My Kaiser Medicare Plan is "converting" from Cost to Advantage!

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dm200
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My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by dm200 » Fri Sep 27, 2019 10:47 am

There are actually several different types of "Part C" Medicare. Overwhelmingly, the most common is "Medicare Advantage" (MA) plans - much discussed and debated here. With MA plans you almost always must get medical services from providers in that MA "network". Another, much less common, type of Part C is "Medicare Cost" (MC) plans. While very similar to MA plans, an MC plan allows participants to use "Original Medicare" outside of the MC Network.

For several years (not sure how many or why), Medicare is forcing many (or most) MC plans to terminate or convert to MA plans. Our Kaiser Medicare plan is an MC plan (and has been since I became Medicare eligible nine years ago. Around the country, where Kaiser facilities are located, almost all of the Kaiser Medicare plans are MA plans.

Even in this area (Washington DC, suburban Virginia and Maryland up to Baltimore area) - while this area is a single Kaiser provider area - the Kaiser Medicare plans are a mixed bag. In Washington DC, it is an MA plan, while in Virginia, it is an MC plan - and in Maryland -in some counties it is MA and in others MC. While the monthly premiums are the same for both MA and MC plans, things like copays, annual out of pocket maximums, etc. are different - with the MA plans are better. The MA plans, however, do not allow use of original Medicare at all.

We have not received all the details yet - will get those next month - we have been notified that next year, our Kaiser plan will be an MA plan. I thought it might happen last year. Since my wife and I have never used the Original Medicare option for any services, nor do we anticipate doing so, I view this as beneficial for us.

While, to me, this does not seem like any "big deal", nonetheless Kaiser is scheduling a lot of information sessions in October and refers to having to "enroll" in the Advantage plan.

I think the folks now in MC plans that are being terminated who are most adversely affected are those who spend significant time out of their MC plan area (such as going to Florida or Arizona in the winter). I suppose such folks will need to return to Original Medicare with a supplement.

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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by Big Dog » Fri Sep 27, 2019 11:35 am

not sure why...
It looks like the phase out of MC plans is baed on a 2015 law change to Medicare. But your point about folks who travel a lot is a good one.

https://www.cms.gov/Medicare/Health-Pla ... index.html

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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by LadyGeek » Sat Sep 28, 2019 12:14 pm

This thread is now in the Personal Finance (Not Investing) forum (Medicare plan).
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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by drawpoker » Sat Sep 28, 2019 12:57 pm

dm200 wrote:
Fri Sep 27, 2019 10:47 am
...While very similar to MA plans, an MC plan allows participants to use "Original Medicare" outside of the MC Network.....
...MA plans, however, do not allow use of original Medicare at all. ....Since my wife and I have never used the Original Medicare option for any services, nor do we anticipate doing so, I view this as beneficial......
....does not seem like any "big deal".....
You may think differently if you or wife are diagnosed with one of the serious cancers. And are shut out of the top treatment centers in the country because you have MA insurance, not Original Medicare, and it is not accepted.

Of course, as MD Anderson helpfully points out on website, you can always self-pay.

Memorial Sloan Kettering won't take Kaiser MA either. But they will take Medicaid if patient is a NY resident. Go figure.

Something to think about before cheering this news as "beneficial", isn't it.

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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by carruthers209 » Sat Sep 28, 2019 8:17 pm

I agree that if you have a very nontraditional cancer or other disease Kaiser's might not be the best fit. They don't do extremely aggressive therapies or surgeries or provide treatments that are highly risky and don't appear to have a high degree of success. My mother had a severe carotid artery blockage that Kaiser's surgeons operated on, saw it was calcified and didn't remove it because it was too dangerous a procedure in their opinion. So instead, my mom went to a university surgery center in southern California with a world wide reputation for doing aggressive (and highly risky surgery) to have the same calcified carotid artery removed and a piece broke off in her brain during that surgery giving her a major stroke that took her speech, her ability to swallow, all movement in her right hand. My dad ended up with a bill of about a $100,000. In retrospect, Kaiser's was correct in their original assessment of my mother's medical condition. Kaiser's has world class surgeons and provides patient centered medical care. My husband had deep brain stimulation for his Parkinson's and had a very successful outcome. We will stick with Kaiser's for all of our medical issues.

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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by Gleevec » Sat Sep 28, 2019 8:36 pm

carruthers209 wrote:
Sat Sep 28, 2019 8:17 pm
I agree that if you have a very nontraditional cancer or other disease Kaiser's might not be the best fit. They don't do extremely aggressive therapies or surgeries or provide treatments that are highly risky and don't appear to have a high degree of success. My mother had a severe carotid artery blockage that Kaiser's surgeons operated on, saw it was calcified and didn't remove it because it was too dangerous a procedure in their opinion. So instead, my mom went to a university surgery center in southern California with a world wide reputation for doing aggressive (and highly risky surgery) to have the same calcified carotid artery removed and a piece broke off in her brain during that surgery giving her a major stroke that took her speech, her ability to swallow, all movement in her right hand. My dad ended up with a bill of about a $100,000. In retrospect, Kaiser's was correct in their original assessment of my mother's medical condition. Kaiser's has world class surgeons and provides patient centered medical care. My husband had deep brain stimulation for his Parkinson's and had a very successful outcome. We will stick with Kaiser's for all of our medical issues.
There are so many fallacies in this post, but the clearest one is about kaiser having world class surgeons. Kaiser provides excellent to amazing (and cost efficient) primary care, this is clear. Those in medicine know it’s specialty issues or issues handling advanced illness. Glad to hear you’ve had a better than average outcome

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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by Northern Flicker » Sun Sep 29, 2019 3:54 am

I think the folks now in MC plans that are being terminated who are most adversely affected are those who spend significant time out of their MC plan area (such as going to Florida or Arizona in the winter). I suppose such folks will need to return to Original Medicare with a supplement.
Is this possible? My impression is that once you are on MA you can only get a Medicare supplemental plan by going through medical underwriting, which is difficult for people who are past age 65.

Kaiser will refer patients to major cancer centers for experimental procedures when they reach the end of the line for conventional treatment options. This is not the care I would prioritize for optimization. Experimental procedures at major research centers are not magic bullets.

I’ve seen some very highly rated specialists treat original Medicare patients quite aggressively. I hope this is not to compensate for lower Medicare fees. A mega-specialist who can do very special procedures does not make a living by not doing the procedures.

I’ve also seen MA HMO’s focus on saving money and have a mediocre outcome. Kaiser is somewhere in between those extremes, but maybe not the optimal point. And with original Medicare you have some choice— you are not obliged to authorize aggressive treatment. Still I currently think Kaiser is a good option. A Kaiser doc I know chose Kaiser MA over original Medicare when he retired.
Last edited by Northern Flicker on Sun Sep 29, 2019 11:15 am, edited 1 time in total.
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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by Kagord » Sun Sep 29, 2019 6:36 am

Never been a fan of being told who to use for medical, I get medigap plan F and a part D supplement for my mother. Yes, it's two thousand or so more in annual premiums, but not having to go to a primary care physician first, and/or not being forced to find in network providers for cost effectiveness, is worth this cost, IMHO.
Last edited by Kagord on Sun Sep 29, 2019 8:51 am, edited 1 time in total.

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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by dodecahedron » Sun Sep 29, 2019 7:19 am

Northern Flicker wrote:
Sun Sep 29, 2019 3:54 am
I think the folks now in MC plans that are being terminated who are most adversely affected are those who spend significant time out of their MC plan area (such as going to Florida or Arizona in the winter). I suppose such folks will need to return to Original Medicare with a supplement.
Is this possible? My impression is that once you are on MA you can only get a Medicare supplemental plan why going through medical underwriting, which is difficult for people who are past age 65.
1) In a few states (e.g., NY) supplement companies are generally required to sell without underwriting, regardless of age.

2) In all states, federal law provides that plan termination creates an open enrollment opportunity for former subscribers to the terminated plan. If the MC plan was terminated, I think the OP would have the right to switch to original Medicare plus supplemental if desired.

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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by Gleevec » Sun Sep 29, 2019 9:18 am

Northern Flicker wrote:
Sun Sep 29, 2019 3:54 am
I think the folks now in MC plans that are being terminated who are most adversely affected are those who spend significant time out of their MC plan area (such as going to Florida or Arizona in the winter). I suppose such folks will need to return to Original Medicare with a supplement.
Is this possible? My impression is that once you are on MA you can only get a Medicare supplemental plan why going through medical underwriting, which is difficult for people who are past age 65.

Kaiser will refer patients to major cancer centers for experimental procedures when they reach the end of the line for conventional treatment options. This is not the care I would prioritize for optimization. Experimental procedures at major research centers are not magic bullets.

I’ve seen some very highly rated specialists treat original Medicare patients quite aggressively. I hope this is not to compensate for lower Medicare fees. A mega-specialist who can do very special procedures does not make a living by not doing the procedures.

I’ve also seen MA HMO’s focus on saving money and have a mediocre outcome. Kaiser is somewhere in between those extremes, but maybe not the optimal point. And with original Medicare you have some choice— you are not obliged to authorize aggressive treatment. Still I currently think Kaiser is a good option. A Kaiser doc I know chose Kaiser MA over original Medicare when he retired.
This is not accurate about referring, and you are conflating aggressive and experimental with expensive (even if needed). We spend a lot of time thinking about organization structure and motivation on this forum (Vanguard vs Fidelity ownership). I would hope people who feel so strongly about this for their financial accounts would apply the same logic to their own lives. Remember Kaiser is its own insurer, so how does it make money (hint: it has to take in more in premiums than it pays out in care). This is fine and works out quite well in their primary care model, but is problematic for for more advanced diagnoses.

Don’t take my word for it though, ask your doc what percent of external specialty referrals above and beyond the one off second option they have granted

I personally value the ability to choose my own doctor and that’s why my HSA gets maxed each year, that said others value cost efficiency primarily which is totally fine too and kaiser is extremely cost efficient and runs very very well for primary care

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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by goodenyou » Sun Sep 29, 2019 10:04 am

Gleevec wrote:
Sat Sep 28, 2019 8:36 pm
carruthers209 wrote:
Sat Sep 28, 2019 8:17 pm
I agree that if you have a very nontraditional cancer or other disease Kaiser's might not be the best fit. They don't do extremely aggressive therapies or surgeries or provide treatments that are highly risky and don't appear to have a high degree of success. My mother had a severe carotid artery blockage that Kaiser's surgeons operated on, saw it was calcified and didn't remove it because it was too dangerous a procedure in their opinion. So instead, my mom went to a university surgery center in southern California with a world wide reputation for doing aggressive (and highly risky surgery) to have the same calcified carotid artery removed and a piece broke off in her brain during that surgery giving her a major stroke that took her speech, her ability to swallow, all movement in her right hand. My dad ended up with a bill of about a $100,000. In retrospect, Kaiser's was correct in their original assessment of my mother's medical condition. Kaiser's has world class surgeons and provides patient centered medical care. My husband had deep brain stimulation for his Parkinson's and had a very successful outcome. We will stick with Kaiser's for all of our medical issues.
There are so many fallacies in this post, but the clearest one is about kaiser having world class surgeons. Kaiser provides excellent to amazing (and cost efficient) primary care, this is clear. Those in medicine know it’s specialty issues or issues handling advanced illness. Glad to hear you’ve had a better than average outcome
The best and brightest Residents don't aspire to work at Kaiser. Especially specialists. It's just a fact.
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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by Gleevec » Sun Sep 29, 2019 10:50 am

goodenyou wrote:
Sun Sep 29, 2019 10:04 am
Gleevec wrote:
Sat Sep 28, 2019 8:36 pm
carruthers209 wrote:
Sat Sep 28, 2019 8:17 pm
I agree that if you have a very nontraditional cancer or other disease Kaiser's might not be the best fit. They don't do extremely aggressive therapies or surgeries or provide treatments that are highly risky and don't appear to have a high degree of success. My mother had a severe carotid artery blockage that Kaiser's surgeons operated on, saw it was calcified and didn't remove it because it was too dangerous a procedure in their opinion. So instead, my mom went to a university surgery center in southern California with a world wide reputation for doing aggressive (and highly risky surgery) to have the same calcified carotid artery removed and a piece broke off in her brain during that surgery giving her a major stroke that took her speech, her ability to swallow, all movement in her right hand. My dad ended up with a bill of about a $100,000. In retrospect, Kaiser's was correct in their original assessment of my mother's medical condition. Kaiser's has world class surgeons and provides patient centered medical care. My husband had deep brain stimulation for his Parkinson's and had a very successful outcome. We will stick with Kaiser's for all of our medical issues.
There are so many fallacies in this post, but the clearest one is about kaiser having world class surgeons. Kaiser provides excellent to amazing (and cost efficient) primary care, this is clear. Those in medicine know it’s specialty issues or issues handling advanced illness. Glad to hear you’ve had a better than average outcome
The best and brightest Residents don't aspire to work at Kaiser. Especially specialists. It's just a fact.
I’m not sure it’s exactly that, the kaiser primary care model attracts some very solid graduates and their work in population health is very strong (in fact their new med school builds on this). It’s just that kaiser is not built to have the world expert in cancer x or rare autoimmune condition y or specific neurosurgical procedure z. It’s funding model (it is its own insurer) doesn’t support that, and many residents/fellows aspire to be that expert.

Will you need a very specialized expertise in your lifetime? Maybe
But could also be you die instantly in car wreck and nothing can save you

For me it’s hard for me to restrict options when it comes to life, but everyone has priorities

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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by Northern Flicker » Sun Sep 29, 2019 11:41 am

This is not accurate about referring,
I personally knew someone who had an unusual cancer, and Kaiser referred him to the local medical school docs for treatment, covering it as in-network.

Where I live, doctors seem to be moving away from accepting original Medicare. A posted flyer where we go for primary care said they would only accept original Medicare for patients who turn 65 as established patients, but new patients already on Medicare must be MA to move to the practice. Not sure where that is going.

And someone I knew who was on original Medicare with an incurable condition was getting weekly hospital-based treatment that was distressing. The primary care doc suggested a less aggressive care plan, and the specialist said that the treatments were what he had to offer— find another doctor if that is not what you want. At some point, Medicare stopped covering the treatments and suddenly the specialist was on board with the less aggressive care plan. This would never have happened at Kaiser.

I can see that there are at times situations where the best person for treating a condition really is a renowned specialist somewhere, and that person is not going to be in-network at an HMO/EPO or MA provider. It would not be possible to keep them busy with the highly specialized cases with the smaller pool of patients from which to draw, so there would not be a driver for hiring such a person.

Of course everyone wants the most effective health care available. I used to think that meant being on original Medicare once I turn 65. Now I’m a bit less sure of that.
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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by dm200 » Sun Sep 29, 2019 1:06 pm

I personally knew someone who had an unusual cancer, and Kaiser referred him to the local medical school docs for treatment, covering it as in-network.
Where I live, doctors seem to be moving away from accepting original Medicare. A posted flyer where we go for primary care said they would only accept original Medicare for patients who turn 65 as established patients, but new patients already on Medicare must be MA to move to the practice. Not sure where that is going.
Yes - in this area, it is very common that Primary Care Physicians will not accept new Original Medicare patients - but will accept Original medicare from existing patients - either their own or another PCP in the same practice. Curiously, to me, many of these same PCPs will accept new Medicare Advantage patients if the PCP participates in an MA plan.

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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by dm200 » Sun Sep 29, 2019 1:13 pm

The best and brightest Residents don't aspire to work at Kaiser. Especially specialists. It's just a fact.
As a layperson, I have no way of knowing about this. As a patient, seeing several Kaiser specialists, my perception and conclusion is that they all seem to be very competent. This includes several types of surgeons that have done surgery on my wife and myself.

Having been with Kaiser off and on over half of the last 40+ years (because of employer provided insurance only offered coverage outside Kaiser), as Kaiser has grown over those years, Kaiser now seems to have many more specialists on staff - leading to (it seems to me) broader expertise in the specialties.

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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by dm200 » Sun Sep 29, 2019 1:25 pm

Kagord wrote:
Sun Sep 29, 2019 6:36 am
Never been a fan of being told who to use for medical, I get medigap plan F and a part D supplement for my mother. Yes, it's two thousand or so more in annual premiums, but not having to go to a primary care physician first, and/or not being forced to find in network providers for cost effectiveness, is worth this cost, IMHO.
While the Kaiser plan documents do state that referrals to specialists are needed from your Primary Care Physician, in actual practice - it is much less burdensome - close to zero burden in my experience.

First, in most cases, your Kaiser PCP can make the specialist referral right when you see him/her for the matter. That referral appointment can be done by the PCP right online. In one case, my wife saw here PCP about an issue at 10 am - and here PCP made the online referral for my wife to see a General Surgeon at 12 noon - same day. In some cases, I have received a PCP referral to a Specialist by email - when the condition was completely outside the expertise of the PCP - Podiatry is an example for me.

In a few cases, to make a Specialist referral at Kaiser, the PCP must go through a little "bureaucracy" to make the referral - but that never has taken me or my wife more than 24 hours to get the referral. I can also say that I have never been denied a Specialist referral when I believed such a referral was appropriate.

Then, once you get that initial referral, you never need another referral for the same specialty and issue.

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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by Northern Flicker » Sun Sep 29, 2019 1:37 pm

Curiously, to me, many of these same PCPs will accept new Medicare Advantage patients if the PCP participates in an MA plan.
I think payments to physicians for specific billing items are higher for MA participants than original Medicare participants.
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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by dm200 » Sun Sep 29, 2019 1:39 pm

Northern Flicker wrote:
Sun Sep 29, 2019 1:37 pm
Curiously, to me, many of these same PCPs will accept new Medicare Advantage patients if the PCP participates in an MA plan.
I think payments to physicians for specific billing items are higher for MA participants than original Medicare participants.
Yes - this must be the case - but still seems odd to me.

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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by Northern Flicker » Sun Sep 29, 2019 2:16 pm

The best and brightest Residents don't aspire to work at Kaiser. Especially specialists. It's just a fact.
I’m skeptical of that. Docs I’ve spoken with about Kaiser say that Kaiser pays their docs well and thus they attract top talent. Not everyone wants to take the business risk of self-employment.

Where I live the top 3 rated hospitals consistently are one conventional hospital, one Kaiser hospital, and the med school hospital. All other hospitals in the area rank lower based on outcome measures. This will not happen if the docs at the Kaiser hospital are mediocre.
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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by dm200 » Sun Sep 29, 2019 2:26 pm

Northern Flicker wrote:
Sun Sep 29, 2019 2:16 pm
The best and brightest Residents don't aspire to work at Kaiser. Especially specialists. It's just a fact.
I’m skeptical of that. Docs I’ve spoken with about Kaiser say that Kaiser pays their docs well and thus they attract top talent. Not everyone wants to take the business risk of self-employment.
Where I live the top 3 rated hospitals consistently are one conventional hospital, one Kaiser hospital, and the med school hospital. All other hospitals in the area rank lower based on outcome measures. This will not happen if the docs at the Kaiser hospital are mediocre.
My approach to medical/health "risk" is to, primarily, focus on avoiding "kooks" and "quacks" as providers. I have encountered several of such Physicians - not in Kaiser. I believe that Kaiser is very successful in screening out such "quacks" an "kooks".

While the net risk is not zero, I am not so focused on getting "the best" medical specialist for the conditions I might get. I am happy and satisfied that I get very competent such physicians.

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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by Gleevec » Sun Sep 29, 2019 11:33 pm

dm200 wrote:
Sun Sep 29, 2019 1:25 pm
Kagord wrote:
Sun Sep 29, 2019 6:36 am
Never been a fan of being told who to use for medical, I get medigap plan F and a part D supplement for my mother. Yes, it's two thousand or so more in annual premiums, but not having to go to a primary care physician first, and/or not being forced to find in network providers for cost effectiveness, is worth this cost, IMHO.
While the Kaiser plan documents do state that referrals to specialists are needed from your Primary Care Physician, in actual practice - it is much less burdensome - close to zero burden in my experience.

First, in most cases, your Kaiser PCP can make the specialist referral right when you see him/her for the matter. That referral appointment can be done by the PCP right online. In one case, my wife saw here PCP about an issue at 10 am - and here PCP made the online referral for my wife to see a General Surgeon at 12 noon - same day. In some cases, I have received a PCP referral to a Specialist by email - when the condition was completely outside the expertise of the PCP - Podiatry is an example for me.

In a few cases, to make a Specialist referral at Kaiser, the PCP must go through a little "bureaucracy" to make the referral - but that never has taken me or my wife more than 24 hours to get the referral. I can also say that I have never been denied a Specialist referral when I believed such a referral was appropriate.

Then, once you get that initial referral, you never need another referral for the same specialty and issue.
Kaiser often won’t cover the procedures or medicines recommended, even if FDA approved and recommended by specialty societies. There is inherent conflict of interest when the insurer and provider are the same towards minimization (not the maximization is optimal in all cases)

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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by Northern Flicker » Mon Sep 30, 2019 1:06 am

That is definitely a concern. They do have community partners: in-network providers who are not Kaiser providers which alleviates this concern for most outpatient care, but anything that happens in a Kaiser hospital will be administered by Kaiser providers. And an expensive medication may not be on their formulary. But this is also true of other insurance, and I’ve not heard that people on original Medicare are exactly jumping for joy over Medicare Part D drug coverage.

Supposedly, Kaiser’s population medicine model is intended to develop care guidelines based on the best expected outcomes for a population to which a patient belongs. I imagine that is an ideal not always achieved, and there is a slippery slope between designing care that tries to optimize expected outcomes based on clinical research and cost-cutting.
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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by Kagord » Mon Sep 30, 2019 8:33 am

OK, I'm not familiar with Kaiser, they haven't been in any cities I've lived, and I may be dated with HMOs. I had a local market HMO for 1 year in the mid nineties, and had some minor medical issues. Back then, my experience, it was a pain, long office waiting room (hours) to see the PCP, then wait months for a specialist, which were overbooked. HMOs were more expensive as well, if I remember correctly. The lure was everything was covered, but the experience, it soured me, maybe it's better now.

I still think, if you have the excess funds that aren't to impacting for your lifestyle/wealth, paying an extra $2K/year for a standard F/G medigap supplement plan gives you the most flexibility, should you ever need it. I mean, you could go to Rochester, MN if you wanted, not sure they'd take you though.

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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by dm200 » Mon Sep 30, 2019 9:12 am

Northern Flicker wrote:
Mon Sep 30, 2019 1:06 am
That is definitely a concern. They do have community partners: in-network providers who are not Kaiser providers which alleviates this concern for most outpatient care, but anything that happens in a Kaiser hospital will be administered by Kaiser providers. And an expensive medication may not be on their formulary. But this is also true of other insurance, and I’ve not heard that people on original Medicare are exactly jumping for joy over Medicare Part D drug coverage.
Supposedly, Kaiser’s population medicine model is intended to develop care guidelines based on the best expected outcomes for a population to which a patient belongs. I imagine that is an ideal not always achieved, and there is a slippery slope between designing care that tries to optimize expected outcomes based on clinical research and cost-cutting.
There are differences in different Kaiser areas. In this area (Washington DC and Virginia/maryland suburbs and Baltimore MD area), there are no Kaiser hospitals - but Kaiser has agreements with certain hospitals that Kaiser only sends patients to (except for Emergency departments) and, in return, these hospitals have Kaiser physicians (Hospitalists) working at these hospitals dealing with Kaiser patients. These hospitals commonly have Kaiser patient dedicated wings.

In this area, Kaiser now has a large number of Kaiser physicians of almost all specialties - so it is now extremely rare that a Kaiser patient would be referred to a non-Kaiser physician. Many years ago, however, when Kaiser was much smaller - it was more common that Kaiser referred patients to non-Kaiser specialists.

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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by dm200 » Mon Sep 30, 2019 9:36 am

Kagord wrote:
Mon Sep 30, 2019 8:33 am
OK, I'm not familiar with Kaiser, they haven't been in any cities I've lived, and I may be dated with HMOs. I had a local market HMO for 1 year in the mid nineties, and had some minor medical issues. Back then, my experience, it was a pain, long office waiting room (hours) to see the PCP, then wait months for a specialist, which were overbooked. HMOs were more expensive as well, if I remember correctly. The lure was everything was covered, but the experience, it soured me, maybe it's better now.
I still think, if you have the excess funds that aren't to impacting for your lifestyle/wealth, paying an extra $2K/year for a standard F/G medigap supplement plan gives you the most flexibility, should you ever need it. I mean, you could go to Rochester, MN if you wanted, not sure they'd take you though.
I have followed the whole HMO matter for about 45 years. Much has changed over time. I always like the idea of HMOs. Back in the early/mid 1970's, I worked for a MegaCorp with excellent medical/health benefits. There was no employee contribution needed. Because of the change in law, my MegaCorp had to offer an HMO - but claimed that was more expensive. I signed up for the HMO (not Kaiser, but one like Kaiser that had their own dedicated Physicians). I paid a little extra - and was generally pleased - BUT had few health issues at the time. Then, I had some matters which, at the time, the HMO had very poor coverage for. I then switched my Megacorp coverage back to the regular (BC/BS as I recall) plan and got better coverage for my situation. In recent years, because of changes in law and regulation, all HMOs now must provide coverage for this condition.

I left that MegaCorp about 1980 - and have had multiple employers over the following years. Over that time, the HMO type where it was a network of private physicians grew and we were in one of those for a while. We also had a PPO for a time, as well as (for one year) the "old fashioned" employer health insurance where I paid nothing and the coverage paid just about 100% of everything :) . I worked at this employer for two years and for the second year - that employer figured out they were paying and lot - and moved to a more "managed care" type of HMO (private network). During that first year - my wife was hospitalized several days with pneumonia or pneumonia-like symptoms. When she checked out, I was expecting to have to pay something to the hospital and/or physicians. To my pleasant surprise, we owed NOTHING - and the billing department folks seemed very happy.

My/our experience over many years with HMOs (Kaiser and several others) has been that we never have had to wait for any kind of appointment with out PCP, or be delayed to see a specialist. Now, with Kaiser, that experience is even better. Even for just a "normal" office visit appointment with my PCP, I can usually schedule it in just a few days - sometimes even later the same day or the next day. If the condition is more "urgent", I can see a physician the same day. Referrals to specialists, for us at kaiser, are usually quick and, if the situation so indicates, withing a week or less. As I posted previously, my wife got a referral from her PCP to a general surgeon within two hours of seeing here PCP.

Frankly, I am often very puzzled that so many folks encounter these negative experiences with Kaiser and other HMOs - that my wife and I have never experienced. It is not that we have not had health problems and issues - we both have. I wonder, perhaps, if my wife and I (for some reason) are better at knowing how to get the service we need/want in a timely and convenient way?

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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by JMacDonald » Mon Sep 30, 2019 9:45 am

I have had Kaiser for some years now in the SoCal area. I have had outstanding care. When I had other insurance and had an appointment, it was not uncommon that I would wait an hour past the appointment time to see the doctor. That has never happen for me with Kaiser. I am very happy that I have Kaiser.
Best Wishes, | Joe

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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by dm200 » Mon Sep 30, 2019 10:02 am

JMacDonald wrote:
Mon Sep 30, 2019 9:45 am
I have had Kaiser for some years now in the SoCal area. I have had outstanding care. When I had other insurance and had an appointment, it was not uncommon that I would wait an hour past the appointment time to see the doctor. That has never happen for me with Kaiser. I am very happy that I have Kaiser.
As I have posted, we have the same experience with Kaiser here in the Washington DC area.

One example - last year I had something I needed to see my PCP about. On a Thursday afternoon, online I made an appointment with my PCP for late in the day on Friday, the next day. When she saw that I made this appointment - my PCP called me (tried on Thursday afternoon, but reached me on Friday morning) to suggest that I come in and see her at 2 pm because if she ordered blood tests - she could see the results - but if I saw her at the end of the day - the lab might not be still open to get the results as quickly. This was well beyond my normal expectations.

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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by drawpoker » Mon Sep 30, 2019 12:06 pm

Kagord wrote:
Mon Sep 30, 2019 8:33 am

....still think, if you have the excess funds that aren't to impacting for your lifestyle/wealth, paying an extra $2K/year for a standard F/G medigap supplement plan gives you the most flexibility, should you ever need it......
Yes, and there was a recent thread asking seniors which did they choose, Medigap (Original Medicare) or Medicare Advantage.

The overwhelming majority of replies favored Medigap.

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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by mariezzz » Mon Sep 30, 2019 1:04 pm

I know a number of oncologists who either currently work for Kaiser or have worked for Kaiser. They've all expressed disagreement with Kaiser's unwillingness to pay for cancer clinical trials that Kaiser isn't involved in, and from what they've said, this isn't the typical position for insurance companies. That reduces the number of clinical trials Kaiser patients can be involved in unless they pay out of pocket themselves.

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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by Northern Flicker » Mon Sep 30, 2019 1:06 pm

I still think, if you have the excess funds that aren't to impacting for your lifestyle/wealth, paying an extra $2K/year for a standard F/G medigap supplement plan gives you the most flexibility, should you ever need it. I mean, you could go to Rochester, MN if you wanted, not sure they'd take you though.
We are not at Medicare age currently, but close enough to be thinking about the options. Because we can always switch from Medicare B plus F/G to a MA plan, but not generally the other way, my current thinking is start with original Medicare, and if the trend for docs not to accept it continues and it becomes a problem, we can switch to an MA plan. While there is political chatter of Medicare for all, we also may be at the infancy of a trend towards original Medicare for nobody— in 20-30 years it may only be MA plans.

We get insurance through the individual market using the ACA exchange. All of the plans available on the ACA exchange in our (and I think most, but maybe not all) states are now EPOs. There had been PPOs initially, but they now a thing of the past on our exchange, except for one which has such a narrow network and no cap on out of network costs that it might as well be an EPO.

Each EPO is aligned with a major hospital system and major clinic in the area. The standard bronze, bronze HSA, silver, and gold plans all look and work pretty much the same. Whether you pick Kaiser or one of the others things will work about the same— a not particularly broad network and zero out of network care.

They all require PCP referrals to specialists, which is generally a formality since there is no out of network coverage. I’ve requested and received referrals by electronic communication without even seeing my PCP but just by describing the reason, incurring no extra office visit fee from the PCP for the referral.

Kaiser does have one major advantage over the others— no big surprise balance billing from out-of-network providers you did not select when receiving care at an in-network hospital. Original medicare also avoids this problem.

And if you are pre-Medicare and have a first rate group PPO plan through employment, don’t assume the problem is solved. If you are wanting to fly to the Mayo Clinic for care, you probably have a condition that will mean leaving employment and 18 months of COBRA before getting individual insurance.

In some cases there may be PPOs offered to individuals not through the exchanges and if you won’t qualify for, or are willing and able to forgo a premium tax credit, could be a way to get a broader network. But even when we had an ACA-compliant PPO with nat’l network, the networks included one hospital and one urgent care clinic in every city outside of plan area that is big enough to have a hospital. I’m pretty sure the Mayo Clinic was not one of them.
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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by dm200 » Mon Sep 30, 2019 1:17 pm

Northern Flicker wrote:
Mon Sep 30, 2019 1:06 pm
I still think, if you have the excess funds that aren't to impacting for your lifestyle/wealth, paying an extra $2K/year for a standard F/G medigap supplement plan gives you the most flexibility, should you ever need it. I mean, you could go to Rochester, MN if you wanted, not sure they'd take you though.
We are not at Medicare age currently, but close enough to be thinking about the options. Because we can always switch from Medicare B plus F/G to a MA plan, but not generally the other way, my current thinking is start with original Medicare, and if the trend for docs not to accept it continues and it becomes a problem, we can switch to an MA plan. While there is political chatter of Medicare for all, we also may be at the infancy of a trend towards original Medicare for nobody— in 20-30 years it may only be MA plans.
We get insurance through the individual market using the ACA exchange. All of the plans available on the ACA exchange in our (and I think most, but maybe not all) states are now EPOs. There had been PPOs initially, but they now a thing of the past on our exchange, except for one which has such a narrow network and no cap on out of network costs that it might as well be an EPO.
Each EPO is aligned with a major hospital system and major clinic in the area. The standard bronze, bronze HSA, silver, and gold plans all look and work pretty much the same. Whether you pick Kaiser or one of the others things will work about the same— a not particularly broad network and zero out of network care.
They all require PCP referrals to specialists, which is generally a formality since there is no out of network coverage. I’ve requested and received referrals by electronic communication without even seeing my PCP but just by describing the reason, incurring no extra office visit fee from the PCP for the referral.
Kaiser does have one major advantage over the others— no big surprise balance billing from out-of-network providers you did not select when receiving care at an in-network hospital. Original medicare also avoids this problem.
And if you are pre-Medicare and have a first rate group PPO plan through employment, don’t assume the problem is solved. If you are wanting to fly to the Mayo Clinic for care, you probably have a condition that will mean leaving employment and 18 months of COBRA before getting individual insurance.
In some cases there may be PPOs offered to individuals not through the exchanges and if you won’t qualify for, or are willing and able to forgo a premium tax credit, could be a way to get a broader network. But even when we had an ACA-compliant PPO with nat’l network, the networks included one hospital and one urgent care clinic in every city outside of plan area that is big enough to have a hospital. I’m pretty sure the Mayo Clinic was not one of them.
1. Yes! I am a great believer in thinking about Medicare options even before becoming eligible, as well as keeping up on the options (pros and cons) by research - including speaking with current Medicare participants. If you wait to do such research until late in the game, you might not be sufficiently informed to make the optimum decision.

2. If this might fit your "research" - when you become Medicare eligible - you can enroll in an MA plan and then switch back to Original Medicare within 12 months. I do not believe that you will close any options by doing this.

3. MA plans usually differ greatly from other MA plans in the same area. I suggest researching all the MA plans available in your area. Things that are big pluses or minuses of one MA plan may be completely different on another MA plan.

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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by Northern Flicker » Mon Sep 30, 2019 2:41 pm

mariezzz wrote:
Mon Sep 30, 2019 1:04 pm
I know a number of oncologists who either currently work for Kaiser or have worked for Kaiser. They've all expressed disagreement with Kaiser's unwillingness to pay for cancer clinical trials that Kaiser isn't involved in, and from what they've said, this isn't the typical position for insurance companies. That reduces the number of clinical trials Kaiser patients can be involved in unless they pay out of pocket themselves.
This concerns me less than issues like not including expensive medications on their formulary because, say a generic equally effective at treating the condition but with more side effects is available. Or a particular surgeon is the recognized leading expert at a particular uncommon procedure.

I’m not sure it is true that it is always typical for insurance companies to cover clinical trials. They likely are out-of-network care, with all of the baggage that entails with whatever insurance you have.
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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by dm200 » Tue Oct 01, 2019 11:28 am

Just got a quick look at some of the details:

Include: Monthly charge goes down from $36 to $25
PCP copay goes down from $10 to $5
Specialist copay goes doen from $45 to $35
X-rays, and similar goes down from $20 to $10
CT and MRI scans go down from $150 to $65
Outpatient surgery goes down from $250 to $125
Urgent care visit goes down from $45 to $35

The annual maximum out of pocket stays at $6,700

It also looks like there are other charges that may go down as well.

We shall see!

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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by Northern Flicker » Wed Oct 02, 2019 7:49 pm

- you can enroll in an MA plan and then switch back to Original Medicare within 12 months.
But there is nothing that requires such a need to develop in the first 12 months.

I few other comments— the issues articulated for Kaiser are actually problems associated with EPOs, not specific to Kaiser. Technically, Kaiser insurance is run by a foundation that is a separate organization from Kaiser clinics and hospitals. On our state exchange, in addition to Kaiser, there is another insurer that is an insurance foundation of a local hospital system, and three traditional insurance companies. All plans on our state exchange are now EPOs, which means they have drug formularies and require pre-authorization for expensive procedures by insurance companies. I think other states are similar. Kaiser may not offer some procedure, but that does not mean one of the other insurance companies would pre-authorize it.

My understanding is that the standard of care at Kaiser is administered by Kaiser doctors. The providers manuals describing it are published transparently on Kaiser web sites, and are open to the scrutiny of the broader medical community. Insurance company pre-authorization decisions are driven opaquely by insurance company administrators and bureaucrats.
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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by dm200 » Thu Oct 03, 2019 1:05 pm

Northern Flicker wrote:
Wed Oct 02, 2019 7:49 pm
- you can enroll in an MA plan and then switch back to Original Medicare within 12 months.
But there is nothing that requires such a need to develop in the first 12 months.
I few other comments— the issues articulated for Kaiser are actually problems associated with EPOs, not specific to Kaiser. Technically, Kaiser insurance is run by a foundation that is a separate organization from Kaiser clinics and hospitals. On our state exchange, in addition to Kaiser, there is another insurer that is an insurance foundation of a local hospital system, and three traditional insurance companies. All plans on our state exchange are now EPOs, which means they have drug formularies and require pre-authorization for expensive procedures by insurance companies. I think other states are similar. Kaiser may not offer some procedure, but that does not mean one of the other insurance companies would pre-authorize it.
My understanding is that the standard of care at Kaiser is administered by Kaiser doctors. The providers manuals describing it are published transparently on Kaiser web sites, and are open to the scrutiny of the broader medical community. Insurance company pre-authorization decisions are driven opaquely by insurance company administrators and bureaucrats.
Very true - cannot experience all aspects in 12 months! What you can do, however, is experience the Physicians available that now apply to you, your actual costs incurred, convenience (or lack thereof, and so on. If your 12 months spans two different calendar years, you will experience an annual change in details of that MA plan.

While this does not apply to us, you may even have access to a Medicare Advantage plan where that MA network even includes your current PCP.

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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by dm200 » Fri Oct 11, 2019 10:49 am

dm200 wrote:
Tue Oct 01, 2019 11:28 am
Just got a quick look at some of the details:
Include: Monthly charge goes down from $36 to $25
PCP copay goes down from $10 to $5
Specialist copay goes doen from $45 to $35
X-rays, and similar goes down from $20 to $10
CT and MRI scans go down from $150 to $65
Outpatient surgery goes down from $250 to $125
Urgent care visit goes down from $45 to $35
The annual maximum out of pocket stays at $6,700
It also looks like there are other charges that may go down as well.
We shall see!
UPDATE: Very confusing - We received the actual notice for 2020 - and this notice showed increases in our monthly premium from $36 to $53 - and no reductions in copays, etc. I called Kaiser about the very confusing and conflicting information - between web site and our notices. After some degree of research, the Kaiser rep said the notice was correct - and that the lower rates on the web site only applied (not to us) to some Virginia folks in different counties. She also said we were being converted to Advantage from Cost - and that we would be receiving that notice soon. The rep also said that the web site will be corrected or clarified.

This seems backwards to me - that we are moving to Advantage from Cost and fees go up??

I will continue to follow this very, very closely. Many aspects of this: 1. make no sense; 2. seem backwards.

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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by dm200 » Sun Oct 13, 2019 1:47 pm

Another (FINAL) Update:

Just received paperwork that I have a choice to keep my existing (Medicare Cost) Kaiser plan (with increased monthly premiums) OR choose to convert to Kaiser Medicare Advantage Plan with lower monthly premiums and lower costs/copays foe most services.

What a confusing mess this has been!!

One choice is a zero monthly premium MA plan with very modest copays and costs for various appointments and procedures. DW and I will go with the MA plan - just not sure whether it will be $25 per month or ZERO$ per month.

FINALLY - nice to have any aspects of health and medical costs go down!! :happy :dollar

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Re: My Kaiser Medicare Plan is "converting" from Cost to Advantage!

Post by dm200 » Mon Jan 13, 2020 11:10 am

dm200 wrote:
Sun Oct 13, 2019 1:47 pm
Another (FINAL) Update:
Just received paperwork that I have a choice to keep my existing (Medicare Cost) Kaiser plan (with increased monthly premiums) OR choose to convert to Kaiser Medicare Advantage Plan with lower monthly premiums and lower costs/copays foe most services.
What a confusing mess this has been!!
One choice is a zero monthly premium MA plan with very modest copays and costs for various appointments and procedures. DW and I will go with the MA plan - just not sure whether it will be $25 per month or ZERO$ per month.
FINALLY - nice to have any aspects of health and medical costs go down!! :happy :dollar
Later FINAL update: For some reason, our enrollment in the Kaiser MA plan was not done - as we discovered in late December. We both, though, were able to change/enroll in the Kaiser MA plan successfully - and new (lower) copays/charges went into effect January 1.

My wife and I both enrolled in the 'standard" option - which has a monthly premium of $25! Almost all charges and copays went down from 2019. Primary care copay is only $5. Charges for CT/MRI scans. X-Rays, outpatient surgery, specialist office visits and Optometry appointments - all went down as well.

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