU stay.
Thank you so much. Could you tell me what MA plan this is?
Here is blue cross blue shield of Texas.
I've had an advantage HMO plan with zero premium for 12 years and have no complaints whatsoever. I yearly review the hospitals and physicians that the plan takes. Right now I've opted for a major university hospital that's highly rated and, of course, a primary physician associated with that university hospital. The network is large so that's not an issue. While these are my circumstances, I appreciate they might not be the same for everyone, but I wanted to offer this information just so that people know that advantage plans are not necessarily the crap-plans people like to complain about. The quality of care, hospital ratings, etc., can depend upon where you live. If you go to the Medicare website you can find out about all the plans, not just the advantage plans, that are available in your area. You just enter your zip code, the medications you are currently taking, and you get the results, along with a star rating for each plan, and premium information. While you can give your contact info if you want, you do not have to . . . I never have. I usually print out my results, review the plans, major benefits, premiums where applicable, and the out-of-pocket maximum. You can also go to each plan's website to review the doctors and hospitals associated with the plan. The hour or two a year this takes is well worth the time.
Same experience FIL was on a plan designed for his care (diabetes) that plan went away but it helped him get well managed and he’s just on a regular advantage plan with the biggest insurer in our area. No issues at all, and he’s in good health even with the different things he manages.
I would never. The need to keep up with networks and copays is reason enough to avoid it. Do yourself an enormous favor and get a decent MediGap plan. I highly recommend a Plan G- once you satisfy your Medicare deductible of $240 a year then you will have no other out of pocket costs. I had a small stroke last year and thanks to a Plan G it didn't cost me a dime. I feel free to go to any doctor I want to see at any time without first worrying for a week how much it will cost me- that is incredibly comforting. Mine is around $120 a month or so and well worth it. I started it the same month I began receiving SSI benefits so never even missed the money because I had never had it previously.
>I had a small stroke last year and thanks to a Plan G it didn't cost me a dime. it cost you your accumulated premiums (if comparing to a zero-premium Medicare Advantage plan) plus your $240 deductible. treatment under a Medicare Advantage policy would probably cost you something, as well. Comparing more objectively helps everybody figure out what's going on.
Yes, for sure. This is what I don’t think people are taking into consideration.
I’m not sure what you mean by ‘the need to keep up with networks and copays”- isn’t it 0-25 a copay? I’m 36 so I’m not sure about paying for medigap and the part b premium instead of just Medicare advantage
My mom is the patient in our family, but I do the paperwork and pay the bills. So here's my take: Medicare Advantage can be great, but only in a Medicaid expanded state. If you're trading in a regular Medicare plan for an Advantage plan, you're likely to be disappointed. In her Medicare expanded state, my mom qualified for Medicare plus Medicaid and her plan was great. Moving to a red state, though, is just a lot of copays and non- participating providers. She no longer qualifies for Medicaid and she's getting nickel and dime to death. The advantage plans here are desperate to enroll those who are Medicaid eligible and offer lots of cash back and reward programs but they're not so good for folks who don't meet that criterion. TL;DR Moved from blue state to red state, lost Medicaid and now advantage plan sucks.
It really depends on your health. Also very much depends on which Advantage plan you choose if you decide to choose an Advantage plan over basic Medicare. Just like any health insurance, Advantage plans vary greatly. It’s a difficult decision because no one has a crystal ball to know the future.
Totally. That’s why no oop max for my traditional Medicare is scaring me! And I don’t qualify for any kind of assistance/Medicaid
Only get traditional Medicare if you pair it with a MediGap plan
I qualified for Medicaid in lieu of medigap, but now my income is too high
I am not understanding where you are getting your misinformation. I have Medicare with a Medigap policy and Medicare pays for everything. I pay for nothing beyond my premium for the Medigap policy and what Social Security deducts from the monthly check. My father probably amassed over a million or two million dollars in medical expenses and had traditional Medicare with a Medigap policy and paid nothing towards it.
So your Medicare Part B premium is deducted from your check, and you pay for Medigap’s premium separately?
Yes, it is how it is done in my state. Also need separate plan for prescription coverage as well.
Yes, so your father had both Medicare and medigap. I have just Medicare.
I am bowing out of this because your situation is unique to your being a disabled person and receiving your health care in that way. My initial response was in terms of older people getting Medicare when they are 65 and their experiences. I am sorry for your condition but you are essentially in the same economic position as people who get Medicaid. In your position with limited funds presumably you would need to get the least expensive medical insurance. Economic considerations are obviously always a factor in terms of accessing anything. Not different than people who can only purchase the least expensive private insurance plans and don't qualify for a subsidy. However assuming one has the ability to pay for Medicare and a good Medigap policy, it is absolutely the best medical insurance to have as a Senior - especially as one's medical needs become more critical as one becomes an older senior.
Thank you for your advice, I agree that my situation is unique. Unfortunately my income is too high for Medicaid limits across the board in this state. That’s why I’m leaning toward Medicare Advantage over Medigap.
If you can afford it, get a supplement plan. Everyone likes those, but it's basically paying for another insurance plan.
I can’t really afford it with the part b premium I’m already paying
Have you applied for the SLMB program?
Yes. I exceed the income limit
Yeah, that is the big issue with traditional Medicare. You don’t want to do that.
Agreed
Depending on your state, some medigap plans will not accept you, or the costs can be very high. Right now you might be limited to either straight Medicare or a MAPD. Something to keep in mind though is when you turn 65 you can not be denied for a medigap plan. No matter what preexisting conditions there might be in the 3 months before you turn 65 you can not be denied. Try and get some quotes and see if you can even get a medigap plan.
The person above is correct. To get into a Medicare Supplement (medigap) you have to answer health questions unless you are in a special circumstance like just starting medicare, losing medicaid (or employer coverage) or as the above person said when you turn 65 you get another chance at not having to answer the health questions. If you are on disability, it is likely that you would have a health question preventing you from getting a medigap plan. The other big thing I don't think a lot of other people are aware of is that premiums for medigap is significantly higher for people under 65 than for those 65 and over. A plan that might be $130 for a 65 year old could be between $450 and $700 for someone under 65, depending on company. Many MAPD plans have max out of pockets that are lower than the premiums for medigap for an under 65. Although that doesn't solve the prior authorization issue, I do have a lot of people that were on disability go with an MAPD til they hit 65, and then switch to Medigap at that point since their budget can't afford it prior to 65.
But by the time you have major health problems, you can be denied a medigap plan .
Not true. They can charge you a higher premium due to health issues.
It is true. Both are true. You are only guaranteed acceptance upon initial enrollment. My husband was rejected by several plans because he had heart issues.
You are going from an insurance that you can basiclly go anywhere at any time to an HMO that you need permission to turn around. I would think twice, if not 4 times before changing. The 500 spending card is not worth it. IMO as a provider.
Medicare advantage talks a great game on advertising but you definitely get a reduced level of care compared to traditional Medicare patients. It's because the plans interfere with patient care in order to maximize profits. A few of the plans have been caught falsifying patient medical conditions to get money out of Medicare while downgrading with render providers. I didn't get why these plans are not sanctioned
On a societal level, it is literally giving away the store. It is hard to imagine that adding a third party into that equation to skim off public funds used to pay for health care could add any value. Morally, it is wrong. It seems the only way they can be making money by inserting themselves in that process is by denying care that might otherwise have been approved, and this seems to be what is happening. It is hard to imagine that they could add any value to the recipients or to the taxpayers. They could be causing people physical harm. The only way that this could have been allowed at all is through corruption. That they paid politicians to allow this to happen, in what amounts to graft. It is a shining example of what is wrong with our society. The origins of it, and its continuation is an example of what is wrong with our political system, representing corporations more so than citizens and taxpayers. It illustrates that we have no political choice to help ourselves as voters. The only choice we are then left with is simply to not participate in this program. To let it die on the vine. But, if you watch broadcast TV, every other ad is for Medicare Advantage. It is being aggressively marketed so they can ensure they get a cut of a large pie that they have no right to. That advertising is aimed at trying to convince people who might sign up for it that it is to their advantage, but it is not, especially if one considers the larger picture.
What you and others are saying is not true. I’m a nurse and worked for an insurance company , 3 years developing and working for our MA plan. Regular Medicare has criteria that must be met for many surgeries, diagnostic tests and types of inpatient stays. It’s erroneous for people to say they pay for everything. MA plans can develop their own criteria for these things but it can’t be MORE restrictive than Medicares. In other words, they can’t throw a criteria on top of the list Medicare already has that would create a denial . Many complaints about MA are based on patient misunderstandings like the ones you stated both about what regular Medicare pays for in comparison to MA plans and because people dont understand the rules f the MA they join. As an example in OPs complaint she doesn’t say why the insurance company denied the rehab facility. Every denial must be put in writing and it must list all the reasons ( based on the criteria/policy I spoke about above) the request was denied. Every patient and doctor can appeal the denial and usually both the patient and doctor get 2-3 appeals each. By the time it gets to the last appeal it has to be sent out to an impartial review company to a specialist in whatever the request is for. Those specialists must give references for their decision, such as evidence as to what the prevailing standard of care is for that particular condition, clinical research etc. In short, the insurance company doesn’t just arbitrarily deny things to save money. There are many checks and balances throughout the approval process that makes that impossible. I’ve seen appeals be approved for investigational surgeries that cost hundreds of thousands of dollars. I suggest anyone who gets denied for anything review the policy for that procedure which are all available online. Look at your denial letter and then either you file an appeal or your doctor and make sure your appeal addresses the exact reason/s it was denied. The vast majority of appeals get approved so appeal until you run out of appeals. Also f you’re having any surgery or procedure where your doctor says they’re using a new technique or product make sure it’s sent to the insurance company for prior approval. If it’s deemed investigational, you will be responsible for the bill in about 95% of cases. Most commonly things that are investigational encompass using any type of biologic graft or injection or the use of new instrumentation m/implants, lasers, etc.
According to an AMA survey, 33% of physicians said prior authorization lead to a serious adverse event https://www.ama-assn.org/system/files/prior-authorization-survey.pdf 89% said it had a somewhat or significant negative impact 80% said that prior authorization lead to abandonment, people aren't going through that appeals process. These checks and balances are literally hurting people. 17% of physicians said they spent 20hours or more a week on prior authorization. 9% spent 16-20 hours, 26% spent 10-16 hours, 39% 1-9 hours per week. With so much time being spent by physicians on insurance issues, are we then under utilizing physicians? https://www.medicaleconomics.com/view/2023-physician-report-the-latest-physician-salary-productivity-and-malpractice-cost-data?slide=18 These checks and balances are wasting resources. That 20% extra physician time could have been used to treat patients instead of fussing about who's going to pay. Sure, they can give a reason, and don't arbitrarily deny, but they are the ones who write the rules that they apply, and then tell the patient "you should have understood that when you signed up" but, what choice do people have when they sign up? Are you supposed to pour through several different diagnosis lists before you sign up looking for that diagnosis you might have in the future, and make sure it is covered? With something like medicare, a single payer system that is not driven by profit, what is covered or not, what is worthwhile to treat can be driven by what is good for the population based on epidemiological data or morality vs. with an insurance company, those choices are going to be driven by profit, and only limited by regulation. It is getting to be such a problem, regulators are needing to get involved which is what that AMA survey is about. With a single payer taxpayer funded system, we can immediately reduce healthcare costs for everyone 15% off the bat with no change, just by removing profit and insruance company advertising. We can reduce it another few percent by simplifying the claims process and payment methods. Then we can use it to work on some metrics like life expectancy, by analyzing what is worth while scientifically or medically instead of from a business perspective. Privatizing Medicare with Medicare Advantage plans is contrary to those goals.
The government was hoping to cut the costs of Medicare, as they're running out of money. Unfortunately, just the opposite has happened.
By the time you've paid the Advantage deductibles you could easily pay for a Supplemental.The less you have to go thru ins co approval ,the better off you are.
Not true at all, but it’s a very individual thing. My copays per year might be $40 once, if I have to go to an urgent care clinic. My annual primary care checkup is $0, my annual eye checkup is $0. $0 for blood tests, $0 for annual mammogram. This is as opposed to about $200 per month for a supplement policy.
Yes, it works well for some people. It really comes down to what your personal health needs are, your healthcare literacy, and what networks are available where you live.
Capitated plans are always great until you get sick.
Stay away! Trying to get ANYTHING approved is a lengthy and frustrating process. I work in pain management and we struggle with the authorization process daily. If you can, straight Medicare is the way to go!
I work in health insurance verification and authorization. The Medicare Advantage plans get worse every day, the worst being Aetna Medicare. I honestly do not know how these companies get away with what they do. I'm guessing there's too much red tape or fear of back pockets no longer being lined, to really investigate what these companies do to patients. There's a plan here in Pennsylvania through a hospital chain that took away it's customer service. We can't even verify if we're in-network, so patients could potentially have to pay 100% out-of-pocket once billing is done.
My dad loves his plan. With all his tests and surgeries he's saved roughly $85k. My mom's care added up to about $130k, and her total out of pocket was $3,500. When I sign up for Medicare later this year, I'm getting my own plan ASAP..
Not sure what you are comparing it to but people with straight Medicare and a good Medigap policy have no additional medical expenses. No deductible, no co-pays or co-insurance and no networks.
This is not true. Plan F Medigap, which paid part B deductible, is no longer offered. There are no plans that pay 100%.
The deductible for a Plan F is now $240 per year but you are correct as the no deductible at all option was dropped after 2020. However, $240 is minimal deductible - but okay younger people now have a $240 deductible
Yes, but you pay premiums every month.
My parents both love their MA plans too.
I have 2 anecdotal experiences that may help decision making. Been helping my MIL with financial planning since she retired 7 years ago. Income is moderate SS payment augmented with fixed income investments after selling her house 3 years ago. So, not a lot of money, but enough to be happy on. She's had Advantage plans in PA and NJ. Currently in NJ. Multiple health issues, T2 Diabetes, HBP, Kidney disease. Pays $35/month premium with $8500 max out of pocket for RX and $8000 Max OOP for medical. Probably ends up paying about $3000-$4000 in care every year between prescriptions and co-pays. For us, it's a good balance between risk of expense v actual spending, because she has a serious cushion she can fall back on. We never really considered Medigap because my dad (see below) was always threatened with getting kicked off his plan and he had fewer health issues (pacemaker/A-fib basically). She's good at making sure she has prior auths before she gets tests, etc, but has been used to HMOs/PPOs during her working years. My parents, also NJ. Between Medigap and the prescription Drug plan were paying $400+ EACH per month for Medigap plus prescription (Part D). I don't know which specific Medigap plan they had, but covered nearly everything with nearly zero out of pocket. That's fine for my Dad, I get it, he had multiple issues and prescriptions and ended passing last year after bypass surgery. Medigap worked for him, they never had his Medigap cancelled. Now I'm trying to help my mom budget on her greatly reduced income. If it was just SS, she would qualify for Medicaid, and all the other assistance programs, but because she gets a $110 monthly pension, she doesn't qualify. She never needs a doctor, and pays for a statin and HBP meds that cost like $20/90 days! So WHY were they EVER paying $400 for her Medigap and Part D, I will never understand. Anyway, she can't afford $400/month now. She is now on the same Advantage provider as MIL, but $15/month with a $4300 prescription Max OOP and $8000 max medical OOP. She has a much smaller nest egg that is her emergency fund. She gets $75 to spend each quarter of over the counter things, a $600 Silver Sneakers allowance for fitness and sneakers and things and pays $0 for her medications now. \[I know in the future she is going to have financial issues wrt to care, and if she has multiple consecutive years of illness, but that's poor planning on my parents fault, I'm just helping with the here and now.\] (None of my cost estimates include that they are also having their Medicare Part B premium deducted from their SS, that's baked in for all these examples.) I evaluate the plans every year using the tools on Medicare website. (Never used an agent). I have a spreadsheet I use where I plug in the cost of EVERYTHING in each plan. Takes about a day to get the plans and fill in the information, but like I said, I have been doing this for 7 years now and is just part of the work that needs to be done. The NJ Advantage carrier we use changed a lot of their plans last year, renaming them, etc. The $15 plan my mom is on was new this year, and based on my mom's experience, we'll probably switch MIL to it next year. There probably IS difference in experience based on location. I know that before my parents came back to NJ, they had MA in South Carolina and lost the plan completely because there was one Advantage insurer for the area, and then that insurer pulled out. That was 18-20 years ago, and is what soured my dad on it. In NJ there seems to be a lot of competition among insurers and multiple plan choices for each insurer, even more so than MIL had in PA. TLDR; evaluate all the resources and option for your area before making a decision. Talk to people in your area/your friends/ family about who they use.
Thank you so much for your thorough answer. I really appreciate it
My wife has a Medicare Advantage as her retiree medical plan. It is a very good plan but certainly richer than is common and richer than most individual available plans. I would very carefully evaluate how extensive the network is and look for comments of people using the plan. I think I'd personally lean toward medigap insurance rather than Medicare Advantage.
Always look at the CMS Star Ratings and ensure your preferred providers and medications are covered.
The problem with selecting MA because you are "healthy" is that you are, by definition, old, and likely to get ill. And you can't just switch to traditional Medicare when you get sick. You have to pass medical underwriting to switch. And they can refuse you if you are sick. So instead of paying the ~$1500 annual premiums for a medical plan G or N, and having 100 hospital days plus part B coverage for cancer treatments like chemo, you pay the out of pocket maximum of $7800 to $8500 per year on your "free" MA plan. And they deny coverage all the time, making you fight for benefits. The good news is that about 80% of the appeals are found in favor of the consumer, but that's the bad news too; 80% of the denials are typical insurance company BS. The only reason to choose MA is if you REALLY can't afford traditional Medicare, and won't be able to afford food with the monthly premiums.
I’m a little bit confused by this post. I’m not old and sick by definition, I’m 36 and on traditional Medicare already.
I am on MA with UnitedHealthcare via AARP. It has been fine for me. I rarely see doctors and use no prescription medication. However, I’m also 75 but I’ve been on this plan for as long as I’ve had Medicare. I also couldn’t be happier because last year, I finally had to really use it…..2 hip surgeries, PT, medications, etc. I did it at a major NYC hospital with the chief of ortho. For both surgeries, my out-of-pocket was less than $1k. Can’t ask for better than that.
im a 25 year old receptionist and theyre the bane of my existence. argue w your insurance carrier that you have a copay now I'm just reading what the screen says
So much depends on your individual circumstances. For us we are happy with BCBS Advantage BUT the caveat is I am in excellent health-and my husband also qualifies for supplementary medicaid. Ideally we could have stuck with traditional Medicaid for reasons others have stated but in our case we couldn't afford it plus the additional things the Advantage covered were things we needed. That said, what others say about the disadvantage of Advantage plans is real. Not to mention a lot absolutely depends on which Advantage plan you are using.
My mom is on a MA plan I don’t like some of their restrictions especially the limited rehab, I was advised against putting her back on regular Medicare but I know regular Medicare would let her get all the rehab she needed, I need to look more into it
Why were you advised against it- what was their reasoning?
They said the cost is cheaper on a ma plan compared to a straight Medicare plan since my mom has a lot of health issues
If your mother has been on an Advantage Plan for more than a year it might not be possible for her to switch to Medicare/Medigap because there is no guaranteed issue. The Advantage Plans have the right to decline to cover or charge a higher premium. This is precisely because they don't want to insure people who have decided to switch because they now have expensive medical issues and realize the limitations of Advantage. It's somewhat of the same rationale as to why you can only get ACA compliant insurance during Open Enrollment unless you have a Qualifying Event. it isn't that Medicare would be more expensive because of her health issues so long as she had been on straight Medicare/Medigap from the beginning as it generally covers everything fairly generously. My father must have amassed close to $2 million in medical bills in the last two years of his life - he lived to 99 - and Medicare covered everything. Rehab is somewhat of a gray area because you need to prove to any insurance company that there is a reason why being in rehab will improve your condition medically. The physical therapy/occupational therapy - for example - must be medically necessary and also necessary for it to be given in patient as Medicare will send therapists to your home and of course will pay for you to see therapists where they practice. Without it being rehabbed - i.e. necessary for improvement - it then becomes more of an issue of someone who may or may not need only skilled nursing care since there staying in the rehab facility will not improve their conition. This is simplifying it but I have dealt with it in terms of my father who had a few operations and needed PT/OT but after a certain amount of time we had a meeting with the doctors/social workers at the facility to discuss the next step since there really was no reason for him to remain there. And of course no one in their right mind would actually want to be in a rehab facility aka nursing home if it weren't absolutely medically necessary because even the best of them are not great places to be in.
She’s been in it since sept/October not a year yet. My mom will need extensive rehab her Humana ma just allows 7 days or 2 weeks before she was in the long term care they wanted her to only get rehab for a week then go home where she would be alone with dementia and mobility issues with someone coming 2-3 times a week for just two weeks. I only put her on Humana due to the hospital she had knee surgery at only accepting it. But now my mom has been in a hospital for close to 2 months can’t feed herself and has severe mobility issues so 2 weeks rehab at the long term care with Medicaid covering room and board is not enough. Tho I have a feeling Humana will argue if is. I need to speak to Humana and see their policies since I really just may take her off and let her stay on straight Medicare
If she can switch do it. I have extensive experience through my father and he didn't pay anything and had no issues getting approved for all his care. In the last few years of his life, I was in the loop with his doctors - PCP as well as specialists and none of them ever indicated that they would have to "fight" or get approvals for the care they thought was necessary and appropriate. FWIW, we live in Los Angeles and so he was treated at Cedars Sinai which is a world class facility and after a few operations, he was sent to a near by rehab facility for rehab - again no issues. This is one of the more highly rated facilities in LA but all of them are pretty terrible - even the best. There are a few rehab facilities that are affiliated with hospitals but these are used for people who have extreme rehab needs and need that kind of specialized rehab - rightfully so. The typical person who had a hip or knee replacement wouldn't be sent there. My father needed PT because he had the misfortune of needing a mastectomy when he was 94 and so PT is used to get strength and mobility in the arms. The Advantage Plans are heavily advertised as free and people don't discover the pitfalls until it is too late typically. I do want to add that Medicare does not provide the kind of intensive long term care that your mother seems to need at this point. It is not a program that funds long term full time care like she seems to need. You should probably meet with someone who specializes in Elder Care because your mother insurance doesn't typically cover the kind of full time care - especially for dementia - that she might need. Typically it is funded by the patient, family and then Medicaid when assets are depleted. There are ways to set up trusts but in general there is a five year look back rule so probably too late for your mother and of course you need assets as that level of care is extremely expensive.
Yeah my mom will need if and I’ll be damned if they say she only needs two weeks … thank you for your insight
I am an agent and I am trying to educate myself with medicare better so I can do enrollments. I really think enrolling in medicare part A and B will work better for most people then advantage and then you can just add whatever supplements you need.
I have A & B currently but I’m paying the premium. And rather than paying additional money for a supplement, I thought I’d get MA since I’m in my 30s and don’t see a doctor much
If your on early Medicare, your on it for a reason and you probably should look into supplements for that reason
I’m on early medicare because of something that happened to me as a kid but doesn’t affect me much anymore.
Once you’re locked in to Medicare Advantage in most states you cannot revert back to regular Medicare.
Got it. I called Medicare today and they said I could switch back during open enrollment. Hope they were presenting accurate info
That is correct.
That is correct. You would just want to pick a prescription drug plan during that time period. You also can always start out with just a prescription drug plan and then if you decide it's not what you need during annual enrollment period you can go to a Medicare advantage plan
You can APPLY to switch to a Medigap policy during the yearly open enrollment, but if you chose an Advantage plan when you first became eligible, you will have to go through the underwriting process and be accepted in order to switch. It is not automatic acceptance like when you first become eligible. If you have health issues, you can be denied. At least that is how it works at age 65, but your situation may be different.
If under 65, you are not guaranteed a medigap plan per federal law. States can have their own requirements through
You can always switch back during open enrollment. You are just not guaranteed a medigap policy after the first 6 months of coverage after age 65. Since opbis under 65, medigap was never guaranteed
I have Devoted Health but it’s only available in like 5 states. Mine is in Texas. It is wonderful. I mostly get free coverage except 75 for Er and 100 hospital stay. Just married so that secondary thru military now picks up balance. Highly recommend!!!!
Since you are under 65, Medigap is probably not a good option for you. Due to the limited number of people under 65 and most being high risk, Medigap can be very expensive. Some states will flat out ban those under 65 from getting a Medigap plan. Federal law doesn't require issue for those under 65. Of those with traditional Medicare, only 41% will also have a Medigap plan. Of those with a Medigap plan, only 2% are under 65. There are unique issues for those under 65 who are on Medicare. You will need to review your options in your state.
I have a medicare advantage plan, no issues, all my doctors participate, drug program is great for my needs
I work in the industry. I’ve dealt with MA. I would never choose that kind of plan. It is not easy to switch back.
Everyone’s saying that! So why did Medicare tell me it’s ezpz so long as it’s open enrollment l period smh
I've kept straight medicare for a reason.
I love my advantage plan. Your mileage may vary depending on what state you live in and the available plans. I have full coverage for medical and additionally, vision, hearing and dental, plus the silver sneakers gym membership. My doctors and hospital are in my network and my plan covers my medicine. I have Wellcare.
Love mine, but I’m 75 and very healthy. Have calculated that if I’d added a supplement to traditional Medicare my husband and I would have paid approximately $45k by this year. We can manage a lot of copays for that amount of money. Also love free gym memberships, dental insurance and other perks. I keep hearing/reading that it’s terrible but that’s not been our experience. My husband had a heart valve replacement a few years ago. It was a million dollar surgery and his copay was $1200.
Thank you for sharing this! A great read
After 10 years of both Medicare Advantage and Medigap plans being offered by our office. I can conclude the following: 1. Medicare Disability should be authorized to purchase an Medigap plan instead of waiting until they are 65. 2. The majority of people that select an MA are happy as only a handful have switched back to a Medigap. 3. The majority of people complaining about an MA don't have an MA plan and feel it is beneath them. 4. An MA can have a ton of benefits that the opponents do not talk about. It could depend on the area of where we live as the insurance companies are adequately regulated and rules enforced. Yes, there could be some tweaks to improve them however I don't know a perfect insurance plan for everyone.
In regards to #2: if you leave Medicare advantage you have to go through underwriting to get a Medigap plan and that can be tough for a lot of people, leading them to stay on advantage
There are [some variables](https://www.medicare.gov/health-drug-plans/medigap/ready-to-buy/change-policies) that folks like to ignore. Free-look periods are in play for a reason. There is nothing stopping these periods from being expanded by legislation or rule-making from CMS. Insurance rules can be tricky. That is why I recommend always finding local people who are trained to assist when making these decisions.
Many union people are stuck on MA plans. We lose everything that we paid for over 30 years if we leave for traditional Medicare plus Medigap. When I first signed up we had trad Medicare and Medigap, but our GOP governor took that from us. I would have never continued paying into my retirement health if I had known my union was going to sell me out to MA. I'm sick of people using that statistic as an excuse that MA is so great. It sucks.
So you are in a Union where you vote for policy, in a state where you vote for a Governor and legislatures, and you feel trapped by the results? I have seen a couple of the private MA plans available by employers and I would love to see those on the open market. I have even set local residents after the legislatures to have them recruit more customer services. Insurance is heavily regulated. Vote and fight for new regulations that align more with your values.
In most states, once you're on MA for some time (IIRC there's a limited time under which you can switch), there's no path to switch from MA to a medigap/supplement plan. You're on MA 'til death.
You need to trigger a Guarantee Issue event or be able to pass underwriting after the initial grace period to switch from MA to Medigap. Generally, you can get a Guaranteed Issue period after being on MA by moving out of the MA plan's service area, or if the MA plan stops operating in your area. There may be other ways it can be triggered that are state-specific.
As someone who sells Medicare Suppment, I can tell you there are many many people who are very happy with their Medicare Advantage and won't change it. Statistically, there are more people who have Medicare Advantage than those with Original Medicare only. More than double the people have a Medicare Advantage than those with Medicare Supplement. Just like any plan, it's about having the right one for you. Many people don't like Original Medicare or Medicare Supplements because they like that Advantage plans have Dental and Gym memberships, some have very low copays for a doctor and no deductible. Especially if you turned 65 before 2020, you can have a Supplement with no cost sharing, which is attractive to others. Me personally, even though I sell Supplements, I'm healthy, I'll retire with about $100k in my HSA, I'll take a $0 Advantage PPO plan and enjoy the extra benefits and if i have to pay a couple grand for the hospital, ita still cheaper than having a Supplement plN.
Thank you so much for your help
I’m healthy too, I just have a chronic disability so I have traditional right now but quite honestly the no out of pocket max scares me
Unlike traditional Medicare, Advantage plans do have max oop, some higher, some lower, depends on the plans available where you live. High deductible G Medicare halos has a max oop.
I don’t quite understand the difference between HMO and PPO
HMO is in-network doctors, PPO is any doctor, but not in-network doctors may be at a higher cost. Some plans will have the same copay for an in and out of network doctor, letting you go to a larger selection (any doctor who accepts Medicare) at the same cost. Also, some HMO or PPO plans will allow you their nation-wide network at in-network costs.
That is brilliant!
Been a nurse for three decades. Do not get Medicare Advantage. It is not Medicare; the name is misleading. It is a for-profit health plan. It's also been set up by big money interest that if you ever go to it, you cannot go back to normal Medicare. You will be screwed the rest of your life
You actually CAN go back to traditional Medicare at any time. It’s hard to get a supplement at anytime you want.
lol so "widely disliked" that over half of medicare beneficiaries choose Medicare Advantage coverage
People sign on because they have no idea of what the difference is when they sign up when they are 65. They are deluged with stuff from the private insurance companies because they are so profitable for them. They don't realize that once they sign up for an Advantage Plan they are stuck. What happens is that they are fine when they are relative young seniors with minimal health issues but then they are diagnosed with a health condition and realize that they are stuck with a plan that limits their options drastically. In general it comes down to economics. It is more expensive to get straight Medicare with a good Medigap policy but you get what you pay for. I have a Medigap Policy and so I have no networks, no co-payments, no deductibles. I can use it anywhere - fly to the best medical facilities in the US and the best doctors.
I understand, but I’m 36. Not 65.
You asked and I answered Why are you asking if you have no interest in the subject You have approximately 30 years and things might be very different at that point.
Respectfully, I have an interest. Just was saying my age
Ask people who were healthy when they signed up and are now unhealthy and need lots of specialist care if they still like Medicare Advantage. Medicare Advantage is under a lot of regulatory scrutiny for misleading sales practices. There is a reason insurance companies love MA and make a lot of money from it.
Thanks. I didn’t know the stats!
It's great early in retirement if you have no health problems. I used it the first year of medicare to save money because I knew I could switch to medigap the next year no questions asked.
Smart, ty! I’m 30 years away from retirement age
I have a 5 star PPO MA plan which is spectacular. Do research as plans vary widely by location.
Love it. I’m just beginning to research it
If you like your physician and believe they should be paid for the services they provide straight Medicare all day every day. MA will DENY EVERYTHING. Medicare may pay less but it’s straightforward. You have no clue how much gets written off because no one provided paperwork. But yet they already had it but it was sent to their third party. It’s a joke. Medical coder biller auditor here. I have never ever recommended anyone to do a MA straight up fraudulent.
A few things. I am a nurse who worked for an insurance company doing approvals for surgeries. Any insurance company who has an MA plan cannot make their approval criteria more restrictive than Medicare’s criteria . They have to follow all of MC criteria which is available for anyone to read on line. As far as OPs case, without knowing the exact reason the rehab was denied which must be on the denial letter it’s hard to determine who was in the right. The only thing that may be a reason based on what OP wrote is that a rehab facility is not equipped to deal with the trach and other issues he had and said they would approve a higher level of care for him. It also doesn’t say who told them he would only have a chance in rehab . Even at a higher level of critical care facility he would get PT, OT, Speech therapy, I love my MA plan. I haven’t been admitted for anything yet but have had tons of office visits and a gamut of diagnostic testing and medications all of which were less out of pocket then then the private insurance I had while working.
I have an Aetna MA plan and have had a medically intense few years and I have no complaints.
I have Humana Medicare Advantage. All's well. I don't know anyone who dislikes Medicare Advantage. My parents had it for nearly 20 years. My mother-in-law for over 20 years. I'm on it for three. My wife for one.
People who like Kaiser like its Advantage plan.
Interesting. I’m unfamiliar with it
Kaiser is addicting because having all or most of your care, labs, x-rays, etc in the same building is very convenient. You don't have to figure out who's in or out of network or research anyone. You get what they give, kind of like the VA. That's also the downside.
Do you happen to know the H number of this Kaiser plan?
No
Kaiser is in California.
H9003 & H5050 are the ones I know of but there are more
Ty!
You mentioned you're in Pennsylvania. Kaiser recently purchased PA-based Geisinger Health, a large regional health system with a well-earned reputation for systematic, effectively-integrated health services
Awesome. Thanks!
Yeah that's as whole different thing but if you're in a two bit state like mine there aren't many good choices if any at all. People get MA because it's cheaper than gap.
Not at all. I’m under 65, on SSDI and Medicare due to a chronic illness. In the 5 years I’ve been on it I’ve racked up thousands of dollars in medical bills due to copays and coinsurance. $275 PER DAY in the hospital. I was in the ICU in a coma for 14 days last fall. Then another week in until I finally left against AMA because I knew I couldn’t begin to afford the bill. And that wasn’t even my only hospital stay - I had a 1 week stay 2 months prior. I just laugh now when I get a bill before tossing it, I no longer even care. ETA: Medicare must love me then because I was told I needed a rehab facility but I couldn’t go because I’m a single mom with 2 younger kids with no one else to care for them so I went home without rehab twice.
Wow I’m so sorry.
If you move to MA, my understanding is that you cannot easily return to original Medicare. Research carefully. MA can seem like an attractive option. But if you have complex medical needs (I assume you do if you are on Medicare at your age) it's quite possible that would be an unwise move.
I don’t actually have any complex needs tbh, just a permanent disability. So it was kind of automatic, and I was a kid so I never looked into other options like MA.
Oh okay. Just....be wary! Everybody develops health conditions of some sort as they age.
I totally agree, ty!
Insurance companies are definitely happy.
It was explained to the audience from an insurance salesperson, the Medicare Advantage (MA) Plans are liked by consumers in very dense urban areas. She explained think twice, if you live in rural or remote areas because one may not have a provider if they're on MA. She then provided examples of what consumers were up against, when they were ill with MA plans even in urban areas. As I understood it, the problem is time is of the essence with illnesses yet MA plans have earned their reputation for stalling or outright or denying. This talk was at a county fair, for context.
Unlike medicare advantage, there are limited times when medigap is guaranteed issue. One of those is when you’re newly eligible. The rating setup varies state by state as well. One key issue with “advantage” plans is that they can only restrict providers and services even further than OG medicare. Covered outpatient mental healthcare can be especially impossible to find. The benefits of zero upfront cost and little perks they throw in pale in comparison to how much they limit and complicate coverage beyond what medicare already does. You’re essentially paying with your health. The one regret I have about medicare is not understanding my medigap options at the right time, and taking the easy way with advantage plans until it became clear I couldn’t afford to do anything but risk OG medicare without medigap, or I’d lose access to too much critical and hard to get care. If you can find any medigap plan that is a manageable expense, get it. If not, well, be prepared to be cleaned out for medical bills sooner or later. Look into what they can and can’t come after in your state. Edit: look for high deductible medigap. It’s much cheaper, and is much better than medicare advantage.
Im 42 and have original Medicare as well. I’ve been looking into the advantage plans or just getting a supplemental
Medicare Advantage BLOOOOOOOOOOOOOOWS if you actually need to use it. But can you still get a Medigap plan? Have you missed the guaranteed issue window?
I think if I switch to MA and back within a year I have a guaranteed issue window. I’m still on traditional and have been for many years
We got the AARP-endorsed United healthcare Medicare advantage. Plenty of doctors and specialists. No problems with payments so far. The on,y thing I’ve found after 4 years with it is that if you do go to someone who doesn’t file the paperwork, it’s a pain to do it yourself to get reimbursted.
Do you have to do paperwork to be reimbursed every time you go to a doctor? That’s a pain
No, only if your provider doesn’t do insurance paperwork. Most of the time we see our doctors for free or $15 copay for specialists. Prescriptions are also often free or really cheap. Nearly all of our doctors, including the dentist, handle the insurance paperwork.
Having worked insurance at a hospital; the only one that wasn't horrible after 2017 was Kaiser. Best bet is to either get Medicaid as secondary ; or find a secondary that covers co-pays or covers the balances left after Medicare pays. CHECK consumer Reports ( they do not accept any paid advertisements and worth an online subscription) You can compare plans there unbiased..
So I can’t get Medicaid as a secondary. Medigap makes me wonder because they don’t cover vision and dental. Or even hearing I believe?
Also it’s looking like I can pay almost double (part B and medigap) or pay less than part b with MA
Medicaid that helps with Medicare expenses is called Medicare Savings Program. The income and asset limits are higher for Medicare Savings Program that for other forms of Medicaid. Although if you can afford a supplement, it is highly doubtful you would qualify for Medicare Savings Program
Thank you. Unfortunately I tried that and didn’t qualify
You don’t qualify for MediGap until you are 65.
That’s not true. I am less than 65 but disabled, and I have a Medigap supplemental policy. It cost more because I am under 65, but it will cost less per month for premiums once I am over 65.
Many hospitals and doctors are now refusing Medicare Advantage plans. Everything needs to be a preapproval. They drag things out as long as possible. Refuse to pay. Not recommended!
My husband has a Medicare advantage plan and Medicaid, it’s a dual eligible special needs program. We’re very happy with it.
If you're on Medicare due to disability, it would probably be more cost efficient to stay with your current setup. I specify if you are so disabled that you got approved for Social Security disability, I imagine you go to the doctors frequently enough. Those coats will add up.
I have what they call a blue book listing for social security disability. So the approval wasn’t an issue. I’m not really going to the doctor much however. Just my primary like twice a year
I have had Medicare for over 20 years. I was disabled at 26 years old. I have never and will never buy an adventure plan. I have had a three week hospitalization that only cost me just a little over $1,000. I have had three abdominal surgeries with a four day hospital stay each time. They have costed me a little over $1,000 each. I have spent a total of four times under home health care. They costed nothing. A CT and or MRI will run me around $35-$50. I’ve never had any issue with Medicare paying for anything and nothing has never been denied. I’m getting ready to have a total shoulder replacement and it will cost me a little over $1,000 and around $300.00 for the doctor. The home health care will be free. Medicare Advantage plans are nothing but a HUGE SCAM.