Medicare Advantage - What's the Deal?

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setsail26
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Re: Medicare Advantage - What's the Deal?

Post by setsail26 »

I haven't read every message here, so forgive me if this has been stated. I'm a bit surprised that Bogleheads would consider Medicare Advantage except in very specific circumstances. First off, anything that advertises giving people additional services for free is obviously nonsense. How do you think they pay for all those services, some even advertising that they will pay you back your part B charges? Yep, they give you less. There is no way around it. And how do they give you less? They make it a giant pain in the butt to get things done. Want labs? Nah, prior authorization needed. An MRI? Only if you get xrays, meds, and 6 weeks of physical therapy. Meds? Even for medications that are covered by straight medicare, medicare advantage plans will ask for a prior auth. Do they have to pay for the meds? Yep. But if they make your doctor jump through enough hoops, sometimes people just give up. And that saves them money. As a primary care Physician, I can say that it is much easier to to deal with regular medicare vs. medicare advantage to get patients what they need.
DetroitRick
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Re: Medicare Advantage - What's the Deal?

Post by DetroitRick »

Maybe it's just me, but it seems like in these discussions people are automatically weighing free or low-cost Advantage programs against various supplement and Prescription D premiums. It's important to see what actual total costs are and can be, in your area, using any preference you have for a particular medical network. The rest is academic. For both Advantage and Supplement/Prescription D combos. Generalities don't count, and like most insurance evaluations, I wouldn't expect a black and white answer as to which system is best for everybody. Frankly, the range in premiums for all these insurance vehicles is massive, given general coverage similarities.

Medicare.gov provides a great tool for doing this (although it's supplement screener is very weak). You can quickly see that some Advantage programs have premiums and some don't. They all differ in copays, coinsurance, deductibles, formularies, and out of pocket maximums. Some are PPO, some are HMO. All very different - no premium/high premium, low out of pocket maxes/high out of pocket maxes, lower prescription costs/high prescription costs, and so on. In my area for example, there are 54 Advantage programs offered. Premiums range from $0 to $299 per month. Out of pocket maximums are all over the place ($7,550 or less for 2021 In Network, more for those that allow out of network). When I ran my own drug costs through the Medicare.gov tool, I got the same general range of costs via Advantage programs as I did with Prescription D policies.

When I got down to comparing specific Advantage programs in my area, considering who had a reputation for good facilities and doctors, looking at whether my own drugs were covered, looking at potential out of pocket costs of all types - the decision definitely got more complicated. Care to predict your level of medical service and prescription needs in a decade? Again, far from a black and white decision. No matter what TV ads say. All I can say is that I recommend considering ALL these things in your decision: accessibility, service quality (providers, facilities and insurers), premium costs, and out of pocket costs.
Wrench
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Re: Medicare Advantage - What's the Deal?

Post by Wrench »

David Jay wrote: Sat Apr 17, 2021 1:30 pm
SevenBridgesRoad wrote: Sat Apr 17, 2021 11:25 am
David Jay wrote: Sat Apr 17, 2021 9:51 am I have seriously looked at the “A + B only” based on this Doctor’s arguments: https://truecostofhealthcare.org/medica ... insurance/

In the end, I chickened out and now we are focusing these choices:
1. High Deducible “G” + Placeholder “D”
2. Priority Health MA PPO, the network is affiliated with Spectrum Hospitals so it covers about 90% of doctors in West Michigan
Would you walk us through your thinking on why you chickened out? Much appreciated.
Tail risk.

I think Dr. Belk is right but we have a moderate portfolio and I fear a large bill. Single digit thousands per year I can handle (i.e. High Deductible G), hundreds of thousands would put us in the poor house. One of the books I read said that if everything went wrong (months-long hospital stays, most expensive drugs possible, etc. for a couple of decades) that one could spend $900,000 over a lifetime on Medicare. I know it's just a theoretical number but it is still concerning.

1. With high-deductible G I know the maximum per year and have nationwide acceptance.

2. With MA PPO I have zero monthly cost, so healthy out-of-pocket is the same as A + B but there will be no Part D penalty if I want to go to an A+B+D in the future due to a need for costly drugs.

I am leaning towards (2) mentally treating it as a "super A+B" plan, I can always return to A + B at open enrollment and I can purchase a more robust Part D penalty-free.
Just to follow up on the size of that tail risk, this article:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5898738/
published in 2018 indicates in Table 5 that ~3% of patients out of >45,000 patients had hospital stays of more than 30 days. Since Medicare A covers up to 60 days after the deductible the risk is low that hospitalization would break the bank. Of greater concern to me though is that those 3% had a total of more than 385 procedures per patient during their hospital stay. Presumably 20% of the charges for those procedures would not be covered by Medicare A & B. Even if the average Medicare allowable cost per procedure was only $100, that would be a bill of 0.2*385*100 = $7K. And that's probably a low estimate - it could easily be two or three times that.

So I am with David Jay and will probably get coverage to protect against this admittedly low tail risk. I am going back and forth between G and High Deductible G (HDG), but am now leaning toward the latter. One limitation I am finding is not all providers offer HDG in my area so my choices are not as wide as I might like.

Wrench
Shallowpockets
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Re: Medicare Advantage - What's the Deal?

Post by Shallowpockets »

setsail26 wrote: Sat Apr 17, 2021 10:00 pm I haven't read every message here, so forgive me if this has been stated. I'm a bit surprised that Bogleheads would consider Medicare Advantage except in very specific circumstances. First off, anything that advertises giving people additional services for free is obviously nonsense. How do you think they pay for all those services, some even advertising that they will pay you back your part B charges? Yep, they give you less. There is no way around it. And how do they give you less? They make it a giant pain in the butt to get things done. Want labs? Nah, prior authorization needed. An MRI? Only if you get xrays, meds, and 6 weeks of physical therapy. Meds? Even for medications that are covered by straight medicare, medicare advantage plans will ask for a prior auth. Do they have to pay for the meds? Yep. But if they make your doctor jump through enough hoops, sometimes people just give up. And that saves them money. As a primary care Physician, I can say that it is much easier to to deal with regular medicare vs. medicare advantage to get patients what they need.
NOT!
Perhaps being a PCP practicing under regular medicare there is a bias.
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beyou
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Re: Medicare Advantage - What's the Deal?

Post by beyou »

This debate is akin to debating merits of a Toyota vs a Lexus. Of course the Lexus with heated seats, a moon roof and more is “better” but more expensive. If you are on a tight budget you get the Corolla and it gets you from here to there. But if I can afford the Lexus not gonna convince myself the Corolla is just as good.

MA = Corolla
with or without gap is Lexus

When I get there I’ll see what I can afford but I lean towards Medigap if affordable or naked Medicare if I can’t afford gap premiums. Just look at all the threads about people not retiring to keep company health plans and avoid ACA. This is because in many places ACA is the Corolla, priced as a Lexus, with small networks and no out of network coverage. Why would I settle for an insurance company telling me what doctors I can see, if I can afford better ?
tj
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Re: Medicare Advantage - What's the Deal?

Post by tj »

Wrench wrote: Sun Apr 18, 2021 11:11 am

So I am with David Jay and will probably get coverage to protect against this admittedly low tail risk. I am going back and forth between G and High Deductible G (HDG), but am now leaning toward the latter. One limitation I am finding is not all providers offer HDG in my area so my choices are not as wide as I might like.

Wrench
This is because the HD G is still really new. Not all the companies that offered HD F have started offering HD G, I would imagine in the coming years there will be more HD G's.
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FIREchief
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Re: Medicare Advantage - What's the Deal?

Post by FIREchief »

setsail26 wrote: Sat Apr 17, 2021 10:00 pm I haven't read every message here, so forgive me if this has been stated. I'm a bit surprised that Bogleheads would consider Medicare Advantage except in very specific circumstances. First off, anything that advertises giving people additional services for free is obviously nonsense. How do you think they pay for all those services, some even advertising that they will pay you back your part B charges? Yep, they give you less. There is no way around it. And how do they give you less? They make it a giant pain in the butt to get things done. Want labs? Nah, prior authorization needed. An MRI? Only if you get xrays, meds, and 6 weeks of physical therapy. Meds? Even for medications that are covered by straight medicare, medicare advantage plans will ask for a prior auth. Do they have to pay for the meds? Yep. But if they make your doctor jump through enough hoops, sometimes people just give up. And that saves them money. As a primary care Physician, I can say that it is much easier to to deal with regular medicare vs. medicare advantage to get patients what they need.
Thank you for posting this. It's always valuable to hear from an "insider" who has better insight into the pros and cons. Health issues are challenging enough without both patient and doctor having to wrestle with insurance issues at the same time. After years of Megacorp high deductible, I'm now in a more traditional plan and it's been like a breath of fresh air. I don't want to go back to the dark side ever again.
I am not a lawyer, accountant or financial advisor. Any advice or suggestions that I may provide shall be considered for entertainment purposes only.
ModifiedDuration
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Re: Medicare Advantage - What's the Deal?

Post by ModifiedDuration »

Wrench wrote: Sun Apr 18, 2021 11:11 am
Just to follow up on the size of that tail risk, this article:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5898738/
published in 2018 indicates in Table 5 that ~3% of patients out of >45,000 patients had hospital stays of more than 30 days. Since Medicare A covers up to 60 days after the deductible the risk is low that hospitalization would break the bank. Of greater concern to me though is that those 3% had a total of more than 385 procedures per patient during their hospital stay. Presumably 20% of the charges for those procedures would not be covered by Medicare A & B. Even if the average Medicare allowable cost per procedure was only $100, that would be a bill of 0.2*385*100 = $7K. And that's probably a low estimate - it could easily be two or three times that.

So I am with David Jay and will probably get coverage to protect against this admittedly low tail risk. I am going back and forth between G and High Deductible G (HDG), but am now leaning toward the latter. One limitation I am finding is not all providers offer HDG in my area so my choices are not as wide as I might like.

Wrench
You sure are doing a lot of research on this!

A few clarifying points:

First, you realize that the data in the report you linked is from 8 years ago and
that it is from a South Korean hospital, so it is unknown how their processes, procedures, rules, government regulation, government involvement, culture, ethics, etc. would cause differences from US hospitals. If you want to use it as a proxy for the US, that’s fine, but just be aware that US hospitals might have very different numbers.

You mention that Medicare covers 60 days in the hospital, which is true. However, Medicare Part A would also cover another 30 days in the hospital, with a copay of $371 a day. In addition, you have a Lifetime Reserve of another 60 days, with a copay of $742 a day.

These copays of over $50,000 would be covered by a Medigap Plan. In addition, a Medigap plan would provide you with another Lifetime Reserve of 365 days.

As far as procedures once you are admitted to a hospital, they would be covered under Part A. What would not be covered under Part A when you are hospitalized is physician services, for physicians who are not employed by the hospital.

So, the services for that brain or heart surgeon would be covered under Part B (and you would have your 20% coinsurance). All those visits from your primary care physician when you are in the hospital would be billed separately and covered under Part B (20% coinsurance). You would not be billed for the services of physicians who are employed by the hospital, such as interns and residents.

There is a lot of potential exposure in that Part B 20% coinsurance - such expenses as any physicians bills, outpatient services (such as biopsies, CAT scans, and MRIs), emergency room visits (when you are not subsequently admitted), and when you are at a hospital just for observation (and not admitted).

Another large potential exposure under Part B is chemotherapy that is administered on an outpatient basis. This can easily run into tens of thousands of dollars, with you responsible for 20% coinsurance.

All of this would be covered by a Medigap plan.

In addition, chemotherapy that is administered via a prescription can also easily run into tens of thousands of dollars and is a good reason to at least get an inexpensive Part D prescription plan for its catastrophe coverage.
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FIREchief
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Re: Medicare Advantage - What's the Deal?

Post by FIREchief »

DetroitRick wrote: Sun Apr 18, 2021 10:13 am When I got down to comparing specific Advantage programs in my area, considering who had a reputation for good facilities and doctors, looking at whether my own drugs were covered, looking at potential out of pocket costs of all types - the decision definitely got more complicated. Care to predict your level of medical service and prescription needs in a decade? Again, far from a black and white decision. No matter what TV ads say. All I can say is that I recommend considering ALL these things in your decision: accessibility, service quality (providers, facilities and insurers), premium costs, and out of pocket costs.
The problem with this is even if I can fully understand all of this at age 65, it's just a single point in time. Things can and do change, especially with loosely regulated MegaInsurance. So my specialist is in network now and I sign up for MA. Two years from now, the MA providers put the squeeze on reimbursements and my top specialist decides not to play. :oops: I'm not as concerned with this with Medigap.

One of the key advantages to Medigap policies is that they're boilerplate and the terms are substantially controlled by Medicare, not the insurance companies. 8-)
I am not a lawyer, accountant or financial advisor. Any advice or suggestions that I may provide shall be considered for entertainment purposes only.
zip605
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Re: Medicare Advantage - What's the Deal?

Post by zip605 »

I didn’t read all the entries in this thread but there was one major factor for me in choosing a Medicare plan. Regardless of the additional items covered in Advantage plans, the patient is always responsible for 20% of the treatment costs. There is no Medigap plan available for purchase at any price when one chooses Medicare Advantage. Plus one needs to be “in network” or pay even more for “out of network” care. Referrals are usually required.

Traditional Medicare pays 80% for care AND you can purchase a Supplemental plan to cover the other 20% if you wish. That possibility was important considering how health could deteriorate in later years. But you must chose this during the sign up period or undergo underwriting.
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tj
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Re: Medicare Advantage - What's the Deal?

Post by tj »

FIREchief wrote: Sun Apr 18, 2021 12:41 pm
DetroitRick wrote: Sun Apr 18, 2021 10:13 am When I got down to comparing specific Advantage programs in my area, considering who had a reputation for good facilities and doctors, looking at whether my own drugs were covered, looking at potential out of pocket costs of all types - the decision definitely got more complicated. Care to predict your level of medical service and prescription needs in a decade? Again, far from a black and white decision. No matter what TV ads say. All I can say is that I recommend considering ALL these things in your decision: accessibility, service quality (providers, facilities and insurers), premium costs, and out of pocket costs.
The problem with this is even if I can fully understand all of this at age 65, it's just a single point in time. Things can and do change, especially with loosely regulated MegaInsurance. So my specialist is in network now and I sign up for MA. Two years from now, the MA providers put the squeeze on reimbursements and my top specialist decides not to play. :oops: I'm not as concerned with this with Medigap.

One of the key advantages to Medigap policies is that they're boilerplate and the terms are substantially controlled by Medicare, not the insurance companies. 8-)
I guess this will really vary by your zip code. In Southern California, I only saw 1 MA PPO and it cost twice as much as a Medigap HD G but it had a much higher OOP max than HD G, so I don't know why anyone would sign up for it. The other 40-50 (or however many MA plans there were) are HMO's.
toofache32
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Re: Profits are the deal

Post by toofache32 »

Bogle7 wrote: Thu Apr 15, 2021 3:22 pm All the insurance companies are paying for subscribers because Medicare is profitable.
Apparently so for these 3rd party companies, but it depends on where you stand in line at the trough to feed. As a physician, Medicare was the 2nd plan I dropped after Medicaid.
TravelforFun
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Re: Medicare Advantage - What's the Deal?

Post by TravelforFun »

David Jay wrote: Sat Apr 17, 2021 9:51 am We are both up for Medicare this winter (birthdays are one month apart).

I have seriously looked at the “A + B only” based on this Doctor’s arguments: https://truecostofhealthcare.org/medica ... insurance/

In the end, I chickened out and now we are focusing these choices:
1. High Deducible “G” + Placeholder “D”
2. Priority Health MA PPO, the network is affiliated with Spectrum Hospitals so it covers about 90% of doctors in West Michigan

I figure that if I am unhappy with MA I can go to A + B + D without underwriting, again based on Dr. Belk’s analysis (link above).
The Doctor seems to suggest 60 days of hospital coverage is more than enough. Well I have a real life example here: my grandson had a blood condition and required a 10-month hospital stay last year. Imagine that happens to you and you had to pay 20% of 8 months hospital stay.

TravelforFun
TravelforFun
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Re: Medicare Advantage - What's the Deal?

Post by TravelforFun »

David Jay wrote: Sat Apr 17, 2021 9:51 am We are both up for Medicare this winter (birthdays are one month apart).

I have seriously looked at the “A + B only” based on this Doctor’s arguments: https://truecostofhealthcare.org/medica ... insurance/

In the end, I chickened out and now we are focusing these choices:
1. High Deducible “G” + Placeholder “D”
2. Priority Health MA PPO, the network is affiliated with Spectrum Hospitals so it covers about 90% of doctors in West Michigan

I figure that if I am unhappy with MA I can go to A + B + D without underwriting, again based on Dr. Belk’s analysis (link above).
The Doctor seems to suggest 60 days of hospital coverage is more than enough. Well I have a real life example here: my grandson had a blood condition and required a 10-month hospital stay last year. Imagine that happens to you and you had to pay 20% of 8 months hospital stay.

TravelforFun
vested1
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Re: Medicare Advantage - What's the Deal?

Post by vested1 »

MA may be fine for some, but we are subject to a few "disadvantages" that make staying with supplemental and Plan D safer.

- We live in a semi-rural area with fewer providers.
- My wife goes to several specialists that would require referrals with MA, adding additional cost for an unneeded visit to her PCP and added time to address the problem. The months it currently takes to get an appointment would be extended.
- My wife takes an outrageously expensive arthritis prescription that would cost much more than the current $5,800 co-pay if she had MA.
- If one of our providers on MA dropped out of the program and we had to find another who would accept MA, there may be none left, so we would have to go through medical underwriting to get back to regular Medicare supplemental and plan D.

Both of our former employers provide a service from non-biased intermediaries that help us to determine the best plans for us. We were cautioned about the hidden pitfalls of Medicare Advantage problems, and that if we wanted to go that route we should know the whole story.

Like many here have stated, when someone is doing the hard sell on you, you can be pretty certain that what they are pushing is to their advantage (no pun intended) not yours.

Regardless, having to go through this decision process every year at open enrollment is overly complicated for aging minds. I imagine many just give up and go with the cheapest option, at least from what they have been told.
sgm7091
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Re: Medicare Advantage - What's the Deal?

Post by sgm7091 »

Thank you all and OP for info on this thread. Very useful.

Can anyone recommend books or sites to understand Medicare and all its details?
ModifiedDuration
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Re: Medicare Advantage - What's the Deal?

Post by ModifiedDuration »

sgm7091 wrote: Mon Apr 19, 2021 6:56 am Thank you all and OP for info on this thread. Very useful.

Can anyone recommend books or sites to understand Medicare and all its details?
Going into Medicare (and knowing that some decisions would be irrevocable), I read 6 books on Medicare. I thought these two were the best:

Medicare For Dummies

Medicare Demystified

The “Medicare and You” publication from the government is a very good place to start:

https://www.medicare.gov/Pubs/pdf/10050 ... nd-You.pdf

I did watch a lot of videos on YouTube, particularly on high-deductible Medigap, which I was very interested in.

Once you have done your research and get an idea of which direction you want to go, you might find it very helpful to run through your thinking and ask your questions to a Medicare insurance agent.

If you decide to go the Medigap route, a good agent can steer you away from the insurance companies that close insurance pools as the participants get older (and rates increase) and start new pools with younger participants at low rates and then, as rates rise in that pool, just repeat the process. If you can’t pass underwriting, you don’t want to be trapped in one of the older pools as people continue to age and the rates increase in a corresponding fashion.

A good Medicare insurance agent, not one who will automatically try and push you to an Advantage Plan because of the higher commission.
Last edited by ModifiedDuration on Mon Apr 19, 2021 7:31 am, edited 2 times in total.
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prudent
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Re: Medicare Advantage - What's the Deal?

Post by prudent »

sgm7091 wrote: Mon Apr 19, 2021 6:56 am Thank you all and OP for info on this thread. Very useful.

Can anyone recommend books or sites to understand Medicare and all its details?
I found a lot of good info at boomerbenefits.com. They also have a boatload of videos on youtube. For me I needed to hear things from different sources to help process the info - I also used the Dummies book.
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David Jay
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Re: Medicare Advantage - What's the Deal?

Post by David Jay »

TravelforFun wrote: Sun Apr 18, 2021 11:04 pm
David Jay wrote: Sat Apr 17, 2021 9:51 am We are both up for Medicare this winter (birthdays are one month apart).

I have seriously looked at the “A + B only” based on this Doctor’s arguments: https://truecostofhealthcare.org/medica ... insurance/

In the end, I chickened out and now we are focusing these choices:
1. High Deducible “G” + Placeholder “D”
2. Priority Health MA PPO, the network is affiliated with Spectrum Hospitals so it covers about 90% of doctors in West Michigan

I figure that if I am unhappy with MA I can go to A + B + D without underwriting, again based on Dr. Belk’s analysis (link above).
The Doctor seems to suggest 60 days of hospital coverage is more than enough. Well I have a real life example here: my grandson had a blood condition and required a 10-month hospital stay last year. Imagine that happens to you and you had to pay 20% of 8 months hospital stay.

TravelforFun
I presume that you are referring to “A + B only”? Because both of my options have annual out-of-pocket maximums.
It's not an engineering problem - Hersh Shefrin | To get the "risk premium", you really do have to take the risk - nisiprius
toofache32
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Re: Medicare Advantage - What's the Deal?

Post by toofache32 »

Shallowpockets wrote: Sun Apr 18, 2021 11:16 am
setsail26 wrote: Sat Apr 17, 2021 10:00 pm I haven't read every message here, so forgive me if this has been stated. I'm a bit surprised that Bogleheads would consider Medicare Advantage except in very specific circumstances. First off, anything that advertises giving people additional services for free is obviously nonsense. How do you think they pay for all those services, some even advertising that they will pay you back your part B charges? Yep, they give you less. There is no way around it. And how do they give you less? They make it a giant pain in the butt to get things done. Want labs? Nah, prior authorization needed. An MRI? Only if you get xrays, meds, and 6 weeks of physical therapy. Meds? Even for medications that are covered by straight medicare, medicare advantage plans will ask for a prior auth. Do they have to pay for the meds? Yep. But if they make your doctor jump through enough hoops, sometimes people just give up. And that saves them money. As a primary care Physician, I can say that it is much easier to to deal with regular medicare vs. medicare advantage to get patients what they need.
NOT!
Perhaps being a PCP practicing under regular medicare there is a bias.
Huh? Can you explain the bias? And Welcome to Bogleheads.
Last edited by toofache32 on Mon Apr 19, 2021 8:55 am, edited 1 time in total.
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David Jay
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Re: Medicare Advantage - What's the Deal?

Post by David Jay »

zip605 wrote: Sun Apr 18, 2021 2:18 pmRegardless of the additional items covered in Advantage plans, the patient is always responsible for 20% of the treatment costs.
???

I just got done wading through a Medicare Advantage EOC (that's the 297 page official coverage document). You were mis-informed if you were told that this is true of all Medicare Advantage plans.
It's not an engineering problem - Hersh Shefrin | To get the "risk premium", you really do have to take the risk - nisiprius
JackoC
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Re: Medicare Advantage - What's the Deal?

Post by JackoC »

setsail26 wrote: Sat Apr 17, 2021 10:00 pm I haven't read every message here, so forgive me if this has been stated. I'm a bit surprised that Bogleheads would consider Medicare Advantage except in very specific circumstances. First off, anything that advertises giving people additional services for free is obviously nonsense. How do you think they pay for all those services, some even advertising that they will pay you back your part B charges? Yep, they give you less. There is no way around it. And how do they give you less? They make it a giant pain in the butt to get things done. Want labs? Nah, prior authorization needed. An MRI? Only if you get xrays, meds, and 6 weeks of physical therapy. Meds? Even for medications that are covered by straight medicare, medicare advantage plans will ask for a prior auth. Do they have to pay for the meds? Yep. But if they make your doctor jump through enough hoops, sometimes people just give up. And that saves them money. As a primary care Physician, I can say that it is much easier to to deal with regular medicare vs. medicare advantage to get patients what they need.
But it's not that simple is because it is not a zero sum game of them collecting less premium thus giving you less stuff. There's also the government funneling money in on the other side, according to formulae which aren't transparent to the consumer. Obviously they are not making *no plan premium* work as profitable product for them solely by cutting corners. :happy Without knowing how the government subsidy relates to the companies' real costs, which you can't, you cannot make a simple common sense determination that MA is a bad deal.

You can reasonably figure that there's cost cutting that *might* result in diminution of your healthcare that's not worth it to you. It is simple common sense and (relatively) current affairs knowledge to know the program exists with the ostensible purpose of reducing total cost to the public (the govt) v original M. However whether it does save (the govt) money is controversial. Which is *not* to get into a public policy debate. The point is again just that you can't make a simple determination based on common sense how much of the apparently attractive pricing they give you reflects an advantage the subsidy formula's give MA, how much reflects real efficiencies MA plans achieve which would not necessarily hurt your healthcare, and how much reflects you simply getting less healthcare. The last element is in there, but you can't quantify it via a brief thought experiment.

I'll repeat though what I said earlier. The consensus among expert advisors AFAIK is that if regular Medicare+robust Medigap (like 'G')+D is easily affordable, just do that. That's our case, and we will. But I don't necessarily agree it's 'surprising anyone would consider MA except in very specific circumstances'. The difference in cost is material to a lot of people even here (most people in general) and it's not actually clear you *do* get a worse deal for your money (it's clear you *risk* that). And if somebody is starting at the very naive point of taking the testimonials in the commercials ('I got all this stuff, it's great', no downside mentioned) at face value that's one thing, but I doubt anyone responding on this thread is in that category. Everyone here realizes it's rare to get something for nothing. But the missing pieces are again the exact degree of government money behind those low/zero MA premiums, and that medical cost control measures don't necessarily 100% translate, $ for $, to 'screwing the patient'.
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Re: Medicare Advantage - What's the Deal?

Post by aburntoutcase »

JackoC wrote: Mon Apr 19, 2021 9:27 am Everyone here realizes it's rare to get something for nothing. But the missing pieces are again the exact degree of government money behind those low/zero MA premiums, and that medical cost control measures don't necessarily 100% translate, $ for $, to 'screwing the patient'.
You hit the nail on the head. The US Govt does pay more to the average Medicare Advantage plan. The average MA plan costs the US Govt 104% of traditional FFS spending. This includes higher reimbursement for higher coding intensity (medical risk of population) and some extra payments for quality payments. Many retirees on this forum will be affluent enough that they will stick with traditional Medicare plus Medigap. For low to moderate income retirees especially those in better than average health MA plans might indeed be a good deal or might even be necessary for those struggling to make ends meet.

Also from a purely policy perspective it makes sense to have MA plans doing some cost and utilization control to keep system wide elderly healthcare costs in check.

Source of data is MedPAC report on Medicare for 2021 below:
http://www.medpac.gov/-documents-/reports
ModifiedDuration
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Re: Medicare Advantage - What's the Deal?

Post by ModifiedDuration »

I guess that I’m the simpleton here.

Here was my thought process when deciding what to do when signing up for Medicare:

1). Decide between Medicare Advantage and Traditional Medicare.

2) If Traditional Medicare, look at Medigap Plans G, High-Deductible G, and N

Pick one

3). If Traditional Medicare, go to Medicare.gov, enter prescriptions, and pick the least expensive Part D plan that pops up.

Done.

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lukestuckenhymer
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Re: Medicare Advantage - What's the Deal?

Post by lukestuckenhymer »

I am not 65, but when my mother-in-law turned 65 this last year, I steered her into Plan G and avoided Medicare Advantage like the plague.

It just seems like a scam to me--Feeding off the bureaucratic confusion of Medicare and needlessly overcomplicating things with the allure of "hidden benefits that you don't get automatically!" How about this: Just get a separate plan for dental. Plan G covers all out-of-pocket costs after the Part B deductible. Period. No copays to worry about, no limits on how many times you can visit a specialist, the E.R., etc. If it's covered, it's covered. That sounds like the best of all worlds to me, but I'm sure it's not the most profitable thing to sell to confused seniors.
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Re: Medicare Advantage - What's the Deal?

Post by EnjoyIt »

philpill wrote: Thu Apr 15, 2021 4:32 pm the correct appellation is MEDICARE DISADVANTAGE. i know nothing about kaiser but here in NJ the disadvantage discourages you from seeing a specialist. they act as a gate keeper and do not utilize elite doctors, but rather those who can not develop a full practice. caveat emptor. not for me!
These plans make money by cutting cost. How do they do that? They minimize healthcare utilization and reimbursement to healthcare providers.
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Re: Medicare Advantage - What's the Deal?

Post by susa »

David Jay wrote: I have seriously looked at the “A + B only” based on this Doctor’s arguments: https://truecostofhealthcare.org/medica ... insurance/

.. chickened out..
Went with A and B Only. Watched all of the Dr. Belk videos and read online entire book. Appears to be well researched.

There is no way to go bankrupt with A + B Only and most seniors don't understand that.
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JoeRetire
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Re: Medicare Advantage - What's the Deal?

Post by JoeRetire »

setsail26 wrote: Sat Apr 17, 2021 10:00 pm I haven't read every message here, so forgive me if this has been stated. I'm a bit surprised that Bogleheads would consider Medicare Advantage except in very specific circumstances. First off, anything that advertises giving people additional services for free is obviously nonsense. How do you think they pay for all those services, some even advertising that they will pay you back your part B charges? Yep, they give you less.
Less than what?
There is no way around it. And how do they give you less? They make it a giant pain in the butt to get things done.
Your medicare advantage experience must differ from mine.

My MA plan is almost exactly the same as the plan I had while employed. Same insurance company, same set of doctors, same set of hospitals - just much cheaper.
Want labs? Nah, prior authorization needed. An MRI? Only if you get xrays, meds, and 6 weeks of physical therapy. Meds? Even for medications that are covered by straight medicare, medicare advantage plans will ask for a prior auth. Do they have to pay for the meds? Yep. But if they make your doctor jump through enough hoops, sometimes people just give up. And that saves them money.
I have experienced exactly none of that. I have gotten prior authorization for everything I have needed so far by email or a phone call. That's a pain in the butt? Not for me.
As a primary care Physician, I can say that it is much easier to to deal with regular medicare vs. medicare advantage to get patients what they need.
Ah. So perhaps you are conflating your side of the equation with the patient's side? Otherwise, I just can't agree with any of the points you are trying to make.
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Re: Medicare Advantage - What's the Deal?

Post by Stinky »

JoeRetire wrote: Tue Apr 20, 2021 3:23 pm
setsail26 wrote: Sat Apr 17, 2021 10:00 pm I haven't read every message here, so forgive me if this has been stated. I'm a bit surprised that Bogleheads would consider Medicare Advantage except in very specific circumstances. First off, anything that advertises giving people additional services for free is obviously nonsense. How do you think they pay for all those services, some even advertising that they will pay you back your part B charges? Yep, they give you less.
Less than what?
There is no way around it. And how do they give you less? They make it a giant pain in the butt to get things done.
Your medicare advantage experience must differ from mine.

My MA plan is almost exactly the same as the plan I had while employed. Same insurance company, same set of doctors, same set of hospitals - just much cheaper.
Want labs? Nah, prior authorization needed. An MRI? Only if you get xrays, meds, and 6 weeks of physical therapy. Meds? Even for medications that are covered by straight medicare, medicare advantage plans will ask for a prior auth. Do they have to pay for the meds? Yep. But if they make your doctor jump through enough hoops, sometimes people just give up. And that saves them money.
I have experienced exactly none of that. I have gotten prior authorization for everything I have needed so far by email or a phone call. That's a pain in the butt? Not for me.
As a primary care Physician, I can say that it is much easier to to deal with regular medicare vs. medicare advantage to get patients what they need.
Ah. So perhaps you are conflating your side of the equation with the patient's side? Otherwise, I just can't agree with any of the points you are trying to make.
Joe Retire’s experience parallels mine.

Same MA insurer as I had when I was working. Same network of doctors and hospitals. Same look and feel to the plan.

But more ancillary benefits (gym, dental, etc) than before retirement. And lower cost to me.

And I can finally use my closest pharmacy instead of the one that my employer forced me to use.
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Re: Medicare Advantage - What's the Deal?

Post by Broken Man 1999 »

Stinky wrote: Tue Apr 20, 2021 5:03 pm
JoeRetire wrote: Tue Apr 20, 2021 3:23 pm
setsail26 wrote: Sat Apr 17, 2021 10:00 pm I haven't read every message here, so forgive me if this has been stated. I'm a bit surprised that Bogleheads would consider Medicare Advantage except in very specific circumstances. First off, anything that advertises giving people additional services for free is obviously nonsense. How do you think they pay for all those services, some even advertising that they will pay you back your part B charges? Yep, they give you less.
Less than what?
There is no way around it. And how do they give you less? They make it a giant pain in the butt to get things done.
Your medicare advantage experience must differ from mine.

My MA plan is almost exactly the same as the plan I had while employed. Same insurance company, same set of doctors, same set of hospitals - just much cheaper.
Want labs? Nah, prior authorization needed. An MRI? Only if you get xrays, meds, and 6 weeks of physical therapy. Meds? Even for medications that are covered by straight medicare, medicare advantage plans will ask for a prior auth. Do they have to pay for the meds? Yep. But if they make your doctor jump through enough hoops, sometimes people just give up. And that saves them money.
I have experienced exactly none of that. I have gotten prior authorization for everything I have needed so far by email or a phone call. That's a pain in the butt? Not for me.
As a primary care Physician, I can say that it is much easier to to deal with regular medicare vs. medicare advantage to get patients what they need.
Ah. So perhaps you are conflating your side of the equation with the patient's side? Otherwise, I just can't agree with any of the points you are trying to make.
Joe Retire’s experience parallels mine.

Same MA insurer as I had when I was working. Same network of doctors and hospitals. Same look and feel to the plan.

But more ancillary benefits (gym, dental, etc) than before retirement. And lower cost to me.

And I can finally use my closest pharmacy instead of the one that my employer forced me to use.
Pretty much my experience, as well. Honestly, we can afford to pay for whatever insurance we might need. We are fortunate MegaCorp offers it free to us, though we do pay the Medicare Part B premium.

MA plans: some like 'em, some don't. They work very well for me, and DW.

The end.

Broken Man 1999
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Re: Medicare Advantage - What's the Deal?

Post by hicabob »

susa wrote: Tue Apr 20, 2021 1:43 pm
David Jay wrote: I have seriously looked at the “A + B only” based on this Doctor’s arguments: https://truecostofhealthcare.org/medica ... insurance/

.. chickened out..
Went with A and B Only. Watched all of the Dr. Belk videos and read online entire book. Appears to be well researched.

There is no way to go bankrupt with A + B Only and most seniors don't understand that.
After listening to Dr Belk it seems Part A + B is the obvious choice but then I realized Part B premiums are based on income ...

income (individual) premium
<$88001 $148.50
$88,001 to $111,000 $207.90
$111,001 to $138,500 $297.00
$138,501 to $165,000 $386.10
$165,001 to $500,000 $475.20
$500,000 or more $504.90

For those of us doing large Roth conversions the premium starts to add up. It's interesting that premiums for advantage plans are not income based.
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Re: Medicare Advantage - What's the Deal?

Post by tj »

hicabob wrote: Sat Apr 24, 2021 12:03 pm
susa wrote: Tue Apr 20, 2021 1:43 pm
David Jay wrote: I have seriously looked at the “A + B only” based on this Doctor’s arguments: https://truecostofhealthcare.org/medica ... insurance/

.. chickened out..
Went with A and B Only. Watched all of the Dr. Belk videos and read online entire book. Appears to be well researched.

There is no way to go bankrupt with A + B Only and most seniors don't understand that.
After listening to Dr Belk it seems Part A + B is the obvious choice but then I realized Part B premiums are based on income ...

income (individual) premium
<$88001 $148.50
$88,001 to $111,000 $207.90
$111,001 to $138,500 $297.00
$138,501 to $165,000 $386.10
$165,001 to $500,000 $475.20
$500,000 or more $504.90

For those of us doing large Roth conversions the premium starts to add up. It's interesting that premiums for advantage plans are not income based.
I believe that is not correct. Those in Medicare Advantage are still subject to IRMAA.
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Re: Medicare Advantage - What's the Deal?

Post by Stinky »

tj wrote: Sat Apr 24, 2021 12:19 pm Those in Medicare Advantage are still subject to IRMAA.
Yes, I can confirm that is absolutely correct. Both the Part B and Part D surcharges.
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ModifiedDuration
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Re: Medicare Advantage - What's the Deal?

Post by ModifiedDuration »

hicabob wrote: Sat Apr 24, 2021 12:03 pm
susa wrote: Tue Apr 20, 2021 1:43 pm
David Jay wrote: I have seriously looked at the “A + B only” based on this Doctor’s arguments: https://truecostofhealthcare.org/medica ... insurance/

.. chickened out..
Went with A and B Only. Watched all of the Dr. Belk videos and read online entire book. Appears to be well researched.

There is no way to go bankrupt with A + B Only and most seniors don't understand that.
After listening to Dr Belk it seems Part A + B is the obvious choice but then I realized Part B premiums are based on income ...

income (individual) premium
<$88001 $148.50
$88,001 to $111,000 $207.90
$111,001 to $138,500 $297.00
$138,501 to $165,000 $386.10
$165,001 to $500,000 $475.20
$500,000 or more $504.90

For those of us doing large Roth conversions the premium starts to add up. It's interesting that premiums for advantage plans are not income based.
You still have to pay the monthly Part B premium and the Income-Related Monthly Adjustment Amount (IRMAA) for both Parts B and D if you have a Medicare Advantage plan.

There are a few exceptions to having to pay the monthly Part B premium with an Advantage plan, such as being on Medicaid.

Also, if your Advantage plan does not cover prescriptions, you would not have to pay the IRMAA for Part D, just for Part B.
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Re: Medicare Advantage - What's the Deal?

Post by hicabob »

ModifiedDuration wrote: Sat Apr 24, 2021 12:26 pm
hicabob wrote: Sat Apr 24, 2021 12:03 pm
susa wrote: Tue Apr 20, 2021 1:43 pm
David Jay wrote: I have seriously looked at the “A + B only” based on this Doctor’s arguments: https://truecostofhealthcare.org/medica ... insurance/

.. chickened out..
Went with A and B Only. Watched all of the Dr. Belk videos and read online entire book. Appears to be well researched.

There is no way to go bankrupt with A + B Only and most seniors don't understand that.
After listening to Dr Belk it seems Part A + B is the obvious choice but then I realized Part B premiums are based on income ...

income (individual) premium
<$88001 $148.50
$88,001 to $111,000 $207.90
$111,001 to $138,500 $297.00
$138,501 to $165,000 $386.10
$165,001 to $500,000 $475.20
$500,000 or more $504.90

For those of us doing large Roth conversions the premium starts to add up. It's interesting that premiums for advantage plans are not income based.
You still have to pay the monthly Part B premium and the Income-Related Monthly Adjustment Amount (IRMAA) for both Parts B and D if you have a Medicare Advantage plan.

There are a few exceptions to having to pay the monthly Part B premium with an Advantage plan, such as being on Medicaid.

Also, if your Advantage plan does not cover prescriptions, you would not have to pay the IRMAA for Part D, just for Part B.
TIL .... Drat, foiled again! :happy

The advantage plans do use sneaky wording.
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Re: Medicare Advantage - What's the Deal?

Post by FIREchief »

ModifiedDuration wrote: Sat Apr 24, 2021 12:26 pm Also, if your Advantage plan does not cover prescriptions, you would not have to pay the IRMAA for Part D, just for Part B.
I thought it was the other way around. Was I mistaken?
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Re: Medicare Advantage - What's the Deal?

Post by sgm7091 »

ModifiedDuration wrote: Mon Apr 19, 2021 7:08 am
sgm7091 wrote: Mon Apr 19, 2021 6:56 am Thank you all and OP for info on this thread. Very useful.

Can anyone recommend books or sites to understand Medicare and all its details?
Going into Medicare (and knowing that some decisions would be irrevocable), I read 6 books on Medicare. I thought these two were the best:

Medicare For Dummies

Medicare Demystified

The “Medicare and You” publication from the government is a very good place to start:

https://www.medicare.gov/Pubs/pdf/10050 ... nd-You.pdf

I did watch a lot of videos on YouTube, particularly on high-deductible Medigap, which I was very interested in.

Once you have done your research and get an idea of which direction you want to go, you might find it very helpful to run through your thinking and ask your questions to a Medicare insurance agent.

If you decide to go the Medigap route, a good agent can steer you away from the insurance companies that close insurance pools as the participants get older (and rates increase) and start new pools with younger participants at low rates and then, as rates rise in that pool, just repeat the process. If you can’t pass underwriting, you don’t want to be trapped in one of the older pools as people continue to age and the rates increase in a corresponding fashion.

A good Medicare insurance agent, not one who will automatically try and push you to an Advantage Plan because of the higher commission.
Thank you and @prudent for the reading info. I downloaded the medicare and you - great start. Getting the books. This and other thread here have been very helpful. Anyone knows if boomerbenefit.com is only TX or available to other states, and also are there other sites like boomercredit that provide consultation? What is in it for them - if I choose traditional say A+B+D+G, do they get commission on D and G perhaps.
ModifiedDuration
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Re: Medicare Advantage - What's the Deal?

Post by ModifiedDuration »

sgm7091 wrote: Sat Apr 24, 2021 6:20 pm Thank you and @prudent for the reading info. I downloaded the medicare and you - great start. Getting the books. This and other thread here have been very helpful. Anyone knows if boomerbenefit.com is only TX or available to other states, and also are there other sites like boomercredit that provide consultation? What is in it for them - if I choose traditional say A+B+D+G, do they get commission on D and G perhaps.
Boomerbenefits sells plans in 48 states.

Insurance agents would get a commission from the insurance company for both your Plan G and Part D policies (but have a large incentive to steer you to Advantage plans, as they get much higher commissions from selling Advantage plans).

After doing my research on Medicare and deciding that I wanted a high-deductible Plan G, I was concerned about finding an insurance agent that would put my interests first and not try and talk me out of a Medigap plan and push me to an Advantage plan.

In looking around the internet, I found a smaller insurance agency, Medicare Nationwide, that only does Medigap (and Part D) and does not have an aversion to selling very low commission Plan G-HD.

I have gotten outstanding service from them (and was impressed that when I apologized to one of the owners for just wanting a low commission Plan G-HD, he replied, “Don’t worry about the commission.”)

I prefer dealing with smaller companies, where I am working with one of the owners and feel that I would be more important to them as opposed to working with a large company where one person’s business really doesn’t matter much to them. But, that’s just me.
ModifiedDuration
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Re: Medicare Advantage - What's the Deal?

Post by ModifiedDuration »

FIREchief wrote: Sat Apr 24, 2021 1:49 pm
ModifiedDuration wrote: Sat Apr 24, 2021 12:26 pm Also, if your Advantage plan does not cover prescriptions, you would not have to pay the IRMAA for Part D, just for Part B.
I thought it was the other way around. Was I mistaken?
Probably a case of me poorly explaining what I meant:

If someone has an Advantage plan with prescription coverage than they would have to pay Part D IRMAA

If someone has an Advantage plan without prescription coverage and separately purchases a Part D prescription plan than they would have to pay Part D IRMAA

If someone has an Advantage plan without prescription coverage and does not separately purchase a Part D prescription than they would not have to pay Part D IRMAA

Does that agree with your understanding?
DetroitRick
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Re: Medicare Advantage - What's the Deal?

Post by DetroitRick »

A relevant article from Morningstar this week, covering some of these discussions on out-of-pocket costs under both programs, enrollment decisions, and denial of patient claims.

https://www.morningstar.com/articles/10 ... protection
miket29
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Re: Medicare Advantage - What's the Deal?

Post by miket29 »

orlandoman wrote: Fri Apr 16, 2021 4:37 pm Let's clear up something about Medicare Advantage plans:
- under the MA PPO plan there are higher deductables/copays/out of pocket maximums if you use out of network doctors/facilities
I find this all a bit confusing. It does sound like they may in some instances be more restrictive than expected.
Finally, we will look at PPO Medicare Advantage plans. These plans usually have the most flexibility out of the three advantage plan types when it comes to networks and coverage. You can see here that you typically do not have to choose a primary care physician or receive referrals from one to see a specialist. You can also seek care outside of your network without prior approval (important: so long as you seek care at a provider that accepts Medicare’s assignment and agrees to bill your plan), but it will still come at a higher out of pocket cost. Lastly, many PPO plans do have a maximum out of pocket for medical procedures that you receive outside of your plan’s network, unlike HMO plans.

Now it is essential to point out that even with a PPO plan, members do not have unlimited flexibility to seek care at any facility they choose. Facilities may accept Medicare assignment, but they do not have to agree to bill your plan or see you as a patient. The mayo clinic is a famous example of one such facility, as you can see here on their website.
https://gmedicareteam.com/medicare-advantage/
And in that Morningstar link immediately above my post it says
“The Medigap option has become a luxury for people who can afford it,” says Tricia Neuman, director of the Medicare policy program at the Kaiser Family Foundation and a co-author of the brief. “It’s the luxury to say that you care about which doctor you’re going to see, or what medical center if you get a serious disease.”
rtt22
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Re: Medicare Advantage - What's the Deal?

Post by rtt22 »

Isn't this worrisome if you choose a certain Medicare Advantage plan and then a big network of providers like the M Health Fairview, which is "a partnership between University of Minnesota, University of Minnesota Physicians, and Fairview Health Services", put out this notice:
M Health Fairview does not accept Humana Medicare Advantage Insurance. This means that we don’t schedule medical visits for Humana Medicare Advantage members. Even if you had an appointment in 2021, you may not be able to make any new appointments.
What are you going to do if you're in the middle of a cancer treatment with one of the U of M doctors?
protagonist
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Re: Medicare Advantage - What's the Deal?

Post by protagonist »

I've been on a Tufts medicare advantage plan (Massachusetts) for 5 years and have had overall very good experiences. No problems seeing specialists.
I'm switching to a Medigap plan during open enrollment this year because I am now living out of network 5-6 months/year and I think national coverage would suit me better.
If your doctors are all in network and if you don't travel extensively , an Advantage plan might suit you fine. Especially if you live in a state where you can switch to a Medigap plan without underwriting if you become chronically ill or whatever. Massachusetts is very good that way. I might have more second thoughts in other states where switching might be problematic.
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Re: Medicare Advantage - What's the Deal?

Post by Dregob »

philpill wrote: Thu Apr 15, 2021 4:32 pm the correct appellation is MEDICARE DISADVANTAGE. i know nothing about kaiser but here in NJ the disadvantage discourages you from seeing a specialist. they act as a gate keeper and do not utilize elite doctors, but rather those who can not develop a full practice. caveat emptor. not for me!
As with anything involved with Medicare you have to dig deep. I have an Advantage Plan and I don't need a referral to see a Specialist.
My plan is essentially what I had for 30 years through employment.
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