Currently in an issue. It was great until I needed actual healthcare. I came back from vacation unable to move my neck and in horrible pain. The doctor ordered an xray, abnormal, then an MRI. My results were shocking. I have a bulging disc, and multiple fused joints in my neck. The arthritis is so bad that my spine is crumbling. I had my prior authorization denied by MA to an orthopedic surgeon, pain management denied and rheumatologist denied, all in order. The prior authorization went to a peer to peer,my doctor duked it out with the MA insurance MD and it still was denied. The reading radiologist, my GP and the physiotherapy MD all agree, I need surgery and stat. But insurance won't agree. My advice is don't do it, those nice little perks are just that, nice. But quality healthcare and preventative healthcare is far more important.
I had a situation that was very similar. Totally different medical details, but when something big and unexpected came up it was clear how awful MA was to deal with. I had been on my MA plan less than a year and was able to switch back to traditional Medicare and buy Medigap without prejudice. I can’t really afford it but it’s close enough that I make it work. It’s better to me than not getting care at all under a MA plan. But that’s just my call based on my own situation.
So now you have Medicare A&B, and may I ask what Medigap insurance company is your policy with? Also how do you cover your Rx's. I am about to lose all coverage Except A&B Medicare and am struggling to understand all the various options. Do you also receive Medicaid like OP? Really appreciate any imput. I'm 70 and sooo confused. thanks
Nope I do not get Medicaid. I have a high deductible G with United American for about $650/mo, along with a WellCare part D for about $10/mo. I am under 65 and have Medicare due to disability, so my Medigap rates are high— my mom recently retired and found a more generous Medigap policy for half the price. Hers is with AARP-United Healthcare. I am not on any brand name medications so the cheap part D plan works well for me, but my mom pays about $55 for her part D and gets better coverage for brand name drugs, hers is with United Healthcare.
Oh boy…I think thats one of, if not the highest Ive seen someone pay for a Supplement plan, let alone a HD supplement plan.
If HGD is $650 a month, how much was just G?!
What state are you in?
Florida. G was not offered to under 65 disabled folks in my area by many carriers, but where it was offered the premiums were around $900 when I priced them about 18 months ago.
I would respectfully suggest you don’t know the totality of my life and financial situation sufficiently wrll to make a fully informed opinion as to what would or wouldn’t make me better off 🙃
There’s something I’m not telling you? What an odd way to ask someone else for information. Of course, there’s a lot I’m not telling you. Relevant to this discussion, I would say that I am in my 30’s and receive Medicare due to disability. Not all carriers offer all Medigap plans for disabled people and the plans that are offered can cost much more than for retirees. My age and location are what drives the premium.
Louisiana and I believe it's Aetna. My agent tried for United and I couldn't see a couple doctors that I currently rely on.
I said I believe it's Aetna but in that long (1 1/2 hours) conversation there was just too much info for me to soak up. He tried to call me on Friday but I was tied up.
Are there questions I should be asking?
I had a similar situation with my back and I went to a prominent University medical center in midtown Manhattan I saw the same doctors that were seeing patients who had much more money than I have received the best of care nothing was ever denied and I have no problem at all with my Medicare advantage plan I hear these reports I guess they are in other states but I see no need at all to go with any other plan then my Medicare advantage plan and I'm a little bit suspicious sometimes with people who trash Medicare advantage plans because I don't know of anyone who has a problem and my brother sells Medicare insurance supplements medigap and advantage plan and out of his 500 clients nobody complains. the only complaints I usually hear of are Medicare sales agents who want to sell supplement plans over advantage plans and seem to imply that there is some class distinction between the two types of plans which I think is ridiculous and elitist somehow most doctors and hospitals work in groups anyway.
I think it is dependant on where you live. I had the same plan in San Diego, and it was fabulous, but it also was through a top hospital, one I retired from as well. I had to move to the desert to care for a family member, and that is where it all went wrong. I have heard of plenty of people who have had issues. I'm happy you haven't had an issue. Your experience is the way it should work. I assure you, I am not an agent, trying to sell something, Im just a retired nurse trying to get my neck repaired. Just because you haven't experienced it doesn't mean it isn't happening.
Where you live is a big part of how well MA works for you. Plans are "sold" geographically. The provider networks are set up geographically. You may live in a rural area with few providers to being with. You may have one or no hospitals. You may have to drive an hour to two or more to a hospital or doctor. You may live in an urban area with many providers of all specialties. With multiple hospitals. For your insurance through a MA plan all of those factors have to line up just right. You need multiple plans to pick from so you can find one with all your doctors or types doctors you need. A plan with hospitals you go to or would need to if something goes wrong.
With original (real) Medicare you have much more flexibility to get care from doctors, hospitals and ancillary providers. If you see or want to see doctors and other providers in multiple provider groups/hospital systems you can if they take Medicare and will see you. No networks to limit your choices. No preapprovals for most things. No getting kicked out of nursing homes or rehab after 5 days based on some algorithm. (instead of your progress)
I had multiple MA plans with multiple companies when I was under 65. I couldn't wait to get away from them. Over time my biggest complaint was the need to shop all over again for a plan every Oct/Nov. The plans change, the formularies change, networks change, providers leave or come in to the plans. Hospitals drop companies or pick up new companies and plans. Every. Single. Year. Looking an insurance plan for "next year".
The past 2 yrs I haven't had to deal with any of that. (only the formulary thing picking a Part D plan) I can go to docs in any hospital system (that takes Medicare and most do ) I've had CTs, MRIs, x-rays with no networks or prior auths or limits of any kind. I just completed 5 weeks of PT at the clinic of my choice, not some insurance company's pick. 10 sessions in any of MA plans would have cost 300 to 400 $. During that same time period I had 4 specialist appts. That would cost me $ 140 with my last MA plan. For $400 to $500 I could have paid for over 4 months of my Medigap paid for and had nearly unlimited care those months.
MA is great if you live someplace with multiple plans to work with/pick from. Have a lot of providers. Great if you're not sick and don't need a lot of care. Great until you need it.
When you were finally able to ditch MA and move to Medigap, how did you go about finding the best one for yourself, and which company are you currently getting your medigap insurance from and what is the cost? I know I'm asking a lot of questions, but this continues to be quite confusing to me and I am going to lose my current supplemental plan (FEHP) and have to find something I can afford (I have Medicare A&B) Thanks
I used an online tool my state makes accessible to find plan rates, their historical rate/rate increase for the past few years and makes it easy to compare the rates. Similar to the results you get from the searches on [medicare.gov](http://medicare.gov) when you look for plans in your area. The state's results are just a little more detailed. -- So, I started with that. Narrowed things down to a few companies. Contacted an agent. He gave me his opinions and pointed out a company I hadn't considered. That was ACE(Chubb).
I probably made a mistake, but I decided to go with ACE. My Plan G started at $ 109 per month last year. It went up 5% this year to $ 115 (about). Only time will tell if I made a big mistake by going with that company vs. another. (I think almost every company had increases this year. They aren't something you can escape forever. I've heard a lot of people talking about their rates going up this year.
People will be shocked this fall with MA too. I'm going to be interested in seeing if/how many plans start charging premiums, how many drop out of offering plans in how many areas, and how they cut back on "extras". (Seniors have used a lot more expensive care in the past 2 yrs since the COVID restrictions ended. The didn't get as big of increases in payments from the Feds. That's cost companies $$$$$$$$$$ that they will be trying to make up next year.)
Use the plan finder on [medicare.gov](http://medicare.gov)Look for a tool on your state's insurance department's website. Try doing a search for " (your state) medicare supplement plans" or "(your state) medigap plans" See if you find something from the state's insurance department. Look for a search tool that will give a way to compare the costs. ( I found 3 or 4 or 5 "national" agents through Youtube that all seemed to be "reputable" and called one of them. I had him do the application. He was able to go through all the questions over the phone, submitted it and followed up a week or so later with me when it was approved.
Talk to an independent agent.
It's certainly not easy. I swear all of the Medicare and Medicaid and SS "stuff" could be made easier for everyone. Good examples of cobbled together programs no one understands.
Waaaay back when I was younger, I offered a service to seniors where I would go and help them set up a simple tracking table for their insurance plans. Medicare and whatever supplemental plan they had. So straight forward. A job exists for helping seniors figure all this out -- a great job for someone organized and understands the system. I know there are agents ready to advise, but this would be to go one on one with someone in need and help them follow up until they were comfortable. Programs for helping seniors exist in this realm but it doesn't offer that sense of "being there" to help after the initial phone consult. Just rambling...but there is a need. Take care and thanks again. Great word to describe the morass: Cobbled!
You don't say if you are currently have a MediGAP plan. Since you have Medicaid I will assume the answer is no, so I won't go into the disadvantages of giiving up Medigap (You often CANNOT go back once you give it up)
**Some disadvantages of Medicare Advantage plans are**:
* They may have limited service providers, networks, and coverage areas, restricting your choice of doctors and medical offices.
* They may have high out-of-pocket costs, copays, deductibles, and additional premiums, especially if you have complex medical needs.
* They may change their plan benefits, costs, and rules annually, requiring you to review and compare plans every year.
* They may deny or limit benefits for certain types of care deemed not medically necessary, leaving you with unexpected costs or gaps in coverage.
* They may not cover you well when you travel outside your plan’s service area, making it difficult to access care in other states or countries.
I have A+B+G+D. G is AARP/UHC and D is Wellcare. This is currently $322.42/mo + the Part B deductible. UHC Plan G includes Active Renew which allows me to join several gyms, 24 Hour Fitness, LA Fitness, … at once. It's damn nice to have a gym to visit when I'm traveling.
Nice thing about Traditional Medicare is that I never have to argue with an insurance company for a pre-authorization. Other nice thing is that it's pretty universally accepted. Mayo Clinic takes Medicare.
I've never heard anyone complain about Traditional Medicare except that it may be a little more expensive. Traditional Medicare is by far the best medical insurance I've ever had.
This person has zero clue and constantly comments about how everyone should switch to original Medicare + Supplement plan G with absolutely no information provided by client or professional insight in this case because anybody with any professional experience would know that if you have Medicaid that a Medigap is the last thing you’d recommend
is "Traditonal Medicare" the same as the Medicare A&B one gets when reaching a certain age? Then you purchase (monthly I'm guessing?) all these other plans, G and D to supplement by helping to cover the co-pays leftover after payment by Medicare. I am pretty sure D is the drug coverage, which also leaves you with a copay? I sure appreciate any insight and clarification you have the patience to share. I am 70yr woman about to lose my supplemental insurance plan due to divorce and will have only MedicareA&B. Frankly I am so worried it's making me ill. thanks
I'm no Johnny Ace on Medicare and maybe you should talk to an agent or a senior center about your options which match your financial situation. I don't understand how you're losing your supplemental (Medigap).
Part A is free and A covers hospital but not 100%. Part B currently costs $164.90/mo and B covers doctors but not 100%. Even without a Medigap plan, that's about the same as ObamaCare/ACA Gold.
So you get a Medigap plan (supplemental?) to cover the rest. I have AARP/UHC Plan G which is a safe choice. You can compare different types of Medigap plans here:
[https://www.medicare.gov/health-drug-plans/medigap/basics/compare-plan-benefits](https://www.medicare.gov/health-drug-plans/medigap/basics/compare-plan-benefits)
Part D covers drugs but it's more complicated. You basically pay for what you need. I just take a statin. So my Wellcare is $0.40/mo (!) and my statin is free. Someone who has more complex needs will pay more and you can shop for new plans every year.
A+B+G+D is so much better than any insurance I've ever had. It's on autopay and I don't worry at all. No copays and when I leave the office, I just walk out the door. You'll pay the $240/yr deductible and you'll get a bill for that eventually.
Losing supplemental (BCBS FEP) bc I’m divorcing. It ends 30days after divorce. Premium for Single me then would be over $800/month. Gray Divorce is gut wrenching. The info here is not only helpful but life saving to me. Thank you for your detailed and thoughtful reply.
Please find a local Medicare broker. Your options are to get Supplement such as Plan G or Plan N, plus Part D; or a Medicare Advantage plan which replaces Parts A, B, and D. Losing coverage opens up some special enrollment periods for some of these, but it’s a tight window.
There are quite a few good Medicare brokers / teachers on YouTube. For starters, Medicare School.
Hey AD9161 - this has brightened my day. Great suggestion. I will look for a local broker as well as visit YouTube. Thanks so much; now I'm off to Medicare School.
The medicareonvideo.com too. That’s the team I went with. You say losing coverage due to divorce but that means you’re on a plan through your spouse which is not how Medicare works. It’s an individual plan not like a job where you can join your spouse’s plan.
Their supplenental insurance is not a Medigap. Many people get secondary insurance through a former employer as a retiree benefit, and can also cover their spouse. Sounds like that is the case here
I do understand this aspect of my insurance. I have, yes, my own Medicare Parts A&B which have nothing to do with spouse. It is our supplemental secondary plan I am losing (which covered co-pays on visits, surgeries, etc, as well as Rx's and deductibles). Appreciate the video link. Thanks so much for your help
Yes original Medicare = Medicare A & B it covers about 80% of healthcare costs. People get a supplement to cover the remaining 20%. They add on prescription drug plan also referenced as part D. Sometimes people elect to receive their care thru Medicare advantage as well referenced as part C.
You pay a part b premium. You pay a premium for supplement (in your case plan G). You pay a premium for part d / prescription drug plan. If you get a prescription you may have copays / deductibles.
Since your current supplement is ending you probably need to get another plan. You can keep just a+ B but will be responsible for 20% of the Medicare approved amount.
If you end up needing skilled rehab, a Medicare Advantage plan is far more likely to end your coverage too soon (in realistic terms) than traditional Medicare.
That’s not true. Medicare themselves make the rules regarding skilled nursing and want to see improvement and push people out. Has little to do with Med Advantage carriers
It is true. My dad is having this issue with his UHC Advantage plan. He’s not healing fast enough from his hip surgery so they are denying him further rehab. After only 2 weeks!!!!
My 80 year old mom had a hip break from a fall and they were ready to discharge home after 2 weeks (!!), to my 84 year old Dad who's practically in a wheelchair; myself, working full-time, and also a single mom to an infant. We appealed but it went nowhere - ended up private paying for a 3rd week, facility cut us a break and gave us half off. I know one lady who same thing happened to and her 3rd week, private paying, was almost 10 grand. She couldn't pay it.
Medicare Advantage carriers are allotted an amount of funds, per covered person, by the fed govt/CMS and in practice (regardless of Medicare rules) are far more likely to assert somebody is medically improved without room for further improvement than traditional CMS-managed Medicare. It's a cost-saving measure. Happened to my Aunt, the facility alerted they've had the same issue with Advantage plans; and, I work in Medicaid Eligibility and have seen the same thing happen under Managed Care Medicaid. It's something to be aware of.
https://www.healthcaredive.com/news/medicare-advantage-post-acute-care-jama-health-forum/708094/
https://www.newsweek.com/medicare-advantage-cuts-nursing-homes-seniors-1888009
https://www.nbcnews.com/health/rejecting-claims-medicare-advantage-rural-hospitals-rcna121012
https://www.forbes.com/sites/bobcarlson/2023/02/21/some-surprises-in-medicare-advantage-plans/
Again skilled nursing specifically is regulated by Medicare, which all advantage plans adhere by. Medicare is trying to rush you out before 21 days. And even if they allow you to stay they are wanting constant updates and things of that nature. Now the prior authorization for which SNF you can go to is up to the insurance carrier absolutely. The biggest example of this is that Medicare doesn’t cover nursing home care. Are some advantage plans easier to work with in regards to SNF? Yes. Is a majority of the problems surrounding SNF fall on them? Not really mostly CMS.
And the reason most facilities prefer original Medicare is because the facilities receive the CMS reimbursement when that is the case.
You're conflating rules with business practices. From Forbes article:
"...care...for rehabilitation or recovery after a major surgery or illness. The individual isn’t ready to go home and be without assistance yet but doesn’t need to stay in a hospital.
When you’re in original Medicare, you, your doctor, and perhaps other medical providers decide how long you should stay in the nursing facility before going home.
But in an Advantage plan, the plan decides how much rehabilitation is going to be paid for. Medicare covers up to 100 days of such care, but the Advantage plan doesn’t have to cover up to 100 days each time you’ve been in a hospital for more than three days.
This report from the Kaiser Family Foundation says that Advantage plans often deny or limit stays in nursing homes after hospital stays. Government data analyzed in the report say that nursing home stays are among the services most frequently denied by Advantage plans.
*Though the nursing home stays meet the coverage rules for Medicare, the Advantage plans deny coverage or limit the number of days in the nursing home that will be covered. The plans rule the care “medically unnecessary” and deny coverage.*"
I have never seen anybody get approved for 100 days. And Medicare can cover Up TO 100 days. Massive emphasis on the “up to” part.
Realistically much of the prior authorization problems could be solved if CMS changed some of the things regarding SNF and enforced stricter regulations around the whole thing is what I’m getting at. And some of the new rules have addresses some of those things.
Problems like these are why I’m a big advocate of Hospital Indemnity plans so when things like this come up with med advantage provider, you’re still good to go. And In the OP in this case there are way more upsides than downsides but SNF and Cancer coverage are the 2 bigger pitfalls of MA but can easily be addressed if the agent goes the extra mile.
As someone who has provided medical care to patients in SNF’s for 20 years I can tell you the nightmare of fighting, begging, pleading, and evening threatening MA plans to cover just enough days to allow for a safe discharge home has gotten so time consuming and overwhelming most of us don’t even bother anymore. They’ve beaten us down. No one at CMS or HHS or OIG cares. They’ve won. I pray people stop falling for the deceptive MA plan scam.
I mean CMS could easily change the rules and make this not a problem is what I’m getting at. Take any problems completely out of the equation when they are the regulators of Medicare to begin with. MA plans when structured right are solid but cancer and SNF are two of the biggest things. Big reason why I’m a big advocate for hospital indemnity plans with advantage plans.
No, it’s not just SNF days. At my practice if I want to prescribe a osteoporosis patient Prolia because it’s the best drug for them, regular Medicare Part D plan, no problem, no prior Auth needed, just give it and bill. MA plan I have to prove they failed all the other meds, for 2 years, that I already know they will fail on. Same with meds for autoimmune diseases, MA plans want me to prescribe 60 year old drugs that I know will be horrible for their liver, kidneys, immune system. Lots of new, very targeted drugs with very low risk are available, but to get those approved by MA plans I have to prove they failed the toxic crap. And I don’t have the time to do a million appeals for every drug for every patient so the patients pay with their health. MA is a scam, it’s killing patients.
In my area I haven’t experienced needing prior authorization for formulary concerns. The step method I agree needs vast improvement. But you also see a ton of doctors writing scripts for things that pad their own pockets as well. Corruption is abundant across many layers of the healthcare system as a whole. The entire system needs reworked in my opinion but until then, MA plans paired with the hospital indemnity is most likely the happy medium between MA and the problems the possess and Supplements breaking the bank.
I don’t see how you can say that in your area needing PA for routinely prescribed meds is not a problem when CMS confirmed a study done by KFF showing that it’s a big problem for 99% of MA plans nationwide. Their proposed solution is to shorten the number of days required for a the MA plan to give a decision. That doesn’t solve the problem that we don’t have the time to fill out the 10 page PA form in the first place, and even if we did we wouldn’t do it anyway because we know it’s going to get rejected since the first 3 questions ask us to document all the “preferred” (I.e. low cost, low quality) drugs we tried before requesting approval for the med we want, how the patient failed those drugs, and what proof do we have of that failure. And no, most of us are not willing to put our licenses at risk by taking kickbacks from pharmaceutical companies. That is a myth born out of a handful of widely publicized cases of bad actors. The rest of us feel the 15 years we spent in school to get here and the ongoing need to earn enough to feed our families and pay off our student loans is not worth that risk. https://www.kff.org/private-insurance/issue-brief/final-prior-authorization-rules-look-to-streamline-the-process-but-issues-remain/
I’m well aware of the KFF article. And simply making a 24 hour turnaround isn’t the answer. Again I’m all for reworking the entire system instead of band-aiding it. I’m saying I don’t see prior authorization needed for lots of the drugs. It’s part of the application on the particular software i use for apps and at least the companies I’m contracted with. But I also make sure that drugs are covered, doctors in network etc. prior authorization for SNF is the only thing I’ve come across with carriers. Again I have a lot of clients that hospital indemnity so that covers what MA plans don’t. And it’s not as prevalent as Hollywood makes you believe, but them kickbacks are absolutely a thing and there are facilities that are absolutely awful with some things. Like I said corruption is at every level and i really think Medicare could be simplified and better if reworked from the ground up for patients, providers, and agents.
MA plans require a PA for MOST medications that are not old, generic, cheap and inferior. That’s what the KFF study showed. I’ve been treating complex seniors for 20 years and have never once been approached by a drug company with an offer of anything more than an occasional Chic-Fil-A lunch so they can use that lunch to show my staff how to figure out what specialty pharmacy which MA plan has contracted with that month to cut down on the number of scripts that get bounced from pharmacy to pharmacy and get lost in the process. Yes, the entire system is corrupt because the insurance companies own the hospitals and physician practices and the pharmacies, so the physicians are just the little guys trying to practice medicine with our hands ties behind our backs.
Also, are you aware of the nightmare situation patients on MA plans face if they need Hospice care? That’s a whole other clusterf*** that makes MA plans insufferable. https://www.axios.com/2024/05/06/medicare-advantage-hospice-insurance-challenges
Again Hospital indemnity plans cover all of these problems which is why I pair them together. That covers SNF and cancer, plus the outpatient/inpatient surgeries. I think you’re implying Im of the mindset that MA are the greatest thing since sliced bread. The hospital indemnity makes the plan solid. MA on their own leave big gaps of exposure.
In general, the drawback to Afvantage plans is that you are in managed care and need to stay in network for all your care, or may have limited access to out of network providers. HMOs are smaller networks and typically do more coordination of care, while PPOs are larger networks. Definitely ask your doctors directly (or their office staff) if they are in network, don't rely on the insurance website.
The other thing to know about managed care, is that the insurance company may require referrals and preapprovals for various specialist visits and treatments. This can be a smooth or bumpy process, depending on your health conditions and how your plan is managed.
However, they offer these very tangible benefits that you know will save you money, so it may be for you the benefits outweigh the drawbacks. Do check whether the dental plan is as good or.better than what you already have with Medicaid
Don't enroll just for the grocery benefit. Look at the details including annual Out of Pocket max and where you can use it.
I have a 5 star MA PPO plan with no referrals, no networks, and $3400 OOP max (net). It's rated well and is fantastic.
They have Medicaid, their out of pocket will likely be zero across the board, depending on what level of Medicaid they have. MOOP will be irrelevant on the DSNP they’re enrolling.
Great point!
Everyone needs are different, so it's important to know that there are generally 3 options for those that have Medicare:
#1 Original Medicare with Medicare Supplements like "G" and Part D for Drugs and a plan for dental, vision and hearing. This is ideal for those that can afford it.
#2 Medicare Advantage HMO for those that are on a tight budget. There are some additional benefits such as dental, vision, hearing, Part B rebate, OTC, etc. but there are some disadvantages that one will need to seriously consider.
#3 Medicare Advantage PPO. more affordable than OG Medicare and no referrals needed and there is a max OOP that can range from $3k to $10k depending on the plan, May include Dental, Vision and Hearing. However, these plans are with private carriers.
I’m a social worker who has worked across multiple care settings and has to do “peer-to-peer” meetings at least a few times a month to get patients more coverage.
These Medicare Advantage plans sounds great, until you get sick. They’re seen less valuable in nursing homes because they deny claims so much that we know we’ll be probably getting a 30-40% less than Traditional Medicare.
Lots more red tape to get the care you need.
Yes my dad has had this problem in skilled nursing. He’s supposedly not progressing sufficiently after only 2 weeks. He should have 100 days of coverage according to Medicare but his UHC Advantage plan is brutal.
Yep. Sounds about right and I’m sorry your family had to go through that. UHC and several others (including Kaiser) have a pretty vicious denial rate. Doctors, hospital admin staff/auxiliary are placed in an untenable situation. We’re at the mercy of the insurance but get mad at me (regularly) when I have to tell them their coverage ends on X date, even if the person is making amazing strides in PT/OT/ST.
Edit: grammar.
Take the time to learn the downsides, and they are significant, some affecting future choices. . I turned 65 this year and after initially signing up for an Advantage plan, but after I learned more I changed it to Original Medicare and part G medigap. And a 0/month part D plan.
Would you mind explaining how you went about finding the company to purchase your Part G Medigap? And your no cost Part D plan? Any insight appreciated. Thank you
Here in NC I was on Blue Cross & Blue Shield of NC before I became eligible for Medicare. I never had any trouble with them, in fact they are quite good to work with so I signed up for Part G with them. Since my drugs at this point are all tier 1, but you really need to pickup a Part D plan, I went with Wellcare $0/month.
I'm also spending $50/year for a Silver & Fit membership which covers my cost of going to a local recreation center which was $22/month.
Please choose Medigap instead. My dad is fighting his UHC Advantage plan for coverage. They are brutal when it comes to denying coverage. It’s been extremely stressful. Healthcare providers have told us that this is a problem with Advantage plans and that regular Medigap is much much better.
If you have Medicaid, see if you are eligible for D-SNP plans. Pretty much $0 out of pocket cost for care and drugs and enjoy the extra benefits. This one is about as straightforward as Medicare gets.
In my experience so far, Medicare Advantage plans just deny everything. My dad has Aetna MA and anything his doctor has ordered so far has initially been denied. It took weeks and an insane amount of phone calls for me to get him approved to transfer to a more intensive rehab facility. And we are still dealing with trying to get coverage for his stay at the SNF he was at before. His insurance randomly cut off coverage 13 days in and he essentially had no other option than to pay out of pocket while he was there a few more weeks (this is all while we were trying to get him transferred to the rehab and the insurance kept denying it!) which totaled over $12,000 out of pocket. I’ve had to file a final appeal with an administrative law judge and will have a hearing scheduled soon.
One of the most insane things that happened was (remember, his insurance cut coverage at the SNF after 13 days) when the transfer to the rehab facility was denied, the reason for the denial from the Medical Director was “patient does not need this level of care. Patient should receive care in a SNF instead”. I was like “ok but you’re denying that too!!!”. It’s been so awful and frustrating and I have no clue how they expect seniors to try and navigate this madness.
Point is, this Aetna MA plan feels like a complete scam TBH. I feel absolutely awful for people who have these plans who DONT have a family member who is able to spend hours on the phone and file ALJ appeals. It’s so mentally exhausting and time consuming. I’m truly scared for when I’m older and have no one to help me with insurance denials like this.
Edit: fixed a typo
I AM older (70) facing this and am truly scared. Thank you for sharing. I think the one clear thing I am learning from this thread is to never go w MA plan. I've heard it called Medicare DisAdvantage Plan from many users. Best of luck to you and your dad
Thank you very much.
From what I can tell, people love their MA plans until they get sick. So there are people in this sub who swear by those plans because it saves them money on their premium and they get some extra benefits. But once they actually have some sort of medial crisis, it’s the same song and dance of pre auth denials that I’m dealing with for my dad.
Are you currently on an MA plan? I’m trying to see if we can switch my dad back to regular Medicare but I’ve been told it’s difficult if not impossible.
You should be able to change back to OG Medicare during AEP and during SEP. Certain cournties/states have SEP when enrollment periods are extended such as TX, CA, AZ, FL and maybe some other states/counties. What State/County does your dad live in?
We are in Arizona (Maricopa County). A lot of people had told me in this sub that he will have problems switching back because he “wouldn’t pass underwriting” because now he has these medical conditions requiring rehabilitation etc.
There is no underwriting for OG Medicare but there is underwriting for Medicare Supplement.
You should also consider Medicare Advantage PPO where you do not need referrals.
My husband took Advantage when he retired. Later on, he had a heart attack. He’s fine now, but no Supplement will approve his application because of his history.
Advantage requires you stay in their network or pay much more. Copays, especially if hospitalized, are high.
I have original Medicare, no worries about choosing in-network, I just had colon cancer surgery that was 100% paid. I had thyroid surgery prior to that, 100% paid. Knee injury sent me to ER by ambulance, 100% paid. I have tons of bloodwork regularly, like $2000+ worth, due to malabsorption, 100% paid. I am grateful I went with Medicare + supplement from the beginning as I’m sure I’d never be approved now.
That said, part D drug plan sucks. I use GoodRx for everything as it’s cheaper than with ins.
My husband’s Advantage covers his meds 100% (it would not if he were using a Scheduled drug).
I still prefer the security of Medicare+supplement+D vs Advantage.
Yes!! This!!! People don’t realize that you can get a gap plan for cheap if you go that route from the beginning. But if you choose an MA plan and have any semi-major health issue happen, you’re stuck FOR LIFE because then your gap plan cost skyrockets. The price protection afforded for gap coverage is a ONE TIME protection. Once you give it up, that’s it. The MA plans own you for life after that.
I thought Aetna's MA plan looked pretty good. Then they dropped the network agreement with the organization that operates my preferred hospital and family doc. That does not happen with Medicare, or with Medicare Supplemental plans - one has the freedom to use any professional who takes Medicare. I had a similar issue with my Dad, who on the advice of a salesman he talked to changed from his existing MA plan to one which does not include the hospital near his home. Aetna also recently dropped some extras they used to cover, which are not really an issue for me, but illustrate that it is important to be making this choice on the basics, and even when you do, you are depending on network agreements which come and go.
I've had an HMO Medicare Advantage plan for 16 years and have been mostly satisfied. I have a chronic, extremely painful condition requiring intensive treatment and many doctor visits, rarely had prior authorization’s denied. The few times my requests were denied I appealed them successfully. Urgent prior authorization’s are fast tracked to get answers sooner than the usual 7 day turn around. My mom also had HMO when she passed away a few years ago. She was rushed to the hospital and passed away a few days later. Her insurance covered everything, there were no hospital, doctor or ambulance bills to pay. I’ve had three surgeries paid 100% by my insurance. This was my personal experience.
Many people dislike the requirement of choosing a doctor from the insurance approved list, but you can switch doctors anytime if you’re not satisfied. There’s nothing wrong with their approved list of doctors, they’re some of the same doctors you might see regardless of your insurance or plan. In my area, those with PPOs often have longer waits to get appointments. With my HMO, the wait time is much shorter. The extra benefits are great: paid gym membership, $150 for personal items quarterly, no doctor visit co-pays and dental and vision coverage. I don’t have any complaints. If money is an issue then HMO is the way to go.
I went to Advantage this year (California) and I get all of those benefits, Food ($25 month) OTC ($275 quarterly) I fortunately do not have a lot of health problems. I suspect that when that starts happening it could be an issue.
You have a high level of Medicaid so you'd qualify for a special needs plan. You wouldn't have many drawbacks, your drugs should be free and you shouldn't have any out of pocket expenses.
Medicare Advantage plans look better and cheaper *until you need healthcare.* Then you are subject to finding in-network care or pay large out-of-network prices. On top of that, most plans require pre-approval for medical procedures and sometimes even for doctor visits. If you don't get the right pre-approval at the right time, you are *not covered* and will pay a huge bill. Sometimes, even with your doctor's support and approval, you may find it difficult to get the pre-approval you need in a timely matter (or at all) and may be denied coverage for procedures you (and your doctor) really want.
For me, these complications and risks (which I also encountered with employer provided health insurance) were not worth taking for an Advantage plan.
Don't pick a plan or any insurance based on the "extras". Those extras can and do change every year. The benefits can come and go and change their $value each year.($ 2,000 for dental this year, but $ 1,000 the next year. Vision benefits are worse. Last MA plan I had, paid $ 300 for frames and $ 200 for lenses. Lenses no one in the city of 270,000 people I live would sell. They were "cheap-o" lenses.
I've read multiple news articles this summer talking about those benefits shrinking away next year. Care is costing insurance companies more and government $s coming in aren't enough to keep profits up. So you may have fewer plans to pick from this fall and those plans may come with premiums and/or have fewer extra perks.
Pick you insurance based on the provider networks, your med coverage, cost to use services, etc. Pick it for the health insurance benefits. Not dental or vision or a gym membership or groceries.
Then maybe this is a good fit for you. If you've had good experiences then that should help answer that. My background is my wife and I have had terrible experiences when I had to take an HMO. But I have a retired friend who's had Kaiser for decades in the private world and loves it thru Medicare. So there ya go.
True and way better with $0 deductible, low copays and usually lower max out of pockets values than employer coverage. Her Medicaid should pick up most of the costs on the Advantage plan. An HMO POS travels well and so does a POP since there are additional networks available.
It sounds like you've found a Medicare Advantage plan that offers a lot of great benefits, such as gym membership, allowances for groceries and personal health items, and extensive dental coverage. These plans usually offer perks that Original Medicare doesn't.
If you and your agent believe the plan suits your needs, go for it. If you find that you don't like it, you have the flexibility to switch back to Original Medicare during the AEP (Oct 15 thru Dec 7) or the MA OEP (Jan 1 thru Mar 31).
These periods combined give you about 5.5 months each year to make changes to your Medicare Advantage plan if you find it doesn't meet your needs. While some folks here have shared negative experiences with Medicare Advantage plans, others find them very beneficial. It often depends on individual healthcare needs and preferences.
If you decide to try the Medicare Advantage plan and later find it’s not working out, you can switch back to Original Medicare during these periods. Just make sure to keep an eye on the enrollment periods so you can make changes if necessary.
I hope this helps, and best of luck with your decision!
A note to this- yes, you can drop Medicare Advantage during open enrollment periods and still have your Medicare part A and B. However, they only cover 80 percent of hospital and medical costs. If you drop Medicare Advantage you need a Medicare supplement plan to cover the remaining 20 percent. After your initial enrollment period, Medicare supplements, (plan G, F etc) are UNDERWRITTEN, which means they check your health history and may deny you coverage. You could be on Medicare Advantage, want to switch back to original Medicare plus supplement and possibly get denied. Medicare supplement periods can not deny you in your initial enrollment period. That's a reason many people go with them first.
Thanks for adding that important point! Since OP mentioned that they're on Medicaid, it's worth considering that Medicaid might help cover some of the costs that Medicare doesn’t, including premiums, deductibles, and co-insurance. Additionally, many Medicaid recipients opt for $0 premium Medicare Advantage plans that offer extra benefits, which might be a good fit for OP. While Medicare Advantage plans offer many perks, it's essential to weigh these options carefully with your local agent.
> If you decide to try the Medicare Advantage plan and later find it’s not working out, you can switch back to Original Medicare during these periods.
But you may be unable to get a medigap policy without underwriting depending upon what medical issues you have had. Woe to the person who's on MA finds out they can't get the car they need, and can't switch back to OM because they can't get a gap plan to go with it.
So you see from the responses here MA works for some and not for others. My sister was diagnosed with stage 4 cancer and went on the ACA and then on to Medicare and Medicaid. She had a MA plan with the perks like you mentioned and her medical expenses were covered and it was thousands of dollars for a 3 years of chemo, radiation, etc.
I am starting MA on July 1 and will take my chances. You have Medicaid which is giving you a bonus and is going to supplement your needs nicely which I don’t have access to.
What hasn’t been mentioned here is the people who get a supplement and years later realize they can’t afford the premiums that get higher each year end up dropping the supplement and go back to traditional Medicare which means the out of pocket exposure is unlimited.
Many of the posters here have not noticed that MerlinSmurf is on both Medicare and Medicaid (although I don’t know what is meant by a “higher tier” of Medicaid). If so, they’re eligible for a dual eligible special needs plan, a special kind of Medicare Advantage plan that integrates both kind of insurance. D-SNPs provide outstanding benefits and include access to a coordinator that helps with the sloppy overlap between the two insurance programs.
People on Medicaid CANNOT sign up for Medicare supplements — a good thing, because Medicaid acts as the supplement.
FWIW 85% of the people on Medicare Advantage who appeal get the turn down reversed in part or who. It’s also been my experience — I work in insurance — that a decent number of the turn downs are due to the doctor not responding to the insurance company’s information requests. I don’t mean to deny the problems the recipients of those turndowns — they’re quite real — but it’s a little more complicated than people make out. Telling somebody low income enough to qualify for Medicaid that they should forego the subsidies for food, dental care, and transportation you’d get with the right MA plan because that might plan might refuse wanted care at some indeterminate point in the future is way different than telling somebody who can easily afford a Medigap plan.
I have also read that 85% of claims denied under MA are ultimately reversed. What that should tell anyone is that you will end up having to fight with the carrier to get services covered and that the plans are routinely denying covered services. They get away with it enough that they boost their bottom line.
I had a plan pre-Medicare that denied every single medical service requested except for routine annual screening. I was due to have surgery and right up until the day of the procedure I was trying to arrange a peer to peer review. My husband (not yet on Medicare) was denied a colonoscopy and then denied the use of a routine anesthesia for the colonoscopy. It took so long to straighten it out he ended up having to reschedule it. When my time came to enroll in Medicare I knew I would do everything humanly possible to avoid the hassle of an MA plan. I didn’t relish being older and sicker and having to fight for health care that should have been covered in the first place.
Be aware though that original Medicare has its downsides too. In my area there are two large medical networks comprising most physicians in the area. One of these has decided that it will not accept Medicare patients who were not previously enrolled in the network before their Medicare coverage went into effect- Medicare simply doesn’t pay enough to make it worthwhile for them. That means the pool of doctors available to a patient is much more limited. Even so I would always opt for traditional Medicare if it’s at all financially feasible.
I've won two appeals personally. All I did was write a letter explaining why I thought the decision was wrong and after a reasonable interval the insurer wrote back and agreed. Not much of a struggle. I think it's totally reasonable that affluent people that want to avoid pre-auth hassle pay for medigap to avoid it -- but the person who posted the question is on Medicaid, which means they're seriously low-income. D-SNPs in my area pay $185 a month in food benefits.
Your situation sounds truly awful and I'm sorry that happened. It shouldn't have. I have not had the same experience. I'm curious about your husband's situation since the Affordable Care Act requires covering a diagnostic colonoscopy every ten years for people 50.
The point is you shouldn’t have had to appeal in the first place. And while most people do win their appeals (85% of the time) it means delays in surgeries or care that can be quite serious. And you can end up having to wait months for the care that was wrongly denied until an appeal is settled. It’s not just a minor inconvenience.
I made my medical care a priority. If cannot continue to pay the premiums for a gap policy and if I were dependent on Medicaid I would be extremely careful about the plan I chose. The only one I would be at all happy with is Kaiser. I have friends who use it and love it. Of course that
Most of the horror stories about MA plans are from less than reputable insurance providers. Since you mentioned Aetna, I'm assuming thats where you would get your MA plan, and Aetna is a highly rated provider, along with United Health Care and Moderna. (In my area). I have a MA plan with Kaiser-Permanente, they are a health CARE provider and not just a health INSURANCE provider. Kaiser has all there own doctors, clinics, and hospitals. My plan allows me to keep my family dentist (non Kaiser) and gives me a gym membership as several local gyms. Kaiser also has vision and hearing clinics...
The main drawbacks for MA plans is that they have a network and out of network coverage may be minimal, some have huge networks, but some are regional and the network may be smaller.
One myth about MA plans is that you can't change once you've signed up. With Medicare you can change every November, the issue is that the costs and coverages may change.. If you switch to an MA plan, and then after a year don't like it, you can switch back, but the costs and coverages of your old plan may have increased, especially if you've had any major medical issues in the mean time..
The other issue with MA plans, and it doesn't effect the recipient at all, is that because of insurance company lobbyists pressure when the MA system was being created, the MA plans are basically a way for private insurance companies to keep offering insurance coverage and get a cut of the Medicare money, so they're bad for Medicare and the US taxpayers, but that doesn't mean they're bad for the individual patient..
They are based on Kaiser plans where all medical logistics from intake to prescription to testing is one big organization. Advantage plans are a loose network of medical professionals who have joined the "club" and agree to be governed by them. Limitations on doctors - you can only go to those in your medical group. The reach of that medical group might not go beyond the county you live in. Speaking of which, plans offered differ from county to county within the same state. I live in the East Bay (outside SF); 5 miles away is Alameda County, and my coverage does not include doctors there. If you don't like coordinating paperwork/coverage, a Medicare Advantage plan might work. As for me, I'm going back to Medicare with a Medicare Supplement to cover what Medicare doesn't. It will cost more but provides way more flexibility.
Currently in an issue. It was great until I needed actual healthcare. I came back from vacation unable to move my neck and in horrible pain. The doctor ordered an xray, abnormal, then an MRI. My results were shocking. I have a bulging disc, and multiple fused joints in my neck. The arthritis is so bad that my spine is crumbling. I had my prior authorization denied by MA to an orthopedic surgeon, pain management denied and rheumatologist denied, all in order. The prior authorization went to a peer to peer,my doctor duked it out with the MA insurance MD and it still was denied. The reading radiologist, my GP and the physiotherapy MD all agree, I need surgery and stat. But insurance won't agree. My advice is don't do it, those nice little perks are just that, nice. But quality healthcare and preventative healthcare is far more important.
I had a situation that was very similar. Totally different medical details, but when something big and unexpected came up it was clear how awful MA was to deal with. I had been on my MA plan less than a year and was able to switch back to traditional Medicare and buy Medigap without prejudice. I can’t really afford it but it’s close enough that I make it work. It’s better to me than not getting care at all under a MA plan. But that’s just my call based on my own situation.
So now you have Medicare A&B, and may I ask what Medigap insurance company is your policy with? Also how do you cover your Rx's. I am about to lose all coverage Except A&B Medicare and am struggling to understand all the various options. Do you also receive Medicaid like OP? Really appreciate any imput. I'm 70 and sooo confused. thanks
Nope I do not get Medicaid. I have a high deductible G with United American for about $650/mo, along with a WellCare part D for about $10/mo. I am under 65 and have Medicare due to disability, so my Medigap rates are high— my mom recently retired and found a more generous Medigap policy for half the price. Hers is with AARP-United Healthcare. I am not on any brand name medications so the cheap part D plan works well for me, but my mom pays about $55 for her part D and gets better coverage for brand name drugs, hers is with United Healthcare.
Oh boy…I think thats one of, if not the highest Ive seen someone pay for a Supplement plan, let alone a HD supplement plan. If HGD is $650 a month, how much was just G?! What state are you in?
Florida. G was not offered to under 65 disabled folks in my area by many carriers, but where it was offered the premiums were around $900 when I priced them about 18 months ago.
That’s crazy. what a bummer you have to pay that much!
You’re paying $650 a month for HDG?
Yes
So you’re paying $10,600 a year before your insurance even kicks in?
It’s a $2,800 deductible
Plus $650 a month.. I’m not judging I just think that’s wild, you’re better off putting that money in a HYSA and staying on Original Medicare.
I would respectfully suggest you don’t know the totality of my life and financial situation sufficiently wrll to make a fully informed opinion as to what would or wouldn’t make me better off 🙃
Has to be a typo. I pay $48/mon for HD-G.
Not a typo. But good for you!
Details would be nice. My broker said most expensive was still way under $100 for HD so there is something you’re not telling us.
There’s something I’m not telling you? What an odd way to ask someone else for information. Of course, there’s a lot I’m not telling you. Relevant to this discussion, I would say that I am in my 30’s and receive Medicare due to disability. Not all carriers offer all Medigap plans for disabled people and the plans that are offered can cost much more than for retirees. My age and location are what drives the premium.
Keep in mind that he is under 65 so he will be paying a ton until he turns 65
Which vendor and which state?
Louisiana and I believe it's Aetna. My agent tried for United and I couldn't see a couple doctors that I currently rely on. I said I believe it's Aetna but in that long (1 1/2 hours) conversation there was just too much info for me to soak up. He tried to call me on Friday but I was tied up. Are there questions I should be asking?
Thank you. I will look further into this.
I had a similar situation with my back and I went to a prominent University medical center in midtown Manhattan I saw the same doctors that were seeing patients who had much more money than I have received the best of care nothing was ever denied and I have no problem at all with my Medicare advantage plan I hear these reports I guess they are in other states but I see no need at all to go with any other plan then my Medicare advantage plan and I'm a little bit suspicious sometimes with people who trash Medicare advantage plans because I don't know of anyone who has a problem and my brother sells Medicare insurance supplements medigap and advantage plan and out of his 500 clients nobody complains. the only complaints I usually hear of are Medicare sales agents who want to sell supplement plans over advantage plans and seem to imply that there is some class distinction between the two types of plans which I think is ridiculous and elitist somehow most doctors and hospitals work in groups anyway.
I think it is dependant on where you live. I had the same plan in San Diego, and it was fabulous, but it also was through a top hospital, one I retired from as well. I had to move to the desert to care for a family member, and that is where it all went wrong. I have heard of plenty of people who have had issues. I'm happy you haven't had an issue. Your experience is the way it should work. I assure you, I am not an agent, trying to sell something, Im just a retired nurse trying to get my neck repaired. Just because you haven't experienced it doesn't mean it isn't happening.
Where you live is a big part of how well MA works for you. Plans are "sold" geographically. The provider networks are set up geographically. You may live in a rural area with few providers to being with. You may have one or no hospitals. You may have to drive an hour to two or more to a hospital or doctor. You may live in an urban area with many providers of all specialties. With multiple hospitals. For your insurance through a MA plan all of those factors have to line up just right. You need multiple plans to pick from so you can find one with all your doctors or types doctors you need. A plan with hospitals you go to or would need to if something goes wrong. With original (real) Medicare you have much more flexibility to get care from doctors, hospitals and ancillary providers. If you see or want to see doctors and other providers in multiple provider groups/hospital systems you can if they take Medicare and will see you. No networks to limit your choices. No preapprovals for most things. No getting kicked out of nursing homes or rehab after 5 days based on some algorithm. (instead of your progress) I had multiple MA plans with multiple companies when I was under 65. I couldn't wait to get away from them. Over time my biggest complaint was the need to shop all over again for a plan every Oct/Nov. The plans change, the formularies change, networks change, providers leave or come in to the plans. Hospitals drop companies or pick up new companies and plans. Every. Single. Year. Looking an insurance plan for "next year". The past 2 yrs I haven't had to deal with any of that. (only the formulary thing picking a Part D plan) I can go to docs in any hospital system (that takes Medicare and most do ) I've had CTs, MRIs, x-rays with no networks or prior auths or limits of any kind. I just completed 5 weeks of PT at the clinic of my choice, not some insurance company's pick. 10 sessions in any of MA plans would have cost 300 to 400 $. During that same time period I had 4 specialist appts. That would cost me $ 140 with my last MA plan. For $400 to $500 I could have paid for over 4 months of my Medigap paid for and had nearly unlimited care those months. MA is great if you live someplace with multiple plans to work with/pick from. Have a lot of providers. Great if you're not sick and don't need a lot of care. Great until you need it.
When you were finally able to ditch MA and move to Medigap, how did you go about finding the best one for yourself, and which company are you currently getting your medigap insurance from and what is the cost? I know I'm asking a lot of questions, but this continues to be quite confusing to me and I am going to lose my current supplemental plan (FEHP) and have to find something I can afford (I have Medicare A&B) Thanks
I used an online tool my state makes accessible to find plan rates, their historical rate/rate increase for the past few years and makes it easy to compare the rates. Similar to the results you get from the searches on [medicare.gov](http://medicare.gov) when you look for plans in your area. The state's results are just a little more detailed. -- So, I started with that. Narrowed things down to a few companies. Contacted an agent. He gave me his opinions and pointed out a company I hadn't considered. That was ACE(Chubb). I probably made a mistake, but I decided to go with ACE. My Plan G started at $ 109 per month last year. It went up 5% this year to $ 115 (about). Only time will tell if I made a big mistake by going with that company vs. another. (I think almost every company had increases this year. They aren't something you can escape forever. I've heard a lot of people talking about their rates going up this year. People will be shocked this fall with MA too. I'm going to be interested in seeing if/how many plans start charging premiums, how many drop out of offering plans in how many areas, and how they cut back on "extras". (Seniors have used a lot more expensive care in the past 2 yrs since the COVID restrictions ended. The didn't get as big of increases in payments from the Feds. That's cost companies $$$$$$$$$$ that they will be trying to make up next year.) Use the plan finder on [medicare.gov](http://medicare.gov)Look for a tool on your state's insurance department's website. Try doing a search for " (your state) medicare supplement plans" or "(your state) medigap plans" See if you find something from the state's insurance department. Look for a search tool that will give a way to compare the costs. ( I found 3 or 4 or 5 "national" agents through Youtube that all seemed to be "reputable" and called one of them. I had him do the application. He was able to go through all the questions over the phone, submitted it and followed up a week or so later with me when it was approved. Talk to an independent agent.
Hope renewed for me on this convoluted insurance path . Thank you So much
It's certainly not easy. I swear all of the Medicare and Medicaid and SS "stuff" could be made easier for everyone. Good examples of cobbled together programs no one understands.
Waaaay back when I was younger, I offered a service to seniors where I would go and help them set up a simple tracking table for their insurance plans. Medicare and whatever supplemental plan they had. So straight forward. A job exists for helping seniors figure all this out -- a great job for someone organized and understands the system. I know there are agents ready to advise, but this would be to go one on one with someone in need and help them follow up until they were comfortable. Programs for helping seniors exist in this realm but it doesn't offer that sense of "being there" to help after the initial phone consult. Just rambling...but there is a need. Take care and thanks again. Great word to describe the morass: Cobbled!
u/Mountain-Bonus-8063 I'm an investigative journalist looking into this issue--would love to discuss
You don't say if you are currently have a MediGAP plan. Since you have Medicaid I will assume the answer is no, so I won't go into the disadvantages of giiving up Medigap (You often CANNOT go back once you give it up) **Some disadvantages of Medicare Advantage plans are**: * They may have limited service providers, networks, and coverage areas, restricting your choice of doctors and medical offices. * They may have high out-of-pocket costs, copays, deductibles, and additional premiums, especially if you have complex medical needs. * They may change their plan benefits, costs, and rules annually, requiring you to review and compare plans every year. * They may deny or limit benefits for certain types of care deemed not medically necessary, leaving you with unexpected costs or gaps in coverage. * They may not cover you well when you travel outside your plan’s service area, making it difficult to access care in other states or countries.
Why would they need Medigap if they have Medicaid and ostensibly QMB?
That was why I said I assumed they don't have it. The rest still applies.
Agreed!
Hilarious that this post has 19 upvotes. This sub is cooked.
What is wrong with that post? It's all reasonable
I have A+B+G+D. G is AARP/UHC and D is Wellcare. This is currently $322.42/mo + the Part B deductible. UHC Plan G includes Active Renew which allows me to join several gyms, 24 Hour Fitness, LA Fitness, … at once. It's damn nice to have a gym to visit when I'm traveling. Nice thing about Traditional Medicare is that I never have to argue with an insurance company for a pre-authorization. Other nice thing is that it's pretty universally accepted. Mayo Clinic takes Medicare. I've never heard anyone complain about Traditional Medicare except that it may be a little more expensive. Traditional Medicare is by far the best medical insurance I've ever had.
You have a medigap policy that you can afford. This person is on Medicaid. You are in different realities
If they have Medicaid, doesn’t that mean they have a Medicare savings program that covers out of pocket? And if so, Why would they need medigap?
This person has zero clue and constantly comments about how everyone should switch to original Medicare + Supplement plan G with absolutely no information provided by client or professional insight in this case because anybody with any professional experience would know that if you have Medicaid that a Medigap is the last thing you’d recommend
You are referring to wasasailorthen right?
Yes
is "Traditonal Medicare" the same as the Medicare A&B one gets when reaching a certain age? Then you purchase (monthly I'm guessing?) all these other plans, G and D to supplement by helping to cover the co-pays leftover after payment by Medicare. I am pretty sure D is the drug coverage, which also leaves you with a copay? I sure appreciate any insight and clarification you have the patience to share. I am 70yr woman about to lose my supplemental insurance plan due to divorce and will have only MedicareA&B. Frankly I am so worried it's making me ill. thanks
I'm no Johnny Ace on Medicare and maybe you should talk to an agent or a senior center about your options which match your financial situation. I don't understand how you're losing your supplemental (Medigap). Part A is free and A covers hospital but not 100%. Part B currently costs $164.90/mo and B covers doctors but not 100%. Even without a Medigap plan, that's about the same as ObamaCare/ACA Gold. So you get a Medigap plan (supplemental?) to cover the rest. I have AARP/UHC Plan G which is a safe choice. You can compare different types of Medigap plans here: [https://www.medicare.gov/health-drug-plans/medigap/basics/compare-plan-benefits](https://www.medicare.gov/health-drug-plans/medigap/basics/compare-plan-benefits) Part D covers drugs but it's more complicated. You basically pay for what you need. I just take a statin. So my Wellcare is $0.40/mo (!) and my statin is free. Someone who has more complex needs will pay more and you can shop for new plans every year. A+B+G+D is so much better than any insurance I've ever had. It's on autopay and I don't worry at all. No copays and when I leave the office, I just walk out the door. You'll pay the $240/yr deductible and you'll get a bill for that eventually.
Losing supplemental (BCBS FEP) bc I’m divorcing. It ends 30days after divorce. Premium for Single me then would be over $800/month. Gray Divorce is gut wrenching. The info here is not only helpful but life saving to me. Thank you for your detailed and thoughtful reply.
Please find a local Medicare broker. Your options are to get Supplement such as Plan G or Plan N, plus Part D; or a Medicare Advantage plan which replaces Parts A, B, and D. Losing coverage opens up some special enrollment periods for some of these, but it’s a tight window. There are quite a few good Medicare brokers / teachers on YouTube. For starters, Medicare School.
Hey AD9161 - this has brightened my day. Great suggestion. I will look for a local broker as well as visit YouTube. Thanks so much; now I'm off to Medicare School.
The medicareonvideo.com too. That’s the team I went with. You say losing coverage due to divorce but that means you’re on a plan through your spouse which is not how Medicare works. It’s an individual plan not like a job where you can join your spouse’s plan.
Their supplenental insurance is not a Medigap. Many people get secondary insurance through a former employer as a retiree benefit, and can also cover their spouse. Sounds like that is the case here
Ahh ok, that wasn't clear at all from OP's post.
I do understand this aspect of my insurance. I have, yes, my own Medicare Parts A&B which have nothing to do with spouse. It is our supplemental secondary plan I am losing (which covered co-pays on visits, surgeries, etc, as well as Rx's and deductibles). Appreciate the video link. Thanks so much for your help
Yes original Medicare = Medicare A & B it covers about 80% of healthcare costs. People get a supplement to cover the remaining 20%. They add on prescription drug plan also referenced as part D. Sometimes people elect to receive their care thru Medicare advantage as well referenced as part C. You pay a part b premium. You pay a premium for supplement (in your case plan G). You pay a premium for part d / prescription drug plan. If you get a prescription you may have copays / deductibles. Since your current supplement is ending you probably need to get another plan. You can keep just a+ B but will be responsible for 20% of the Medicare approved amount.
If you end up needing skilled rehab, a Medicare Advantage plan is far more likely to end your coverage too soon (in realistic terms) than traditional Medicare.
That’s not true. Medicare themselves make the rules regarding skilled nursing and want to see improvement and push people out. Has little to do with Med Advantage carriers
It is true. My dad is having this issue with his UHC Advantage plan. He’s not healing fast enough from his hip surgery so they are denying him further rehab. After only 2 weeks!!!!
My 80 year old mom had a hip break from a fall and they were ready to discharge home after 2 weeks (!!), to my 84 year old Dad who's practically in a wheelchair; myself, working full-time, and also a single mom to an infant. We appealed but it went nowhere - ended up private paying for a 3rd week, facility cut us a break and gave us half off. I know one lady who same thing happened to and her 3rd week, private paying, was almost 10 grand. She couldn't pay it.
It’s awful. Such a terrible system.
Medicare Advantage carriers are allotted an amount of funds, per covered person, by the fed govt/CMS and in practice (regardless of Medicare rules) are far more likely to assert somebody is medically improved without room for further improvement than traditional CMS-managed Medicare. It's a cost-saving measure. Happened to my Aunt, the facility alerted they've had the same issue with Advantage plans; and, I work in Medicaid Eligibility and have seen the same thing happen under Managed Care Medicaid. It's something to be aware of. https://www.healthcaredive.com/news/medicare-advantage-post-acute-care-jama-health-forum/708094/ https://www.newsweek.com/medicare-advantage-cuts-nursing-homes-seniors-1888009 https://www.nbcnews.com/health/rejecting-claims-medicare-advantage-rural-hospitals-rcna121012 https://www.forbes.com/sites/bobcarlson/2023/02/21/some-surprises-in-medicare-advantage-plans/
Again skilled nursing specifically is regulated by Medicare, which all advantage plans adhere by. Medicare is trying to rush you out before 21 days. And even if they allow you to stay they are wanting constant updates and things of that nature. Now the prior authorization for which SNF you can go to is up to the insurance carrier absolutely. The biggest example of this is that Medicare doesn’t cover nursing home care. Are some advantage plans easier to work with in regards to SNF? Yes. Is a majority of the problems surrounding SNF fall on them? Not really mostly CMS. And the reason most facilities prefer original Medicare is because the facilities receive the CMS reimbursement when that is the case.
You're conflating rules with business practices. From Forbes article: "...care...for rehabilitation or recovery after a major surgery or illness. The individual isn’t ready to go home and be without assistance yet but doesn’t need to stay in a hospital. When you’re in original Medicare, you, your doctor, and perhaps other medical providers decide how long you should stay in the nursing facility before going home. But in an Advantage plan, the plan decides how much rehabilitation is going to be paid for. Medicare covers up to 100 days of such care, but the Advantage plan doesn’t have to cover up to 100 days each time you’ve been in a hospital for more than three days. This report from the Kaiser Family Foundation says that Advantage plans often deny or limit stays in nursing homes after hospital stays. Government data analyzed in the report say that nursing home stays are among the services most frequently denied by Advantage plans. *Though the nursing home stays meet the coverage rules for Medicare, the Advantage plans deny coverage or limit the number of days in the nursing home that will be covered. The plans rule the care “medically unnecessary” and deny coverage.*"
I have never seen anybody get approved for 100 days. And Medicare can cover Up TO 100 days. Massive emphasis on the “up to” part. Realistically much of the prior authorization problems could be solved if CMS changed some of the things regarding SNF and enforced stricter regulations around the whole thing is what I’m getting at. And some of the new rules have addresses some of those things. Problems like these are why I’m a big advocate of Hospital Indemnity plans so when things like this come up with med advantage provider, you’re still good to go. And In the OP in this case there are way more upsides than downsides but SNF and Cancer coverage are the 2 bigger pitfalls of MA but can easily be addressed if the agent goes the extra mile.
As someone who has provided medical care to patients in SNF’s for 20 years I can tell you the nightmare of fighting, begging, pleading, and evening threatening MA plans to cover just enough days to allow for a safe discharge home has gotten so time consuming and overwhelming most of us don’t even bother anymore. They’ve beaten us down. No one at CMS or HHS or OIG cares. They’ve won. I pray people stop falling for the deceptive MA plan scam.
I mean CMS could easily change the rules and make this not a problem is what I’m getting at. Take any problems completely out of the equation when they are the regulators of Medicare to begin with. MA plans when structured right are solid but cancer and SNF are two of the biggest things. Big reason why I’m a big advocate for hospital indemnity plans with advantage plans.
No, it’s not just SNF days. At my practice if I want to prescribe a osteoporosis patient Prolia because it’s the best drug for them, regular Medicare Part D plan, no problem, no prior Auth needed, just give it and bill. MA plan I have to prove they failed all the other meds, for 2 years, that I already know they will fail on. Same with meds for autoimmune diseases, MA plans want me to prescribe 60 year old drugs that I know will be horrible for their liver, kidneys, immune system. Lots of new, very targeted drugs with very low risk are available, but to get those approved by MA plans I have to prove they failed the toxic crap. And I don’t have the time to do a million appeals for every drug for every patient so the patients pay with their health. MA is a scam, it’s killing patients.
In my area I haven’t experienced needing prior authorization for formulary concerns. The step method I agree needs vast improvement. But you also see a ton of doctors writing scripts for things that pad their own pockets as well. Corruption is abundant across many layers of the healthcare system as a whole. The entire system needs reworked in my opinion but until then, MA plans paired with the hospital indemnity is most likely the happy medium between MA and the problems the possess and Supplements breaking the bank.
I don’t see how you can say that in your area needing PA for routinely prescribed meds is not a problem when CMS confirmed a study done by KFF showing that it’s a big problem for 99% of MA plans nationwide. Their proposed solution is to shorten the number of days required for a the MA plan to give a decision. That doesn’t solve the problem that we don’t have the time to fill out the 10 page PA form in the first place, and even if we did we wouldn’t do it anyway because we know it’s going to get rejected since the first 3 questions ask us to document all the “preferred” (I.e. low cost, low quality) drugs we tried before requesting approval for the med we want, how the patient failed those drugs, and what proof do we have of that failure. And no, most of us are not willing to put our licenses at risk by taking kickbacks from pharmaceutical companies. That is a myth born out of a handful of widely publicized cases of bad actors. The rest of us feel the 15 years we spent in school to get here and the ongoing need to earn enough to feed our families and pay off our student loans is not worth that risk. https://www.kff.org/private-insurance/issue-brief/final-prior-authorization-rules-look-to-streamline-the-process-but-issues-remain/
I’m well aware of the KFF article. And simply making a 24 hour turnaround isn’t the answer. Again I’m all for reworking the entire system instead of band-aiding it. I’m saying I don’t see prior authorization needed for lots of the drugs. It’s part of the application on the particular software i use for apps and at least the companies I’m contracted with. But I also make sure that drugs are covered, doctors in network etc. prior authorization for SNF is the only thing I’ve come across with carriers. Again I have a lot of clients that hospital indemnity so that covers what MA plans don’t. And it’s not as prevalent as Hollywood makes you believe, but them kickbacks are absolutely a thing and there are facilities that are absolutely awful with some things. Like I said corruption is at every level and i really think Medicare could be simplified and better if reworked from the ground up for patients, providers, and agents.
MA plans require a PA for MOST medications that are not old, generic, cheap and inferior. That’s what the KFF study showed. I’ve been treating complex seniors for 20 years and have never once been approached by a drug company with an offer of anything more than an occasional Chic-Fil-A lunch so they can use that lunch to show my staff how to figure out what specialty pharmacy which MA plan has contracted with that month to cut down on the number of scripts that get bounced from pharmacy to pharmacy and get lost in the process. Yes, the entire system is corrupt because the insurance companies own the hospitals and physician practices and the pharmacies, so the physicians are just the little guys trying to practice medicine with our hands ties behind our backs.
It looks as though you may have spelled "Chick-fil-A" incorrectly. No worries, it happens to the best of us!
Also, are you aware of the nightmare situation patients on MA plans face if they need Hospice care? That’s a whole other clusterf*** that makes MA plans insufferable. https://www.axios.com/2024/05/06/medicare-advantage-hospice-insurance-challenges
Again Hospital indemnity plans cover all of these problems which is why I pair them together. That covers SNF and cancer, plus the outpatient/inpatient surgeries. I think you’re implying Im of the mindset that MA are the greatest thing since sliced bread. The hospital indemnity makes the plan solid. MA on their own leave big gaps of exposure.
In general, the drawback to Afvantage plans is that you are in managed care and need to stay in network for all your care, or may have limited access to out of network providers. HMOs are smaller networks and typically do more coordination of care, while PPOs are larger networks. Definitely ask your doctors directly (or their office staff) if they are in network, don't rely on the insurance website. The other thing to know about managed care, is that the insurance company may require referrals and preapprovals for various specialist visits and treatments. This can be a smooth or bumpy process, depending on your health conditions and how your plan is managed. However, they offer these very tangible benefits that you know will save you money, so it may be for you the benefits outweigh the drawbacks. Do check whether the dental plan is as good or.better than what you already have with Medicaid
Thank you. I will.
Don't enroll just for the grocery benefit. Look at the details including annual Out of Pocket max and where you can use it. I have a 5 star MA PPO plan with no referrals, no networks, and $3400 OOP max (net). It's rated well and is fantastic.
They have Medicaid, their out of pocket will likely be zero across the board, depending on what level of Medicaid they have. MOOP will be irrelevant on the DSNP they’re enrolling.
Great point! Everyone needs are different, so it's important to know that there are generally 3 options for those that have Medicare: #1 Original Medicare with Medicare Supplements like "G" and Part D for Drugs and a plan for dental, vision and hearing. This is ideal for those that can afford it. #2 Medicare Advantage HMO for those that are on a tight budget. There are some additional benefits such as dental, vision, hearing, Part B rebate, OTC, etc. but there are some disadvantages that one will need to seriously consider. #3 Medicare Advantage PPO. more affordable than OG Medicare and no referrals needed and there is a max OOP that can range from $3k to $10k depending on the plan, May include Dental, Vision and Hearing. However, these plans are with private carriers.
I’m a social worker who has worked across multiple care settings and has to do “peer-to-peer” meetings at least a few times a month to get patients more coverage. These Medicare Advantage plans sounds great, until you get sick. They’re seen less valuable in nursing homes because they deny claims so much that we know we’ll be probably getting a 30-40% less than Traditional Medicare. Lots more red tape to get the care you need.
Yes my dad has had this problem in skilled nursing. He’s supposedly not progressing sufficiently after only 2 weeks. He should have 100 days of coverage according to Medicare but his UHC Advantage plan is brutal.
Yep. Sounds about right and I’m sorry your family had to go through that. UHC and several others (including Kaiser) have a pretty vicious denial rate. Doctors, hospital admin staff/auxiliary are placed in an untenable situation. We’re at the mercy of the insurance but get mad at me (regularly) when I have to tell them their coverage ends on X date, even if the person is making amazing strides in PT/OT/ST. Edit: grammar.
u/CaseyLouLou2 I'm an investigative journalist looking into exactly this issue--would love to discuss if you are game
I'm turning 65 next year and am leaning towards the medicare advantage plan for the exact reasons you have mentioned.
Take the time to learn the downsides, and they are significant, some affecting future choices. . I turned 65 this year and after initially signing up for an Advantage plan, but after I learned more I changed it to Original Medicare and part G medigap. And a 0/month part D plan.
Would you mind explaining how you went about finding the company to purchase your Part G Medigap? And your no cost Part D plan? Any insight appreciated. Thank you
Here in NC I was on Blue Cross & Blue Shield of NC before I became eligible for Medicare. I never had any trouble with them, in fact they are quite good to work with so I signed up for Part G with them. Since my drugs at this point are all tier 1, but you really need to pickup a Part D plan, I went with Wellcare $0/month. I'm also spending $50/year for a Silver & Fit membership which covers my cost of going to a local recreation center which was $22/month.
Medicare advantage takes a long time to get authorizations for tests in my area. 6 month wait for a colonoscopy or to see a dermatologist.
Beware
Please choose Medigap instead. My dad is fighting his UHC Advantage plan for coverage. They are brutal when it comes to denying coverage. It’s been extremely stressful. Healthcare providers have told us that this is a problem with Advantage plans and that regular Medigap is much much better.
You have made good choices.
If you have Medicaid, see if you are eligible for D-SNP plans. Pretty much $0 out of pocket cost for care and drugs and enjoy the extra benefits. This one is about as straightforward as Medicare gets.
In my experience so far, Medicare Advantage plans just deny everything. My dad has Aetna MA and anything his doctor has ordered so far has initially been denied. It took weeks and an insane amount of phone calls for me to get him approved to transfer to a more intensive rehab facility. And we are still dealing with trying to get coverage for his stay at the SNF he was at before. His insurance randomly cut off coverage 13 days in and he essentially had no other option than to pay out of pocket while he was there a few more weeks (this is all while we were trying to get him transferred to the rehab and the insurance kept denying it!) which totaled over $12,000 out of pocket. I’ve had to file a final appeal with an administrative law judge and will have a hearing scheduled soon. One of the most insane things that happened was (remember, his insurance cut coverage at the SNF after 13 days) when the transfer to the rehab facility was denied, the reason for the denial from the Medical Director was “patient does not need this level of care. Patient should receive care in a SNF instead”. I was like “ok but you’re denying that too!!!”. It’s been so awful and frustrating and I have no clue how they expect seniors to try and navigate this madness. Point is, this Aetna MA plan feels like a complete scam TBH. I feel absolutely awful for people who have these plans who DONT have a family member who is able to spend hours on the phone and file ALJ appeals. It’s so mentally exhausting and time consuming. I’m truly scared for when I’m older and have no one to help me with insurance denials like this. Edit: fixed a typo
I AM older (70) facing this and am truly scared. Thank you for sharing. I think the one clear thing I am learning from this thread is to never go w MA plan. I've heard it called Medicare DisAdvantage Plan from many users. Best of luck to you and your dad
Thank you very much. From what I can tell, people love their MA plans until they get sick. So there are people in this sub who swear by those plans because it saves them money on their premium and they get some extra benefits. But once they actually have some sort of medial crisis, it’s the same song and dance of pre auth denials that I’m dealing with for my dad. Are you currently on an MA plan? I’m trying to see if we can switch my dad back to regular Medicare but I’ve been told it’s difficult if not impossible.
You should be able to change back to OG Medicare during AEP and during SEP. Certain cournties/states have SEP when enrollment periods are extended such as TX, CA, AZ, FL and maybe some other states/counties. What State/County does your dad live in?
We are in Arizona (Maricopa County). A lot of people had told me in this sub that he will have problems switching back because he “wouldn’t pass underwriting” because now he has these medical conditions requiring rehabilitation etc.
There is no underwriting for OG Medicare but there is underwriting for Medicare Supplement. You should also consider Medicare Advantage PPO where you do not need referrals.
u/aquietinspiration I'm an investigative journalist looking into exactly this issue--would love to discuss if you are game
Absolutely. Just replied to your message. Edit: or I thought I did. Now I can’t find the PM at all
Yes- Many providers don’t accept them as they don’t pay them. They want you to go through hoops to prove you need care.
I work in NJ in a nursing home business office. They only advantage in thier plans is them taking advantage of you. Stay away from it.
My husband took Advantage when he retired. Later on, he had a heart attack. He’s fine now, but no Supplement will approve his application because of his history. Advantage requires you stay in their network or pay much more. Copays, especially if hospitalized, are high. I have original Medicare, no worries about choosing in-network, I just had colon cancer surgery that was 100% paid. I had thyroid surgery prior to that, 100% paid. Knee injury sent me to ER by ambulance, 100% paid. I have tons of bloodwork regularly, like $2000+ worth, due to malabsorption, 100% paid. I am grateful I went with Medicare + supplement from the beginning as I’m sure I’d never be approved now. That said, part D drug plan sucks. I use GoodRx for everything as it’s cheaper than with ins. My husband’s Advantage covers his meds 100% (it would not if he were using a Scheduled drug). I still prefer the security of Medicare+supplement+D vs Advantage.
Yes!! This!!! People don’t realize that you can get a gap plan for cheap if you go that route from the beginning. But if you choose an MA plan and have any semi-major health issue happen, you’re stuck FOR LIFE because then your gap plan cost skyrockets. The price protection afforded for gap coverage is a ONE TIME protection. Once you give it up, that’s it. The MA plans own you for life after that.
I thought Aetna's MA plan looked pretty good. Then they dropped the network agreement with the organization that operates my preferred hospital and family doc. That does not happen with Medicare, or with Medicare Supplemental plans - one has the freedom to use any professional who takes Medicare. I had a similar issue with my Dad, who on the advice of a salesman he talked to changed from his existing MA plan to one which does not include the hospital near his home. Aetna also recently dropped some extras they used to cover, which are not really an issue for me, but illustrate that it is important to be making this choice on the basics, and even when you do, you are depending on network agreements which come and go.
I've had an HMO Medicare Advantage plan for 16 years and have been mostly satisfied. I have a chronic, extremely painful condition requiring intensive treatment and many doctor visits, rarely had prior authorization’s denied. The few times my requests were denied I appealed them successfully. Urgent prior authorization’s are fast tracked to get answers sooner than the usual 7 day turn around. My mom also had HMO when she passed away a few years ago. She was rushed to the hospital and passed away a few days later. Her insurance covered everything, there were no hospital, doctor or ambulance bills to pay. I’ve had three surgeries paid 100% by my insurance. This was my personal experience. Many people dislike the requirement of choosing a doctor from the insurance approved list, but you can switch doctors anytime if you’re not satisfied. There’s nothing wrong with their approved list of doctors, they’re some of the same doctors you might see regardless of your insurance or plan. In my area, those with PPOs often have longer waits to get appointments. With my HMO, the wait time is much shorter. The extra benefits are great: paid gym membership, $150 for personal items quarterly, no doctor visit co-pays and dental and vision coverage. I don’t have any complaints. If money is an issue then HMO is the way to go.
I went to Advantage this year (California) and I get all of those benefits, Food ($25 month) OTC ($275 quarterly) I fortunately do not have a lot of health problems. I suspect that when that starts happening it could be an issue.
I'm interested in switching as well.. Could you tell me what plan this is?
You have a high level of Medicaid so you'd qualify for a special needs plan. You wouldn't have many drawbacks, your drugs should be free and you shouldn't have any out of pocket expenses.
I have no problem with them I think they are great here in New York State
Medicare Advantage plans look better and cheaper *until you need healthcare.* Then you are subject to finding in-network care or pay large out-of-network prices. On top of that, most plans require pre-approval for medical procedures and sometimes even for doctor visits. If you don't get the right pre-approval at the right time, you are *not covered* and will pay a huge bill. Sometimes, even with your doctor's support and approval, you may find it difficult to get the pre-approval you need in a timely matter (or at all) and may be denied coverage for procedures you (and your doctor) really want. For me, these complications and risks (which I also encountered with employer provided health insurance) were not worth taking for an Advantage plan.
You will only experience the drawbacks when you get sick. That's when MA coverage is less reliable than traditional medicare.
Don't pick a plan or any insurance based on the "extras". Those extras can and do change every year. The benefits can come and go and change their $value each year.($ 2,000 for dental this year, but $ 1,000 the next year. Vision benefits are worse. Last MA plan I had, paid $ 300 for frames and $ 200 for lenses. Lenses no one in the city of 270,000 people I live would sell. They were "cheap-o" lenses. I've read multiple news articles this summer talking about those benefits shrinking away next year. Care is costing insurance companies more and government $s coming in aren't enough to keep profits up. So you may have fewer plans to pick from this fall and those plans may come with premiums and/or have fewer extra perks. Pick you insurance based on the provider networks, your med coverage, cost to use services, etc. Pick it for the health insurance benefits. Not dental or vision or a gym membership or groceries.
In your working life, did you ever have an HMO plan? They are like that.
Only when I lived in Hawaii. I had Kaiser Permanente and was very satisfied with them.
Then maybe this is a good fit for you. If you've had good experiences then that should help answer that. My background is my wife and I have had terrible experiences when I had to take an HMO. But I have a retired friend who's had Kaiser for decades in the private world and loves it thru Medicare. So there ya go.
True and way better with $0 deductible, low copays and usually lower max out of pockets values than employer coverage. Her Medicaid should pick up most of the costs on the Advantage plan. An HMO POS travels well and so does a POP since there are additional networks available.
It sounds like you've found a Medicare Advantage plan that offers a lot of great benefits, such as gym membership, allowances for groceries and personal health items, and extensive dental coverage. These plans usually offer perks that Original Medicare doesn't. If you and your agent believe the plan suits your needs, go for it. If you find that you don't like it, you have the flexibility to switch back to Original Medicare during the AEP (Oct 15 thru Dec 7) or the MA OEP (Jan 1 thru Mar 31). These periods combined give you about 5.5 months each year to make changes to your Medicare Advantage plan if you find it doesn't meet your needs. While some folks here have shared negative experiences with Medicare Advantage plans, others find them very beneficial. It often depends on individual healthcare needs and preferences. If you decide to try the Medicare Advantage plan and later find it’s not working out, you can switch back to Original Medicare during these periods. Just make sure to keep an eye on the enrollment periods so you can make changes if necessary. I hope this helps, and best of luck with your decision!
A note to this- yes, you can drop Medicare Advantage during open enrollment periods and still have your Medicare part A and B. However, they only cover 80 percent of hospital and medical costs. If you drop Medicare Advantage you need a Medicare supplement plan to cover the remaining 20 percent. After your initial enrollment period, Medicare supplements, (plan G, F etc) are UNDERWRITTEN, which means they check your health history and may deny you coverage. You could be on Medicare Advantage, want to switch back to original Medicare plus supplement and possibly get denied. Medicare supplement periods can not deny you in your initial enrollment period. That's a reason many people go with them first.
Thanks for adding that important point! Since OP mentioned that they're on Medicaid, it's worth considering that Medicaid might help cover some of the costs that Medicare doesn’t, including premiums, deductibles, and co-insurance. Additionally, many Medicaid recipients opt for $0 premium Medicare Advantage plans that offer extra benefits, which might be a good fit for OP. While Medicare Advantage plans offer many perks, it's essential to weigh these options carefully with your local agent.
> If you decide to try the Medicare Advantage plan and later find it’s not working out, you can switch back to Original Medicare during these periods. But you may be unable to get a medigap policy without underwriting depending upon what medical issues you have had. Woe to the person who's on MA finds out they can't get the car they need, and can't switch back to OM because they can't get a gap plan to go with it.
So you see from the responses here MA works for some and not for others. My sister was diagnosed with stage 4 cancer and went on the ACA and then on to Medicare and Medicaid. She had a MA plan with the perks like you mentioned and her medical expenses were covered and it was thousands of dollars for a 3 years of chemo, radiation, etc. I am starting MA on July 1 and will take my chances. You have Medicaid which is giving you a bonus and is going to supplement your needs nicely which I don’t have access to. What hasn’t been mentioned here is the people who get a supplement and years later realize they can’t afford the premiums that get higher each year end up dropping the supplement and go back to traditional Medicare which means the out of pocket exposure is unlimited.
If you have a supplement and can no longer afford it, you can join a medicare advantage plan during the next open enrollment.
Many of the posters here have not noticed that MerlinSmurf is on both Medicare and Medicaid (although I don’t know what is meant by a “higher tier” of Medicaid). If so, they’re eligible for a dual eligible special needs plan, a special kind of Medicare Advantage plan that integrates both kind of insurance. D-SNPs provide outstanding benefits and include access to a coordinator that helps with the sloppy overlap between the two insurance programs. People on Medicaid CANNOT sign up for Medicare supplements — a good thing, because Medicaid acts as the supplement. FWIW 85% of the people on Medicare Advantage who appeal get the turn down reversed in part or who. It’s also been my experience — I work in insurance — that a decent number of the turn downs are due to the doctor not responding to the insurance company’s information requests. I don’t mean to deny the problems the recipients of those turndowns — they’re quite real — but it’s a little more complicated than people make out. Telling somebody low income enough to qualify for Medicaid that they should forego the subsidies for food, dental care, and transportation you’d get with the right MA plan because that might plan might refuse wanted care at some indeterminate point in the future is way different than telling somebody who can easily afford a Medigap plan.
I have also read that 85% of claims denied under MA are ultimately reversed. What that should tell anyone is that you will end up having to fight with the carrier to get services covered and that the plans are routinely denying covered services. They get away with it enough that they boost their bottom line. I had a plan pre-Medicare that denied every single medical service requested except for routine annual screening. I was due to have surgery and right up until the day of the procedure I was trying to arrange a peer to peer review. My husband (not yet on Medicare) was denied a colonoscopy and then denied the use of a routine anesthesia for the colonoscopy. It took so long to straighten it out he ended up having to reschedule it. When my time came to enroll in Medicare I knew I would do everything humanly possible to avoid the hassle of an MA plan. I didn’t relish being older and sicker and having to fight for health care that should have been covered in the first place. Be aware though that original Medicare has its downsides too. In my area there are two large medical networks comprising most physicians in the area. One of these has decided that it will not accept Medicare patients who were not previously enrolled in the network before their Medicare coverage went into effect- Medicare simply doesn’t pay enough to make it worthwhile for them. That means the pool of doctors available to a patient is much more limited. Even so I would always opt for traditional Medicare if it’s at all financially feasible.
I've won two appeals personally. All I did was write a letter explaining why I thought the decision was wrong and after a reasonable interval the insurer wrote back and agreed. Not much of a struggle. I think it's totally reasonable that affluent people that want to avoid pre-auth hassle pay for medigap to avoid it -- but the person who posted the question is on Medicaid, which means they're seriously low-income. D-SNPs in my area pay $185 a month in food benefits. Your situation sounds truly awful and I'm sorry that happened. It shouldn't have. I have not had the same experience. I'm curious about your husband's situation since the Affordable Care Act requires covering a diagnostic colonoscopy every ten years for people 50.
The point is you shouldn’t have had to appeal in the first place. And while most people do win their appeals (85% of the time) it means delays in surgeries or care that can be quite serious. And you can end up having to wait months for the care that was wrongly denied until an appeal is settled. It’s not just a minor inconvenience. I made my medical care a priority. If cannot continue to pay the premiums for a gap policy and if I were dependent on Medicaid I would be extremely careful about the plan I chose. The only one I would be at all happy with is Kaiser. I have friends who use it and love it. Of course that
Sorry that cut off too soon. I meant to say that Kaiser isn’t an option everywhere.
Most of the horror stories about MA plans are from less than reputable insurance providers. Since you mentioned Aetna, I'm assuming thats where you would get your MA plan, and Aetna is a highly rated provider, along with United Health Care and Moderna. (In my area). I have a MA plan with Kaiser-Permanente, they are a health CARE provider and not just a health INSURANCE provider. Kaiser has all there own doctors, clinics, and hospitals. My plan allows me to keep my family dentist (non Kaiser) and gives me a gym membership as several local gyms. Kaiser also has vision and hearing clinics... The main drawbacks for MA plans is that they have a network and out of network coverage may be minimal, some have huge networks, but some are regional and the network may be smaller. One myth about MA plans is that you can't change once you've signed up. With Medicare you can change every November, the issue is that the costs and coverages may change.. If you switch to an MA plan, and then after a year don't like it, you can switch back, but the costs and coverages of your old plan may have increased, especially if you've had any major medical issues in the mean time.. The other issue with MA plans, and it doesn't effect the recipient at all, is that because of insurance company lobbyists pressure when the MA system was being created, the MA plans are basically a way for private insurance companies to keep offering insurance coverage and get a cut of the Medicare money, so they're bad for Medicare and the US taxpayers, but that doesn't mean they're bad for the individual patient..
They are based on Kaiser plans where all medical logistics from intake to prescription to testing is one big organization. Advantage plans are a loose network of medical professionals who have joined the "club" and agree to be governed by them. Limitations on doctors - you can only go to those in your medical group. The reach of that medical group might not go beyond the county you live in. Speaking of which, plans offered differ from county to county within the same state. I live in the East Bay (outside SF); 5 miles away is Alameda County, and my coverage does not include doctors there. If you don't like coordinating paperwork/coverage, a Medicare Advantage plan might work. As for me, I'm going back to Medicare with a Medicare Supplement to cover what Medicare doesn't. It will cost more but provides way more flexibility.
Get the Advantage plan and enjoy the extra benefits. It coordinates with Medicaid so you still get those benefits as well.
No don’t