do doctors/hospitals HATE Medicare Advantage (as payers)

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montanagirl
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do doctors/hospitals HATE Medicare Advantage (as payers)

Post by montanagirl »

It's that time of year again, and I am really tempted to jump from Plan G + Part D to United's MA offering. I'm 71, my knee surgery is done, I have two very cheap meds and (of course) I don't anticipate anything bad happening next year. :P And we don't travel. My premium would go from 200 to 35, and conveniently come out of SS so I don't have to remember to set it aside in checking.

I AM NOT LOOKING FOR MEDICAL ADVICE

But I have heard various rumors that providers hate MA, for whatever reasons, at least the ones in my limited market. Also a friend's sister works at CMS and says one well known MA provider that advertises relentlessly on TV is a horrible payer who disputes every little charge, and that their reputation has definitely gotten around to providers.

Admit I've been proud to have a supplement that is as much as I can do to be a good paying patient, given that Medicare patients aren't all that popular.

But do the providers even know who's paying what or what kind of insurance a patient has? Would they turn down a patient with MA?

I AM NOT LOOKING FOR MEDICAL ADVICE
Last edited by montanagirl on Tue Oct 20, 2020 12:43 pm, edited 1 time in total.
HomeStretch
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by HomeStretch »

Your safest bet is to contact your providers to ask if they are in-network for whatever new plan you are considering. If they are, then there shouldn’t be an issue or any “hate”.
Rex66
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by Rex66 »

What I personally don’t like is it’s much more difficult to get approval for certain things for my Medicare advantage patients in the outpatient setting. Occasionally can’t get things approved that straight Medicare would easily cover.
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montanagirl
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by montanagirl »

Rex66 wrote: Tue Oct 20, 2020 12:35 pm What I personally don’t like is it’s much more difficult to get approval for certain things for my Medicare advantage patients in the outpatient setting. Occasionally can’t get things approved that straight Medicare would easily cover.
Ah right, the approval problem. I had MA for one year when I first turned 65 and never used it.

Gotta think about that. I mean your health is fine, til it isn't .
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Stinky
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by Stinky »

HomeStretch wrote: Tue Oct 20, 2020 12:31 pm Your safest bet is to contact your providers to ask if they are in-network for whatever new plan you are considering. If they are, then there shouldn’t be an issue or any “hate”.
I agree.

I don’t think that anybody else’s experience with MA will necessarily be correlated with your experience. I doubt that there are any generalities that can be drawn.
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downshiftme
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by downshiftme »

Sorry, I have no direct experience to add to this discussion, but I do have a concern about Medicare Advantage plans. I'm still on a traditional workplace health insurance and I have recently had to have some significant medical care. In theory everything about the care i received should be covered, but in practice I am still fighting billing issues six months after the fact. My plan has a difference for in-network and out of network care, and even though my doctor is in-network and all the facilities were in-network, it seems that randomly assistants, technicians, or other specialists turn out to be out of network and I get stuck with direct bills from them about 10 times the going rate after insurance refuses to pay. I've also been dinged repeatedly because the way a provider coded a procedure doesn't fit the insurance network preferred method, so they kick that out too.

My concern about Medicare Advantage plans is that they offer great coverage in-network, but what happens if you go out of network, or even like I did, have a significant medical issue, so that among the numerous providers there are sure to be some out of network ones. What I found when admitted to the hospital was that my assigned doctor changed every eight hours and further, no two days in a row were consistent, so that after several days I had nominally been cared for by every doctor in the dept. Inevitably, some were out of network. Is this a problem for Medicare Advantage plans the same way it's a problem for my traditional workplace plan.
prd1982
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by prd1982 »

I'm on regular Medicare with a supplemental. I'd love to switch to a lower cost Medicare Advantage plan, but something doesn't add up:

* MA shows a much lower monthly premium.

* MA promises more services.

* The same insurance companies sell Medicare supplemental and Advantage plans.

* The insurance companies advertise their Medical Advantage plans a lot more than their supplemental plans. I take this to mean the insurance companies make more profits from their Advantage plans.

So how do the insurance companies make more profits selling plans that cost less and provide more? Until I can figure this out, I'm staying with traditional Medicare. Something tells me that Medicare Advantage is a good deal for healthy "young" (60s/70s), and worse as people age and require more services. But that is just a concern and I have no evidence.
bwalling
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by bwalling »

MA is very low margin for the payers, so they do what they can to eek out margin. That often makes it hard on the provider and/or the patient. They'll require more documentation, scrutinize it more, and default more towards denial, figuring the valid ones will get disputed. That all makes for more work for the provider to get reimbursement.
bigskyguy
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by bigskyguy »

Let me give you a real life comparison. My supplement is AARP United Healthcare Plan F. My Brother in law, same age, is on a Medicare Advantage Plan. We both live in Missoula, MT, and have access to the same health systems. Both of us developed low back disc disease, both went through PT without benefit. When it came time for me to have surgical intervention, I called my neurosurgeon, had a visit, and underwent micro-discetomy three days later. My brother in law called his Advantage Plan, was re-referred for additional PT, no benefit; was required to complete a number of weeks of medical management with Neurontin, antiinflammatories, and eventually sent to the one back surgeon in network for his Advantage plan. I am a retired physician (37 years practice in our community) and personally would never have gone to the individual who he was required to see. 6 weeks after my successful intervention, my brother in law had the same surgery, successfully.
I had my choice of providers, my brother in law didn't. I was able to expedite timing of my intervention.

Medicare Advantage provides some bells and whistles that my Plan F doesn't, and is indeed less expensive. It also limits your panel of providers, mandates calls to the insurer to have referrals, and requires that one follow a proscribed formulation of care that works in the aggregate, but rarely allows for expedient or personalized care.

Your choice, your care.
Deblog
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by Deblog »

I recently listened to a podcast Medicare with supplement versus advantage plan. Something they made a big deal about wad if you travel slit, get regular Medicare. Many advantage plans may not cover you elsewhere. They were speaking about US travel.
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montanagirl
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by montanagirl »

bigskyguy wrote: Tue Oct 20, 2020 2:42 pm Let me give you a real life comparison. My supplement is AARP United Healthcare Plan F. My Brother in law, same age, is on a Medicare Advantage Plan. We both live in Missoula, MT, and have access to the same health systems. Both of us developed low back disc disease, both went through PT without benefit. When it came time for me to have surgical intervention, I called my neurosurgeon, had a visit, and underwent micro-discetomy three days later. My brother in law called his Advantage Plan, was re-referred for additional PT, no benefit; was required to complete a number of weeks of medical management with Neurontin, antiinflammatories, and eventually sent to the one back surgeon in network for his Advantage plan. I am a retired physician (37 years practice in our community) and personally would never have gone to the individual who he was required to see. 6 weeks after my successful intervention, my brother in law had the same surgery, successfully.
I had my choice of providers, my brother in law didn't. I was able to expedite timing of my intervention.

Medicare Advantage provides some bells and whistles that my Plan F doesn't, and is indeed less expensive. It also limits your panel of providers, mandates calls to the insurer to have referrals, and requires that one follow a proscribed formulation of care that works in the aggregate, but rarely allows for expedient or personalized care.

Your choice, your care.
Whoa. Since we're in the same town, can you tell me which company's MA? Here it always seems to come down to Blue Cross, Humana and United.

Not that there's that much difference.
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Picasso
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by Picasso »

prd1982 wrote: Tue Oct 20, 2020 2:29 pm I'm on regular Medicare with a supplemental. I'd love to switch to a lower cost Medicare Advantage plan, but something doesn't add up:

* MA shows a much lower monthly premium.

* MA promises more services.

* The same insurance companies sell Medicare supplemental and Advantage plans.

* The insurance companies advertise their Medical Advantage plans a lot more than their supplemental plans. I take this to mean the insurance companies make more profits from their Advantage plans.

So how do the insurance companies make more profits selling plans that cost less and provide more? Until I can figure this out, I'm staying with traditional Medicare. Something tells me that Medicare Advantage is a good deal for healthy "young" (60s/70s), and worse as people age and require more services. But that is just a concern and I have no evidence.
These are highly profitable plans to insurers - many more seniors consider an MA plan than a Med Supp plan which is why you are likely seeing more advertising for them. Without getting into too much detail, the PROFIT is in the hundreds of dollars per member per month.

One thing to remembers is that there are many consumers who are what we call "healthcare avoiders" and just refuse to go to the doctor unless it is an absolute emergency. Think 55-65% of people (in our state at least). These folks are very lucrative :moneybag
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FIREchief
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by FIREchief »

bigskyguy wrote: Tue Oct 20, 2020 2:42 pm Let me give you a real life comparison. My supplement is AARP United Healthcare Plan F. My Brother in law, same age, is on a Medicare Advantage Plan. We both live in Missoula, MT, and have access to the same health systems. Both of us developed low back disc disease, both went through PT without benefit. When it came time for me to have surgical intervention, I called my neurosurgeon, had a visit, and underwent micro-discetomy three days later. My brother in law called his Advantage Plan, was re-referred for additional PT, no benefit; was required to complete a number of weeks of medical management with Neurontin, antiinflammatories, and eventually sent to the one back surgeon in network for his Advantage plan. I am a retired physician (37 years practice in our community) and personally would never have gone to the individual who he was required to see. 6 weeks after my successful intervention, my brother in law had the same surgery, successfully.
I had my choice of providers, my brother in law didn't. I was able to expedite timing of my intervention.

Medicare Advantage provides some bells and whistles that my Plan F doesn't, and is indeed less expensive. It also limits your panel of providers, mandates calls to the insurer to have referrals, and requires that one follow a proscribed formulation of care that works in the aggregate, but rarely allows for expedient or personalized care.

Your choice, your care.
Thanks for posting this. I'm not yet to Medicare age, but am 99% certain that I will use a Medigap policy vs. Medicare Advantage. Posts like this one are what have convinced me.
I am not a lawyer, accountant or financial advisor. Any advice or suggestions that I may provide shall be considered for entertainment purposes only.
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by JoeRetire »

I have a Medicare Advantage plan. It's from the same provider I used before I reached Medicare age.

As far as I can tell, it provides exactly the same benefits as I used to have (at lower cost to me). And the network of providers (across two states) is exactly the same as I used to have.

If the payees I use hate this plan, I haven't heard about it. Nor can I say I would care.
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by Broken Man 1999 »

bigskyguy wrote: Tue Oct 20, 2020 2:42 pm Let me give you a real life comparison. My supplement is AARP United Healthcare Plan F. My Brother in law, same age, is on a Medicare Advantage Plan. We both live in Missoula, MT, and have access to the same health systems. Both of us developed low back disc disease, both went through PT without benefit. When it came time for me to have surgical intervention, I called my neurosurgeon, had a visit, and underwent micro-discetomy three days later. My brother in law called his Advantage Plan, was re-referred for additional PT, no benefit; was required to complete a number of weeks of medical management with Neurontin, antiinflammatories, and eventually sent to the one back surgeon in network for his Advantage plan. I am a retired physician (37 years practice in our community) and personally would never have gone to the individual who he was required to see. 6 weeks after my successful intervention, my brother in law had the same surgery, successfully.
I had my choice of providers, my brother in law didn't. I was able to expedite timing of my intervention.

Medicare Advantage provides some bells and whistles that my Plan F doesn't, and is indeed less expensive. It also limits your panel of providers, mandates calls to the insurer to have referrals, and requires that one follow a proscribed formulation of care that works in the aggregate, but rarely allows for expedient or personalized care.

Your choice, your care.
You and your brother's experiences point out very well a possible reason to not use a MA plan. You both live in a very small town, population of 75,516, within a very small MSA (Metropolitan Statistical Area) population of 118,791.

Honestly, though I have had access to excellent medical care with my MA plan, if I lived in your home town I wouldn't use a MA plan. A MA plan network has to be pretty thin there.

DW and I are closest to Tampa, population 399,700, our MSA population is 3.1 million. Our medical services networks are huge. As is the number of providers willing to accept MA plans. Our MA plan is a PPO, offering even more choices. Ours covers out of network the same as in network. And, no referrals are needed.

Given the penetration MA HMO/PPO/EPN plans have made in the metro areas, not to mention the sheer number of plans, I'm not too sure many medical providers could be so choosy as to not accept MA plans, though I imagine there are some out there. We haven't ran across any of them so far.

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InMyDreams
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by InMyDreams »

Here's an article of patient satisfaction with MedAdvantage plans.
https://healthpayerintelligence.com/new ... remain-low

There are frequent positive reports on BH from Kaiser participants. I'm guessing (no basis) that integrated MA plans like Kaiser may be more satisfying than non-integrated.

There has been a troubling thread about MedAdvantage and hospice benefit - if you need/choose to revert back to curative care, that is (please search in search box).

My impression has been (sorry, no data to back it up): if you're healthy, you're probably happy with your low-cost MA. If you're sick and using benefits, you get to find out just how good your MA manager is.

Unfortunately, for those of us in many of the states, the leap into an MA plan is one way - once you've walked away from your age-65 open enrollment, you may not be offered an opportunity to move into a supplement, or it may be high cost.

My brother read Medicare for Dummies and came away with not wanting an MA plan. I will be reading it this year.
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by Rex66 »

JoeRetire wrote: Tue Oct 20, 2020 4:23 pm I have a Medicare Advantage plan. It's from the same provider I used before I reached Medicare age.

As far as I can tell, it provides exactly the same benefits as I used to have (at lower cost to me). And the network of providers (across two states) is exactly the same as I used to have.

If the payees I use hate this plan, I haven't heard about it. Nor can I say I would care.
As i mentioned, i find it typically is about coverage for higher priced products/medications. In my practice, i on rare occasion need a very expensive dressing for certain wounds. I probably need this a dozen times a year. If the patient has straight medicare, they are always approved. If they have an advantage plan, they are always denied. I appeal these decisions and less than 1/2 the time can i get these things with an advantage plan. Funny thing is then i have to turn around and send them to a wound care specialist and it costs more but thats another topic.

You will never notice the difference in benefits on paper they provide. It doesnt really make sense that its the same benefits at lower costs. And it isnt like the CEOs/admins are making less. That doesnt mean someone shouldnt pick an advantage plan. Id off the cuff guess that 2/3 of my medicare patients are advantage patients. it is popular bc of the reduced costs. Most of my patients dont notice the issue im talking about. But if you do fall into such a situation, you will.
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by Stinky »

JoeRetire wrote: Tue Oct 20, 2020 4:23 pm I have a Medicare Advantage plan. It's from the same provider I used before I reached Medicare age.

As far as I can tell, it provides exactly the same benefits as I used to have (at lower cost to me). And the network of providers (across two states) is exactly the same as I used to have.

If the payees I use hate this plan, I haven't heard about it. Nor can I say I would care.
This is almost exactly my experience. Same provider for MA as pre retirement. PPO, no referrals. All hospitals in the state, and 99% of the doctors, are in the PPO.

As I see it, we’re getting more services than under traditional Medicare plus supplement plus drug plan, and DW and I are saving about $300 per month.

From the threads I’ve read about MA, it seems that satisfaction with MA is very location-specific. I am satisfied with our MA; those in a different location may have a different experience.
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by manusnd1 »

I am a doctor that works in the hospital and I find that the advantage plan members have busier doctors with higher patient loads and less time per patient. I find that they have harder time getting expensive medicine approved. In my opinion people are getting free dental/vision and other cheap services in exchange for saving money in other areas. It doesn't add up and I would avoid them at all costs. Plus once you are locked in to advantage it is harder to get out.
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R.e: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by orlandoman »

The issue brought up by at least two of the doctors in this thread is 'pre-approvals'. Many if not all MA plans require pre-approvals for certaim procedures & Part B drugs. When reviewing MA plans people tend not to catch that term & what it means. For those with a MA plan, I suggest you review the EOC (Evidence of Coverage) of your plan & look for that term, in the items your plan covers. Medicare has almost no pre-approval requirements. This isn't necessarily a good/bad thing, just another criteria to consider in your healthcare selection.
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by Broken Man 1999 »

Rex66 wrote: Tue Oct 20, 2020 4:49 pm
JoeRetire wrote: Tue Oct 20, 2020 4:23 pm I have a Medicare Advantage plan. It's from the same provider I used before I reached Medicare age.

As far as I can tell, it provides exactly the same benefits as I used to have (at lower cost to me). And the network of providers (across two states) is exactly the same as I used to have.

If the payees I use hate this plan, I haven't heard about it. Nor can I say I would care.
As i mentioned, i find it typically is about coverage for higher priced products/medications. In my practice, i on rare occasion need a very expensive dressing for certain wounds. I probably need this a dozen times a year. If the patient has straight medicare, they are always approved. If they have an advantage plan, they are always denied. I appeal these decisions and less than 1/2 the time can i get these things with an advantage plan. Funny thing is then i have to turn around and send them to a wound care specialist and it costs more but thats another topic.

You will never notice the difference in benefits on paper they provide. It doesnt really make sense that its the same benefits at lower costs. And it isnt like the CEOs/admins are making less. That doesnt mean someone shouldnt pick an advantage plan. Id off the cuff guess that 2/3 of my medicare patients are advantage patients. it is popular bc of the reduced costs. Most of my patients dont notice the issue im talking about. But if you do fall into such a situation, you will.
Interesting! When I have had wounds, and I have had some interesting ones, I have only gone to a wound care specialist, the one my PCP recommened 20+ years ago. Last time I went to him his office was working with a new type wound vac. I agreed they could use my wound measurements and the sales representative was always there when I was at an appointment. The doctor is a vascular surgeon, but he has a thriving wound care practice.

If I may ask, what kind of doctor are you? And, forgive my ignorance, are all Medicare codes available to every doctor, no matter their specialty, or if they are not a specialist?

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Alan S.
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by Alan S. »

montanagirl wrote: Tue Oct 20, 2020 12:26 pm It's that time of year again, and I am really tempted to jump from Plan G + Part D to United's MA offering. I'm 71, my knee surgery is done, I have two very cheap meds and (of course) I don't anticipate anything bad happening next year. :P And we don't travel. My premium would go from 200 to 35, and conveniently come out of SS so I don't have to remember to set it aside in checking.

I AM NOT LOOKING FOR MEDICAL ADVICE

But I have heard various rumors that providers hate MA, for whatever reasons, at least the ones in my limited market. Also a friend's sister works at CMS and says one well known MA provider that advertises relentlessly on TV is a horrible payer who disputes every little charge, and that their reputation has definitely gotten around to providers.

Admit I've been proud to have a supplement that is as much as I can do to be a good paying patient, given that Medicare patients aren't all that popular.

But do the providers even know who's paying what or what kind of insurance a patient has? Would they turn down a patient with MA?

I AM NOT LOOKING FOR MEDICAL ADVICE
Not sure what providers think, but you would be getting unresponsive and downright terrible customer service with a MA plan with UHC.

The representations they make during the annual enrollment period are not made in good faith. In my case, they terminated my PC doctor on the spot without any advance notice, cancelled out all his pending pre authorization requests, and it was all their error, not the provider. They refused to listen to me or the providers employer (a local hospital), ignored their statements on providing a 30 day advance notice when terminating a provider and for not discontinuing a current course of treatment, and simply told me to find a new PC provider. I would then have to start over with a new PC and lose at least a month in the treatment process. Again, the termination of the PC was not anything the PC did, it was totally their error and they will not own up to it or make things right. This affected at least 100 patients, but of course not all were undergoing serious treatment. :annoyed

If you still want to sign up for MA, at least get a PPO plan where there is no PC pre authorization requirement. The specialists get their own authorizations, and you might want to get a copy of the approval from the specialist. Of course, a specialist could be terminated or could resign on their own, but at least one middleman is eliminated. And avoid UHC if you do not want to experience something like this.
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by cone774413 »

I am a physician who works on a largely inpatient basis (in the hospital). FWIW, I'm at a major academic medical center. I would say 95% of the time I have no clue (nor desire to know, frankly) what insurance my patient has. I would have think where to find it in our EMR. Patients throughout our medical system (and this was true at 2 other major institutions where I trained for residency and fellowship) get whatever test they need on an inpatient basis no questions asked. Again this is from an inpatient standpoint but I can't remember a recent time where I couldn't order any type of test at my discretion due to the person's insurance.
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by Broken Man 1999 »

InMyDreams wrote: Tue Oct 20, 2020 4:46 pm Here's an article of patient satisfaction with MedAdvantage plans.
https://healthpayerintelligence.com/new ... remain-low

There are frequent positive reports on BH from Kaiser participants. I'm guessing (no basis) that integrated MA plans like Kaiser may be more satisfying than non-integrated.

There has been a troubling thread about MedAdvantage and hospice benefit - if you need/choose to revert back to curative care, that is (please search in search box).

My impression has been (sorry, no data to back it up): if you're healthy, you're probably happy with your low-cost MA. If you're sick and using benefits, you get to find out just how good your MA manager is.

Unfortunately, for those of us in many of the states, the leap into an MA plan is one way - once you've walked away from your age-65 open enrollment, you may not be offered an opportunity to move into a supplement, or it may be high cost.

My brother read Medicare for Dummies and came away with not wanting an MA plan. I will be reading it this year.
If you are concerned about Hospice and curative care I would suggest that you read the info presented in the yearly Medicare and You booklet and also the documents of your plan.

Getting medical information here is somewhat like trying to understand what Mr Bogle said about this or that: Go to the sources!

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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by prudent »

My research has been lengthy - discussions with 3 brokers, watched dozens of youtube videos on the subject of MA vs Supplement, and consultation with my sister who's a nurse in a doctors' office.

Not claiming to be infallible but my takeaways were these:
- you're guaranteed to be accepted for a Supplement plan only when you first sign up for Medicare. If you don't take a supplement plan then, or want to change, or switch from an MA plan to a Supplement plan, you go through medical underwriting and might not be accepted
- Plans have different methods of determining rates (community-rated, issue-age, and attained age). Each of these affect future rates differently, AND in addition there is the "general" increases.
- Over time a Supplement plan is going to be more costly. It may eventually become unaffordable for some. But they can always switch to an MA plan if that happens. (And again, going back to a Supplement plan would require medical underwriting)
- Supplement plans have no say in your care. If Medicare covers something, the Supplement plan must pay their part. MA plans take Medicare out of the loop and it's up to the insurer to determine the hoops one must jump through for care (as evidenced in some posts above). The insurer gets a lump sum per enrollee per month from Medicare, so there's an incentive to throttle care.
- Supplement plans are good anywhere that takes Medicare, and that's probably 90%+ of all providers and hospitals. And remember some of the remainder are pediatricians who have no need to accept Medicare. The "network" with Supplement plans is enormous. MA plans typically charge more when out of network.
- My sister has years of experience trying to go to bat for patients with insurance companies for various reasons and has seen more struggles with MA plans.

In our area there is a behemoth health care system. They own/control probably 75% of the practices and hospitals here. They offer a dozen different MA plans but no Supplement plans - they like to control the entire interaction. They market MA plans relentlessly, some with $0 premiums, a gym membership and some dental/vision/hearing thrown in (those benefits are pretty sparse, but they get to say they have them). Recently they decided to charge in-network rates to MA plan subscribers if they are traveling to 5 specific states (states where retirees tend to travel in winter), possibly due to complaints of snowbirds getting socked with big bills. But for people who like to travel, there is a risk of out-of-network issues.
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by chalet »

cone774413 wrote: Tue Oct 20, 2020 6:28 pm FWIW, I'm at a major academic medical center.

that could be a factor


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Rex66
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by Rex66 »

Broken Man 1999 wrote: Tue Oct 20, 2020 6:05 pm
Rex66 wrote: Tue Oct 20, 2020 4:49 pm
JoeRetire wrote: Tue Oct 20, 2020 4:23 pm I have a Medicare Advantage plan. It's from the same provider I used before I reached Medicare age.

As far as I can tell, it provides exactly the same benefits as I used to have (at lower cost to me). And the network of providers (across two states) is exactly the same as I used to have.

If the payees I use hate this plan, I haven't heard about it. Nor can I say I would care.
As i mentioned, i find it typically is about coverage for higher priced products/medications. In my practice, i on rare occasion need a very expensive dressing for certain wounds. I probably need this a dozen times a year. If the patient has straight medicare, they are always approved. If they have an advantage plan, they are always denied. I appeal these decisions and less than 1/2 the time can i get these things with an advantage plan. Funny thing is then i have to turn around and send them to a wound care specialist and it costs more but thats another topic.

You will never notice the difference in benefits on paper they provide. It doesnt really make sense that its the same benefits at lower costs. And it isnt like the CEOs/admins are making less. That doesnt mean someone shouldnt pick an advantage plan. Id off the cuff guess that 2/3 of my medicare patients are advantage patients. it is popular bc of the reduced costs. Most of my patients dont notice the issue im talking about. But if you do fall into such a situation, you will.
Interesting! When I have had wounds, and I have had some interesting ones, I have only gone to a wound care specialist, the one my PCP recommened 20+ years ago. Last time I went to him his office was working with a new type wound vac. I agreed they could use my wound measurements and the sales representative was always there when I was at an appointment. The doctor is a vascular surgeon, but he has a thriving wound care practice.

If I may ask, what kind of doctor are you? And, forgive my ignorance, are all Medicare codes available to every doctor, no matter their specialty, or if they are not a specialist?

Broken Man 1999
I’m a skin cancer specialist

I actually go through the companies that make these things to get approval bc they are experts at it and they make a bunch

Codes are same

Wound vacs are easier to get coverage
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by Northern Flicker »

prd1982 wrote: Tue Oct 20, 2020 2:29 pm I'm on regular Medicare with a supplemental. I'd love to switch to a lower cost Medicare Advantage plan, but something doesn't add up:

* MA shows a much lower monthly premium.

* MA promises more services.

* The same insurance companies sell Medicare supplemental and Advantage plans.

* The insurance companies advertise their Medical Advantage plans a lot more than their supplemental plans. I take this to mean the insurance companies make more profits from their Advantage plans.

So how do the insurance companies make more profits selling plans that cost less and provide more? Until I can figure this out, I'm staying with traditional Medicare. Something tells me that Medicare Advantage is a good deal for healthy "young" (60s/70s), and worse as people age and require more services. But that is just a concern and I have no evidence.
One reason is that the govt pays medicare advantage providers more to provide coverage than the average cost of medicare services per person. Another is that some medicare advantage plans control costs by not encouraging the most aggressive treatment plan when less aggressive and less expensive care plans have been found to have better outcomes.
Last edited by Northern Flicker on Tue Oct 20, 2020 7:11 pm, edited 1 time in total.
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by goodenyou »

Some have narrow networks. Had a patient today that came a long distance for a cancer consultation (Head and Neck Cancer). They were disappointed to find out that their Aetna Advantage Plan was out of network in the hospitals and surgery centers where I operate. The only ones in network are the ones I wouldn't operate at for very good reasons. The reimbursement is as bad as all Medicare products.
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by PowderDay9 »

Picasso wrote: Tue Oct 20, 2020 4:02 pm
prd1982 wrote: Tue Oct 20, 2020 2:29 pm I'm on regular Medicare with a supplemental. I'd love to switch to a lower cost Medicare Advantage plan, but something doesn't add up:

* MA shows a much lower monthly premium.

* MA promises more services.

* The same insurance companies sell Medicare supplemental and Advantage plans.

* The insurance companies advertise their Medical Advantage plans a lot more than their supplemental plans. I take this to mean the insurance companies make more profits from their Advantage plans.

So how do the insurance companies make more profits selling plans that cost less and provide more? Until I can figure this out, I'm staying with traditional Medicare. Something tells me that Medicare Advantage is a good deal for healthy "young" (60s/70s), and worse as people age and require more services. But that is just a concern and I have no evidence.
These are highly profitable plans to insurers - many more seniors consider an MA plan than a Med Supp plan which is why you are likely seeing more advertising for them. Without getting into too much detail, the PROFIT is in the hundreds of dollars per member per month.

One thing to remembers is that there are many consumers who are what we call "healthcare avoiders" and just refuse to go to the doctor unless it is an absolute emergency. Think 55-65% of people (in our state at least). These folks are very lucrative :moneybag
You are correct in that MA is more profitable then Med Supp but I can assure you it's not hundreds of dollars PMPM (per member per month) in profit. CMS would not approve that.

An insurance company makes more on MA because there's more premium at stake. CMS pays a capitation PMPM for each enrolled MA member. This amount is based on a set county level rate book. Then this amount, usually around $800-$1000 PMPM is multiplied by the members risk score. Risk score is based on things like age, sex, medical conditions, etc. So if you are sicker the insurance company gets more money.

Med Supp premiums are usually between $100-$300 PMPM and paid by the members. The insurer gets no money from CMS. Less money at stake means less profit dollars for the insurance company.

With this approximate $1,000 MA payment the insurance company then offers benefits at least as rich as Original Medicare. The insurance company saves money by managing care, negotiating provider fee schedules, removing high cost providers, etc. With that savings, the insurance company can offer better benefits not only on medical but add things like dental, hearing, vision, etc.

Medicare Advantage is very similar to plans that get offered through group insurance with your employer. However MA plans vary widely based on HMO/PPO, member location, benefits, and insurance company.

Medicare Advantage is usually the better deal for the consumer when comparing to just original Medicare. Original Medicare has no max out of pocket where as all MA plans do. If you pair Med Supp with original Medicare you are buying the best coverage but it's generally more expensive than the value you get out of it. Medicare advantage is cheaper and has less rich medical benefits but is the better value. It all comes down to if you can afford and want to pay for Med Supp.
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by Watty »

One of the big concerns I have about Medicare Advantage plans is that you could make a good choice and have a good plan but then 10 years from now it might have problems and it would be hard to change to a different MA plan or back to original Medicare.

InMyDreams wrote: Tue Oct 20, 2020 4:46 pm My brother read Medicare for Dummies and came away with not wanting an MA plan. I will be reading it this year.
Just FYI, there is a new updated edition of this which is coming out by the end of the month. I already have it on preorder.

I used an earlier edition when I was helping my wife to figure out her medicare and that was very useful. I will be figuring out my Medicare soon so I thought that it was worth getting the updated edition of the book.
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by mtmingus »

Interesting.
So Medicare Advantage vs traditional Medicare plans is similar to HMO vs PPO?
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by Stinky »

mtmingus wrote: Tue Oct 20, 2020 8:10 pm Interesting.
So Medicare Advantage vs traditional Medicare plans is similar to HMO vs PPO?
Not all MA is HMO-like.

My MA is PPO, where the network is essentially all doctors and hospitals in the state.

YMMV
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by PowderDay9 »

mtmingus wrote: Tue Oct 20, 2020 8:10 pm Interesting.
So Medicare Advantage vs traditional Medicare plans is similar to HMO vs PPO?
No. Medicare advantage plans are mostly either HMO or PPO or a few are something else (PFFS, HMO-POS) . Many of the zero dollar plans are HMO. You can buy a PPO and get out of network coverage. Employer plans are HMO or PPO as well.
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by runninginvestor »

mtmingus wrote: Tue Oct 20, 2020 8:10 pm Interesting.
So Medicare Advantage vs traditional Medicare plans is similar to HMO vs PPO?
More like nationwide PPO (Traditional Medicare) vs local/regional PPO (MA PPO plans). HMOs are even more restrictive.
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by montanagirl »

Watty wrote: Tue Oct 20, 2020 7:54 pm One of the big concerns I have about Medicare Advantage plans is that you could make a good choice and have a good plan but then 10 years from now it might have problems and it would be hard to change to a different MA plan or back to original Medicare.
Two different plans have folded here in the last 6 years, including a Blue Cross Advantage which my husband signed up for. It really was good, good dental and optical. They sent a nurse out twice to take his vitals, talk to him.. But then he landed in the hospital and had to pay 1500+ in copays.

That year the company dropped the plan he was able to get back on Plan F for 2018. So did a friend, who had been the same plan but his cancer came back. Both were able to get on F again.

So I wondered if it isn't almost inevitable that MA plans will give up because they can't make any money in this market? Almost encouraging.

But I am looking at just switching supplements now. Mutual of Omaha seems to have some competitive pricing.
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by PowderDay9 »

Watty wrote: Tue Oct 20, 2020 7:54 pm One of the big concerns I have about Medicare Advantage plans is that you could make a good choice and have a good plan but then 10 years from now it might have problems and it would be hard to change to a different MA plan or back to original Medicare.
Why do you say it would be hard to change MA plans? You can switch to any available MA plan during open enrollment. If you mean it would be disruptive to have a different network and benefits, then I agree. One downside to MA is that the network and benefits can change each year. I would say it changes at a rate much faster than employer group plans.

The downside to Med Supp is it's impossible to predict your rate increases each year, and depending on your state, you may have to go through underwriting (UW) to switch insurance companies. A lot of Med Supp plans eventually are closed to new members and turn into death spirals. Healthy members can pass UW so they leave for a better rate with another carrier. All the unhealthy members stay because they can't pass UW. These members get stuck with huge rate increases and either pay them or go to MA. If you're going to pick a Med Supp plan you need to be aware of how many people are in the plan you pick. I would prefer large membership in well known large insurers.

You can always go to original medicare. You just might not be able to get Med Supp without being underwritten.
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by Blondemommer »

I manage a urology practice and really dislike Medicare advantage plans as compared to Medicare. One must remember that these Medicare advantage plans are run by the big payers and they will do whatever they can to not pay claims fairly and promptly. The prior authorization requirements can be lengthy And cumbersome. If every I isn’t dotted and every T isn’t crossed, they will deny claims that Medicare would cover quickly. From the physician office perspective, my advice is to stay with Medicare and your supplement and stay far away from MA plans
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by PowderDay9 »

montanagirl wrote: Tue Oct 20, 2020 8:51 pm So I wondered if it isn't almost inevitable that MA plans will give up because they can't make any money in this market? Almost encouraging.
There's much more value in the bigger markets for Medicare Advantage. If you're in a small market, your options are probably more limited and it's possible the MA plans are struggling to make money. You might be better off switching Med Supp plans. If your state guarantees Med Supp coverage without UW then I'd switch to the lowest cost carrier. If UW applies then I'd be much more particular on which plan and carrier I picked.
Last edited by PowderDay9 on Thu Oct 22, 2020 11:15 am, edited 1 time in total.
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by alpha88 »

I don't pay attention to what insurance patients have when I am seeing them in the office and discussing treatment plans.
I am a specialist.
The problem I encounter is with precerts for scans and prior auths for medications. For many people, if they need a scan, I can order it have it done the same day, so I can send them down to radiology and then have them come back up to review images and decided what today. If they don't need/want scan same day, I can still schedule it while they are still in office. Medicare advantage plans want all their records first to determine if scan is needed (they do tend to approve), it just takes a day or two, and then we have to phone tag the patient to get it scheduled.

Likewise, with prescriptions - it requires more paperwork on our end to get them covered, so instead of leaving my office and going to the pharmacy there can be a few days of turn arounds.
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by JAZZISCOOL »

goodenyou wrote: Tue Oct 20, 2020 7:11 pm Some have narrow networks. Had a patient today that came a long distance for a cancer consultation (Head and Neck Cancer). They were disappointed to find out that their Aetna Advantage Plan was out of network in the hospitals and surgery centers where I operate. The only ones in network are the ones I wouldn't operate at for very good reasons. The reimbursement is as bad as all Medicare products.
This NY Times article discusses this issue (network coverage) and also the dilemma of not being able to switch back from MA to traditional Medicare once you make the selection. Cancer diagnosis discussed in one patient. Feb. 2020.

https://www.nytimes.com/2020/02/21/busi ... ement.html
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by FrugalInvestor »

montanagirl wrote: Tue Oct 20, 2020 12:43 pm
Rex66 wrote: Tue Oct 20, 2020 12:35 pm What I personally don’t like is it’s much more difficult to get approval for certain things for my Medicare advantage patients in the outpatient setting. Occasionally can’t get things approved that straight Medicare would easily cover.
Ah right, the approval problem. I had MA for one year when I first turned 65 and never used it.

Gotta think about that. I mean your health is fine, til it isn't.
IMO you hit the nail on the head with that last sentence and as you age that "isn't" day becomes much more likely. For that reason I have a traditional "G" supplement and would never consider Medicare Advantage. If cost overrides all all other factors then MA should probably be considered. If not, then in my book traditional medicare + supplement is the way to go. Where I live once a MA plan is chosen you can't go back (after a brief grace period). In addition, networks can be limited and things can change from year-to-year. I'm staying with a "Cadillac" plan because I value my health (and my healthcare) above nearly everything else.
Last edited by FrugalInvestor on Wed Oct 21, 2020 7:20 am, edited 1 time in total.
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by Northern Flicker »

Blondemommer wrote: Tue Oct 20, 2020 9:02 pm I manage a urology practice and really dislike Medicare advantage plans as compared to Medicare. One must remember that these Medicare advantage plans are run by the big payers and they will do whatever they can to not pay claims fairly and promptly. The prior authorization requirements can be lengthy And cumbersome. If every I isn’t dotted and every T isn’t crossed, they will deny claims that Medicare would cover quickly. From the physician office perspective, my advice is to stay with Medicare and your supplement and stay far away from MA plans
This seems to be dependent on the state and the provider. Where I live, docs don't seem to want traditional medicare patients, and some practices will only accept traditional medicare for patients already part of the practice when the patient turns 65. Those practices will accept MA patients.

My current understanding is that someone can go back to traditional medicare with a supplement and not need to go through medical underwriting for the supplement if they move to a place where their MA provider lacks a presence or if the MA provider stops offering MA plans where the person lives. In the past, I thought someone could only choose another MA plan in these circumstances, but that does not seem to be correct.
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by JoeRetire »

Rex66 wrote: Tue Oct 20, 2020 4:49 pmMost of my patients dont notice the issue im talking about. But if you do fall into such a situation, you will.
How will these patients notice?
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by Cubicle »

Yes, they hate them. Advantage plan patients are not prioritized. I know this fun the patient & provider side.

I tell people straight Medicare is like cornflakes. The original & still the best.
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by Rex66 »

JoeRetire wrote: Wed Oct 21, 2020 5:51 am
Rex66 wrote: Tue Oct 20, 2020 4:49 pmMost of my patients dont notice the issue im talking about. But if you do fall into such a situation, you will.
How will these patients notice?


They will only notice if they are one of the relatively rare folks who needs something that the advantage plans either are slow to approve or won’t approve. Otherwise they have no idea. Frankly neither do I since I don’t look at type of insurance until such situations come up
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by pennywise »

prd1982 wrote: Tue Oct 20, 2020 2:29 pm I'm on regular Medicare with a supplemental. I'd love to switch to a lower cost Medicare Advantage plan, but something doesn't add up:

* MA shows a much lower monthly premium.

* MA promises more services.

* The same insurance companies sell Medicare supplemental and Advantage plans.

* The insurance companies advertise their Medical Advantage plans a lot more than their supplemental plans. I take this to mean the insurance companies make more profits from their Advantage plans.

So how do the insurance companies make more profits selling plans that cost less and provide more? Until I can figure this out, I'm staying with traditional Medicare. Something tells me that Medicare Advantage is a good deal for healthy "young" (60s/70s), and worse as people age and require more services. But that is just a concern and I have no evidence.
The government subsidizes insurance providers for each enrollee in a MA plan. I believe the last figure I saw was that it averages out at $11,000/person per year.

That's how MA plans can offer No Premiums! Free Vision! Free Dental! or whatever other Free! bennies they tout. It's not free, the government is just propping up the balance sheet behind the scenes.

And it's a fairly normal risk premium algorithm for the insurance provider in terms of healthy seniors subsidizing those who use more resources. Thus the restrictions, limited practitioners to network a la PPO/HMOs etc.
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by curious george »

I tend to agree with most comments.
MA plans offer restrictions and limits. It is trade-off - lower cost but you give up some freedoms.
In some parts of the country, it won’t matter much as the large local healthcare system participate. (However, if you want to go out of state to seek a second opinion at top hospital like Harvard or Hopkins that may not happen). Oddly enough, if you have MA plan and you can’t get a referral, you can’t even pay cash! (Complex rules about billing patients with insurance if the hospital participated with MA)

If you develop a rare condition and want to seek the input of a national specialist- that may be tough.
How often will that happen ? Probably not that often.
In a sense - it’s like you are paying more for flexibility. If you stay healthy, you won’t ever need it.
If you get sick, it may be worth it.

The calculations are different for each person depending upon how much money they have, how much they value flexibility, and how concerned they are about the scenario where you may develop a rare or odd condition. Unfortunately, there are many unknowns and for many once you enter MA, it is hard to return to traditional Medicare as underwriting can be challenging as one gets older and accumulates more medical conditions.

Good luck
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by Watty »

PowderDay9 wrote: Tue Oct 20, 2020 8:53 pm
Watty wrote: Tue Oct 20, 2020 7:54 pm One of the big concerns I have about Medicare Advantage plans is that you could make a good choice and have a good plan but then 10 years from now it might have problems and it would be hard to change to a different MA plan or back to original Medicare.
Why do you say it would be hard to change MA plans? You can switch to any available MA plan during open enrollment. If you mean it would be disruptive to have a different network and benefits, then I agree. One downside to MA is that the network and benefits can change each year. I would say it changes at a rate much faster than employer group plans.

The downside to Med Supp is it's impossible to predict your rate increases each year, and depending on your state, you may have to go through underwriting (UW) to switch insurance companies. A lot of Med Supp plans eventually are closed to new members and turn into death spirals. Healthy members can pass UW so they leave for a better rate with another carrier. All the unhealthy members stay because they can't pass UW. These members get stuck with huge rate increases and either pay them or go to MA. If you're going to pick a Med Supp plan you need to be aware of how many people are in the plan you pick. I would prefer large membership in well known large insurers.

You can always go to original medicare. You just might not be able to get Med Supp without being underwritten.
The risk is that there might not be different good Medicare Advantage plan available or you might not be able to get a supplement if you have health problems. It has been a while since I looked at it but as I recall the cost of some MediGap plans also varied by how old you were when it was first issued.

Someone posted about switching when their Medicare Advantage plan stopped being offered but as I recall that triggers some sort of a special enrolment period that you would not have if were just unhappy with the Medicare Advantage plan you were in.

As I recall a few states also have special rules that make switching or getting into a MedicGap plan easier so you also need to look at your state rules.
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by dodecahedron »

montanagirl wrote: Tue Oct 20, 2020 12:26 pm It's that time of year again, and I am really tempted to jump from Plan G + Part D to United's MA offering. I'm 71, my knee surgery is done, I have two very cheap meds and (of course) I don't anticipate anything bad happening next year. :P And we don't travel. My premium would go from 200 to 35, and conveniently come out of SS so I don't have to remember to set it aside in checking.
I boldfaced and underlined the words above in the OP because the *current* reality is that a medical emergency can *force* anyone into involuntary travel as a growing number of regions are experiencing overcrowded hospital conditions and transporting patients long distances to hospitals in other regions that have more capacity.

I live in Upstate NY, which (so far) has escaped the ravages that hit downstate and we have had plenty of hospital capacity throughout 2020 to this point. But the memory is vivid of ambulance buses and helicopters transporting downstate patients to hospitals near me. I understand that other areas of the country have experienced similar patient relocations since then.

I now sleep better with traditional Medicare plus the HD-Plan F than I would on the *excellent* highly rated MA plan I used to have. My previous MA plan was great but had a *regional* network that might cause issues if I needed to be medically relocated for any reason. (Grateful to live in NY, one of the few states that allows switching at any time without underwriting. I contacted an agent in early March and was able to switch effective 4/1/2020.)

Edited to add: and yes, *in theory*, MA plans cover out-of-network emergency treatment but the last thing I would want to inflict on my POA in a medical crisis is dealing with unnecessary red tape of any sort. My MA plan was $0 per month and included Part D coverage. My Medigap HD-F is $57 a month and I pay $13 monthly for the cheapest Part D coverage. Cost is $840 per year but I get a much lower OOP max if something expensive hits plus priceless peace of mind about reduced paperwork/red tape hassles.

Also, the OP mentioned the convenience that MA premiums can be automatically deducted from SS. My Medigap and Part D plans are convenient autopays from my checking account. (And if and when I switch carriers in the future, it is much easier to change a checking account autopay than an SS automatic deduction!)
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