do doctors/hospitals HATE Medicare Advantage (as payers)

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

Post by DetroitRick »

I think the answer to this question is all local. My MA networks are not your MA networks. Somebody's MA experience in So Cal, for example, has little relevance to my potential experience here. And rural areas that have few choices seem like a potential issue.

But, my area actually has a number of very decent MA networks. So, I've been asking this question this year as I prepare for my own initial signup next month. Talked to my own 3 providers, none of which had a strong opinion. One of those, who is on Medicare, went the supplement route. But he didn't express any concern about the MA choices here either. At that point, it was still a coin toss for me.

Talking to others in my area who are on Medicare, those on supplements (past or present) often expressed dissatisfaction with premium increases. But that was the ONLY complaint I've personally heard here. Of course nearly all of those either have or had attained-age supplements. Yet, none seemed to understand the inherent age-related increases. I have yet to find another person here who had a complaint or issue with service under either MA or traditional Medicare. But I'm sure there must be some, and I've read about them in various articles.

Frankly, I could go either route. But I'm applying now for Medicare G anyway, and compared to G-HD and N as well. My cost, compared to what I am used to in the individual insurance market (both ACA and pre), just is not a big deal to me. And I like the flexibility. But I don't see either MA or supplement decisions as changing things much for me. Now an MA plan somewhere else - that's a complete unknown (we are not in, I hope, our final retirement location).

My Supplement G premium at 65 will be $130.06/month. Add my Prescription D = $23/month and it seems very affordable. At current rates, that $130.06 only goes to $244 at age 80, the oldest age tier for that particular carrier. Still not bad. Anyway, in my mind, this choice (supplement + Prescription D) gives me flexibility, freedom from dealing with insurance companies (always a good thing), and reasonable costs. Down the road, I can always switch to an MA during annual enrollment. As far as the additional coverages for MA plans - very limited dental, vision, hearing, they were not significant enough to sway me.

Best of luck with your decision.
radiowave
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by radiowave »

Thanks all for the very helpful (and actionable) thread. I'm < 6 mo from my Medicare decision.
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Colorado Guy
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by Colorado Guy »

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Last edited by Colorado Guy on Tue Oct 27, 2020 11:25 am, edited 1 time in total.
Farmboyslim83
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by Farmboyslim83 »

FWIW, most BCBS MA plans in the East/Northeast have almost ALL BCBS plans as “in-network.” I.e., sign up for Highmark in PA, Florida Blue providers, as an example, are “in-network.” I think the only Blues plan that does not participate like this is one of the Maryland BCBS plans. YMMV.
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TexasPE
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by TexasPE »

downshiftme wrote: Tue Oct 20, 2020 1:38 pm 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.
Is your employer self-insured? (Uses an insurance company to administer claims, but pays the claims themselves). Most mega employers are. If so, there is probably someone in HR who serves as an health insurance ombudsman for employees - presenting issues such as yours to an internal corporate review committee. I had 100% success in appealing a half-dozen mystery out-of-network issues, denial of a $3,500 genetic test, etc. YMMV - but worth checking.
At 20: I cared what everyone thought about me | At 40: I didn't give a damn what anyone thought of me | Now that I'm 60: I realize that no one was really thinking about me at all | Winston Churchill (?)
Northern Flicker
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by Northern Flicker »

One other point is the traditional medicare avoids the balance billing problem where you are treated in an in-network hospital by out-of-network doctor or for whom you had zero input into the selection.
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BigJohn
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by BigJohn »

JAZZISCOOL wrote: Tue Oct 20, 2020 9:56 pm 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
I have to make my Medicare decision in the next 9 months so very interested in this discussion. I remain confused about the following.

The NYT article makes is clear that Medigap coverage is subject to underwriting and will likely not be available after the initial enrollment if you develop a serious health condition. Several comments in the discussion seem to imply that those same underwriting issues may apply when switching MA providers. So my questions are...

Is switching MA policies within the same state subject to medical underwriting review?

If not, is the answer different if I’m moving to a new state?
orlandoman
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by orlandoman »

BigJohn wrote: Wed Oct 21, 2020 4:46 pm
JAZZISCOOL wrote: Tue Oct 20, 2020 9:56 pm 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
I have to make my Medicare decision in the next 9 months so very interested in this discussion. I remain confused about the following.

The NYT article makes is clear that Medigap coverage is subject to underwriting and will likely not be available after the initial enrollment if you develop a serious health condition. Several comments in the discussion seem to imply that those same underwriting issues may apply when switching MA providers. So my questions are...

Is switching MA policies within the same state subject to medical underwriting review?

If not, is the answer different if I’m moving to a new state?
Each & every year you can switch between any MA available to you in your zip code of residence without any medical underwiting, no matter what state you live in or move to.
"Don't Believe Everything You Think"
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JAZZISCOOL
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by JAZZISCOOL »

BigJohn wrote: Wed Oct 21, 2020 4:46 pm
JAZZISCOOL wrote: Tue Oct 20, 2020 9:56 pm 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
I have to make my Medicare decision in the next 9 months so very interested in this discussion. I remain confused about the following.

The NYT article makes is clear that Medigap coverage is subject to underwriting and will likely not be available after the initial enrollment if you develop a serious health condition. Several comments in the discussion seem to imply that those same underwriting issues may apply when switching MA providers. So my questions are...

Is switching MA policies within the same state subject to medical underwriting review?

If not, is the answer different if I’m moving to a new state?
I don't know the answer but every state has a local SHIP office (non-profit) that will help with your questions. You can search on this site for your state:

https://www.shiptacenter.org/

"The State Health Insurance Assistance Programs (SHIPs) provide local, in-depth, and objective insurance counseling and assistance to Medicare-eligible individuals, their families, and caregivers."

You might also try a local medicare insurance broker or other BH's will chime in. :happy
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LilyFleur
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by LilyFleur »

Wow, this is confusing :shock:
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celia
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by celia »

We have had Medicare + Plan F/G since we became of age. We can go to 90% of the doctors anywhere without worrying about referrals. We have had specialists refer us to "more specialized" specialists whom we were able to see when needed. These more specializeds admit they wouldn't have accepted us if we had been on Medicare Advantage since the HMOs are slow to pay and don't pay the same.

It's bad enough that Medicare lowers the amount that they approve, but do you really want to see providers that are even lower paid or that accept Medicaid? Are you willing to wait longer before there is an open appointment slot?
Rex66
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by Rex66 »

I accept Medicaid by the way.
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beyou
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by beyou »

I just don’t see why one would voluntarily agree to reduce their choice of doctors and fight for care with insurance companies when they don’t need to. I can’t wait to go on Medicare for these reasons alone.
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FIREchief
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by FIREchief »

beyou wrote: Wed Oct 21, 2020 8:34 pm I just don’t see why one would voluntarily agree to reduce their choice of doctors and fight for care with insurance companies when they don’t need to.
Lower premiums?
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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beyou
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by beyou »

FIREchief wrote: Wed Oct 21, 2020 8:50 pm
beyou wrote: Wed Oct 21, 2020 8:34 pm I just don’t see why one would voluntarily agree to reduce their choice of doctors and fight for care with insurance companies when they don’t need to.
Lower premiums?
Lowest premiums are having no insurance at all.
Why not take that option ?
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FIREchief
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by FIREchief »

beyou wrote: Wed Oct 21, 2020 11:35 pm
FIREchief wrote: Wed Oct 21, 2020 8:50 pm
beyou wrote: Wed Oct 21, 2020 8:34 pm I just don’t see why one would voluntarily agree to reduce their choice of doctors and fight for care with insurance companies when they don’t need to.
Lower premiums?
Lowest premiums are having no insurance at all.
Why not take that option ?
Do you have a serious question??
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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beyou
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by beyou »

Yes. If someone posted “do I really need life insurance, it’s so expensive”, or “do I really need bonds in my portfolio, yields are so low”, there would be spirited discussion about who needs to “spend” more and why. I understand why I needed life insurance. I understand why 100% equities despite recent history is not wise. But I do not understand why MA is an “advantage”. Just because it’s cheaper? It was mentioned above that it seems too good to be true, is it ? This thread asks about one concern that maybe it is too good to be true, which I always suspected to be true. I am still on employer benefits now, and doing my annual elections. Our company has 2 dental options (3 if you count none as an option). I have never considered one of the 3 choices as a worthwhile choice. I take the most expensive one to have freedom to go to any dentist, not the DMO that limits me to a small lost of dentists (that do not include my 1st choice or a 2nd or 3rd choice of dentist). Yes it’s cheaper, but the only other option I would consider is no dental insurance and pay out of pocket. Medicare is clearly different, self insure is not a wise way to save in premiums. Why is MA advantage a wise way to save premium cost ? I don’t see it. What am I missing ? The OP is clearly concerned and so am I. This thread has not convinced me to consider saving $ via MA, what am I missing ?
pennywise
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by pennywise »

beyou wrote: Thu Oct 22, 2020 6:24 am I take the most expensive one to have freedom to go to any dentist, not the DMO that limits me to a small lost of dentists (that do not include my 1st choice or a 2nd or 3rd choice of dentist). Yes it’s cheaper, but the only other option I would consider is no dental insurance and pay out of pocket. Medicare is clearly different, self insure is not a wise way to save in premiums. Why is MA advantage a wise way to save premium cost ? I don’t see it. What am I missing ? The OP is clearly concerned and so am I. This thread has not convinced me to consider saving $ via MA, what am I missing ?
You are missing the fact that many people on Medicare have very limited financial resources. Your ability to choose options without consideration of cost reflects your financial status--not a criticism, just a fact. This discussion is being held on the Bogleheads forum, most of whose membership has far different and higher net worth/income/retirement resources than the financial profile of the "average" retiree. Here's an interesting stat:

Most people aged 65 and older receive the majority of their income from Social Security.[1] Without Social Security benefits, 37.8 percent of elderly Americans would have incomes below the official poverty line, all else being equal; with Social Security benefits, only 9.7 percent do. (See Figure 1.) These benefits lift 14.8 million elderly Americans above the poverty line, these estimates show.

Source: https://www.cbpp.org/research/social-se ... ure%201.)

For many people, MA plans are indeed a huge advantage. For someone on a tight budget It can be well worth it to trade off a limited number of practitioner choices as well as preapproval , test limits etc to gain solid health care insurance that often includes dental and vision and other side goodies like exercise, well care advice etc.

As with many other aspects of life, having more money gives you more choices and so it is with Medicare additional insurance options.
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Stinky
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by Stinky »

pennywise wrote: Thu Oct 22, 2020 7:32 am For many people, MA plans are indeed a huge advantage. For someone on a tight budget It can be well worth it to trade off a limited number of practitioner choices as well as preapproval , test limits etc to gain solid health care insurance that often includes dental and vision and other side goodies like exercise, well care advice etc.
Excellent point.
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mur44
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by mur44 »

Medicare + Medigap "G" is Gold Standard. If you could afford the
Medigap premium, just stick with it.

I worked as Volunteer Medicare Counselor in the State of New Jersey.
mtmingus
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by mtmingus »

mur44 wrote: Thu Oct 22, 2020 7:53 am Medicare + Medigap "G" is Gold Standard. If you could afford the
Medigap premium, just stick with it.

I worked as Volunteer Medicare Counselor in the State of New Jersey.
For people can afford, what are the alphabets they need, A + B + D + G?
Thank you!
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by Broken Man 1999 »

beyou wrote: Wed Oct 21, 2020 8:34 pm I just don’t see why one would voluntarily agree to reduce their choice of doctors and fight for care with insurance companies when they don’t need to. I can’t wait to go on Medicare for these reasons alone.
I have seen my PCP and wound care doctor for over 20 years. During that time I have been with 4 different HMOs/PPOs/EPN. Never had to change doctors, or for that matter specialists.

I don't believe I have ever had to fight for services, and believe me I have consumed a bunch over the years. I'm not a profit center for any medical insurance I might have.

In Metro areas there is plenty of access, rural areas by neccesity have smaller networks. I certainly wouldn't use a MA plan in a rural area. Though, rural areas have other challanges for medical care than medical insurance.

Perhaps I have had good results because MegaCorp provides our retirement insurace. At any rate, our MA PPO plan is more than worth the money I pay for it, zero at the moment.

Broken Man 1999
“If I cannot drink Bourbon and smoke cigars in Heaven then I shall not go. " -Mark Twain
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gasdoc
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by gasdoc »

My perspective is from being married to a case manager at our local medical center. She, and all the other case managers, despise Medicare Advantage. The reason- while it is possible to check to see if your favorite provider is on the panel, there is no way to check every possible occurrence. For example, say you break your hip and go to your favorite hospital. All is fine. And you see your favorite ortho doc. All is fine. Then they tell you to go to a nursing facility for rehab- not good because now you are into areas where they cut costs and nobody does research. So maybe the only facility you can go is the terribly run, filthy nursing facility that barely passes accreditation and the only people that go there are those with that medicare advantage plan because they have no choice. Then, when you need a specific kind of ambulation device, oh no, it is not covered! My wife would never allow me to purchase a medical advantage plan. She works with them every day. I hope this saves people some heartache.

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

Post by hightower »

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
Most doctors are employed these days and could care less what kind of insurance you carry. I'm sure the big wigs in corporate America who run our medical system dislike medicare though because it eats into their CEO's multimillion dollar bonuses.
ModifiedDuration
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by ModifiedDuration »

gasdoc wrote: Thu Oct 22, 2020 9:44 am My perspective is from being married to a case manager at our local medical center. She, and all the other case managers, despise Medicare Advantage. The reason- while it is possible to check to see if your favorite provider is on the panel, there is no way to check every possible occurrence. For example, say you break your hip and go to your favorite hospital. All is fine. And you see your favorite ortho doc. All is fine. Then they tell you to go to a nursing facility for rehab- not good because now you are into areas where they cut costs and nobody does research. So maybe the only facility you can go is the terribly run, filthy nursing facility that barely passes accreditation and the only people that go there are those with that medicare advantage plan because they have no choice. Then, when you need a specific kind of ambulation device, oh no, it is not covered! My wife would never allow me to purchase a medical advantage plan. She works with them every day. I hope this saves people some heartache.

gasdoc
Thank you, this is very helpful.
hightower
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by hightower »

cone774413 wrote: Tue Oct 20, 2020 6:28 pm 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.
Same here, hospitalist for 10 years. The reason we don't have to worry about this is because the hospital fights with the insurance companies behind the scenes. If insurance doesn't pay, sometimes they just try to bill the patient directly. This all happens months after the patient is already discharged. The most successful hospitals are those that are very good at negotiating payments with the many different insurers out there. Rarely would a hospital discourage the physicians from ordering testing because the more you order, the more they can bill and profit.
One time in my career I can remember the hospital asking us to not order a certain test because of how expensive it was and because none of the insurers were paying for it (a respiratory viral panel).
PowderDay9
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by PowderDay9 »

gasdoc wrote: Thu Oct 22, 2020 9:44 am My perspective is from being married to a case manager at our local medical center. She, and all the other case managers, despise Medicare Advantage. The reason- while it is possible to check to see if your favorite provider is on the panel, there is no way to check every possible occurrence. For example, say you break your hip and go to your favorite hospital. All is fine. And you see your favorite ortho doc. All is fine. Then they tell you to go to a nursing facility for rehab- not good because now you are into areas where they cut costs and nobody does research. So maybe the only facility you can go is the terribly run, filthy nursing facility that barely passes accreditation and the only people that go there are those with that medicare advantage plan because they have no choice. Then, when you need a specific kind of ambulation device, oh no, it is not covered! My wife would never allow me to purchase a medical advantage plan. She works with them every day. I hope this saves people some heartache.

gasdoc
Asking a provider case manager if they like Medicare Advantage is like asking a hedge fund manager if they want more transparency and reporting requirements on them. A case manager for a local medical center at best has no incentive to watch costs and at worst has an incentive to bill as much as possible. Of course they'd rather not have somebody (MA plan) oversee what they are recommending and ordering. If the practice charges and wastes too much then they get dropped from the network.

When you have any insurance you are part of a risk pool. If there are no controls on cost then members can get any test, procedure, special kind of ambulation device, even if it's not necessary or there's a similar less expensive option. This would be Med Supp and can be expensive. If you'd rather be a part of a risk pool that values monitoring what gets spent in hopes of avoiding waste then this would be Medicare Advantage.

I find it interesting that us Bogleheads really value getting the most bang for our buck and paying low costs but some don't find that same value in a health care product that attempts to do the same thing. I'd be curious to know why that is.
JackoC
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by JackoC »

Stinky wrote: Thu Oct 22, 2020 7:47 am
pennywise wrote: Thu Oct 22, 2020 7:32 am For many people, MA plans are indeed a huge advantage. For someone on a tight budget It can be well worth it to trade off a limited number of practitioner choices as well as preapproval , test limits etc to gain solid health care insurance that often includes dental and vision and other side goodies like exercise, well care advice etc.
Excellent point.
The problem seems to me the compounding of 'natural' uncertainty about our own future health outcomes with the opaqueness of the medical system generally. We all know the reason for MA premiums being lower than medigap is not charity by the providers, what Adam Smith was saying in 'it is not from the benevolence of the butcher, the brewer or the baker that we expect our dinner, but from their regard to their own interest'. We can't, unfortunately, just establish that ins co's are profit making organizations, or even that their upper management gets paid very well, and therefore conclude their MA offerings must be a bad deal. There *is* a lot of unnecessary health spending and little incentive to control it in traditional Medicare, so again just the idea that ins co's do try to control it in MA, in their own interest, does not make it a bad deal, especially considering the extra's thrown in. It's just very hard to assess how good a deal it does offer in a particular plan, place, personal lifestyle (travel, etc), personal health profile, and of course what else we'd do with the money saved. Is it used it shore up provision of necessities, or just leave more $'s behind? The latter is the prospect for many saved $'s by retirees on BH forum, but as the previous post said that's much less true of retirees in general. The goal of saving $'s here is much more 'it's the principal of it!'.

I'm beginning to scope out Medicare, a couple of years away. As of now I'm thinking probably medigap because of the 'one way' obstacles in getting back from MA to medigap, possibility of living in different parts of the country different times of year, and the difference is just not a huge amount of money for us, fortunately.
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montanagirl
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by montanagirl »

beyou wrote: Wed Oct 21, 2020 11:35 pm
FIREchief wrote: Wed Oct 21, 2020 8:50 pm
beyou wrote: Wed Oct 21, 2020 8:34 pm I just don’t see why one would voluntarily agree to reduce their choice of doctors and fight for care with insurance companies when they don’t need to.
Lower premiums?
Lowest premiums are having no insurance at all.
Why not take that option ?
Asset protection? Even MA limits your out of pocket expense.
PowderDay9
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by PowderDay9 »

JackoC wrote: Thu Oct 22, 2020 10:42 am
Stinky wrote: Thu Oct 22, 2020 7:47 am
pennywise wrote: Thu Oct 22, 2020 7:32 am For many people, MA plans are indeed a huge advantage. For someone on a tight budget It can be well worth it to trade off a limited number of practitioner choices as well as preapproval , test limits etc to gain solid health care insurance that often includes dental and vision and other side goodies like exercise, well care advice etc.
Excellent point.
The problem seems to me the compounding of 'natural' uncertainty about our own future health outcomes with the opaqueness of the medical system generally. We all know the reason for MA premiums being lower than medigap is not charity by the providers, what Adam Smith was saying in 'it is not from the benevolence of the butcher, the brewer or the baker that we expect our dinner, but from their regard to their own interest'. We can't, unfortunately, just establish that ins co's are profit making organizations, or even that their upper management gets paid very well, and therefore conclude their MA offerings must be a bad deal. There *is* a lot of unnecessary health spending and little incentive to control it in traditional Medicare, so again just the idea that ins co's do try to control it in MA, in their own interest, does not make it a bad deal, especially considering the extra's thrown in. It's just very hard to assess how good a deal it does offer in a particular plan, place, personal lifestyle (travel, etc), personal health profile, and of course what else we'd do with the money saved. Is it used it shore up provision of necessities, or just leave more $'s behind? The latter is the prospect for many saved $'s by retirees on BH forum, but as the previous post said that's much less true of retirees in general. The goal of saving $'s here is much more 'it's the principal of it!'.

I'm beginning to scope out Medicare, a couple of years away. As of now I'm thinking probably medigap because of the 'one way' obstacles in getting back from MA to medigap, possibility of living in different parts of the country different times of year, and the difference is just not a huge amount of money for us, fortunately.
+1

Also these same insurance companies that sell Medicare Advantage also sell Medicare Supplement. The annual commissions as a percentage of premium are extremely high on Med Supp. Often 25-35% for the first few years and then usually in the 10-15% range every year after. That's just commission, there's also admin costs for the insurance company. You can actually look up the rate filings at most state insurance regulation websites and find the breakdown of costs. You might be surprised to see Med Supp loss ratios commonly filled at the state minimum, meaning a good portion of the premium is going to a sales person and insurance company admin.

Medicare Advantage commissions are much lower as a percentage of premium and have a maximum dollar limitation imposed by CMS. Even though Medicare Advantage has much more premium at stake, the commission dollar amounts can be similar for a broker for Med Supp and MA.
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gasdoc
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by gasdoc »

PowderDay9 wrote: Thu Oct 22, 2020 10:30 am
gasdoc wrote: Thu Oct 22, 2020 9:44 am My perspective is from being married to a case manager at our local medical center. She, and all the other case managers, despise Medicare Advantage. The reason- while it is possible to check to see if your favorite provider is on the panel, there is no way to check every possible occurrence. For example, say you break your hip and go to your favorite hospital. All is fine. And you see your favorite ortho doc. All is fine. Then they tell you to go to a nursing facility for rehab- not good because now you are into areas where they cut costs and nobody does research. So maybe the only facility you can go is the terribly run, filthy nursing facility that barely passes accreditation and the only people that go there are those with that medicare advantage plan because they have no choice. Then, when you need a specific kind of ambulation device, oh no, it is not covered! My wife would never allow me to purchase a medical advantage plan. She works with them every day. I hope this saves people some heartache.

gasdoc
Asking a provider case manager if they like Medicare Advantage is like asking a hedge fund manager if they want more transparency and reporting requirements on them. A case manager for a local medical center at best has no incentive to watch costs and at worst has an incentive to bill as much as possible. Of course they'd rather not have somebody (MA plan) oversee what they are recommending and ordering. If the practice charges and wastes too much then they get dropped from the network.

When you have any insurance you are part of a risk pool. If there are no controls on cost then members can get any test, procedure, special kind of ambulation device, even if it's not necessary or there's a similar less expensive option. This would be Med Supp and can be expensive. If you'd rather be a part of a risk pool that values monitoring what gets spent in hopes of avoiding waste then this would be Medicare Advantage.

I find it interesting that us Bogleheads really value getting the most bang for our buck and paying low costs but some don't find that same value in a health care product that attempts to do the same thing. I'd be curious to know why that is.
This is just not correct. I see where you are going, but she is not that kind of "case manager." The nurses in her department are responsible only for placement once a patient is ready to leave the hospital. Often, for various reasons, a patient cannot return to the situation where he/she resided before hospital admission. A common need is for rehab before going back home. The case managers in this situation help provide that liaison between the docs' requirements and the practical side of actual placement and securing an empty bed in a specific facility. It is not uncommon for her to be the person that has to tell the patients and their families, who are often to the point of tears when they find out how limited their choices are for the facility to which they must be transferred, that because they are Medicare Advantage instead of regular Medicare / Supplement, they must choose an undesirable situation or incur large additional costs. The Medicare Advantage facility can be one star, whereas the others are 5 star, in a given community. The lower ranked facilities have all the incentives to negotiate aggressively with Medicare Advantage to access their patients.

gasdoc
PowderDay9
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by PowderDay9 »

gasdoc wrote: Thu Oct 22, 2020 11:40 am
PowderDay9 wrote: Thu Oct 22, 2020 10:30 am
gasdoc wrote: Thu Oct 22, 2020 9:44 am My perspective is from being married to a case manager at our local medical center. She, and all the other case managers, despise Medicare Advantage. The reason- while it is possible to check to see if your favorite provider is on the panel, there is no way to check every possible occurrence. For example, say you break your hip and go to your favorite hospital. All is fine. And you see your favorite ortho doc. All is fine. Then they tell you to go to a nursing facility for rehab- not good because now you are into areas where they cut costs and nobody does research. So maybe the only facility you can go is the terribly run, filthy nursing facility that barely passes accreditation and the only people that go there are those with that medicare advantage plan because they have no choice. Then, when you need a specific kind of ambulation device, oh no, it is not covered! My wife would never allow me to purchase a medical advantage plan. She works with them every day. I hope this saves people some heartache.

gasdoc
Asking a provider case manager if they like Medicare Advantage is like asking a hedge fund manager if they want more transparency and reporting requirements on them. A case manager for a local medical center at best has no incentive to watch costs and at worst has an incentive to bill as much as possible. Of course they'd rather not have somebody (MA plan) oversee what they are recommending and ordering. If the practice charges and wastes too much then they get dropped from the network.

When you have any insurance you are part of a risk pool. If there are no controls on cost then members can get any test, procedure, special kind of ambulation device, even if it's not necessary or there's a similar less expensive option. This would be Med Supp and can be expensive. If you'd rather be a part of a risk pool that values monitoring what gets spent in hopes of avoiding waste then this would be Medicare Advantage.

I find it interesting that us Bogleheads really value getting the most bang for our buck and paying low costs but some don't find that same value in a health care product that attempts to do the same thing. I'd be curious to know why that is.
This is just not correct. I see where you are going, but she is not that kind of "case manager." The nurses in her department are responsible only for placement once a patient is ready to leave the hospital. Often, for various reasons, a patient cannot return to the situation where he/she resided before hospital admission. A common need is for rehab before going back home. The case managers in this situation help provide that liaison between the docs' requirements and the practical side of actual placement and securing an empty bed in a specific facility. It is not uncommon for her to be the person that has to tell the patients and their families, who are often to the point of tears when they find out how limited their choices are for the facility to which they must be transferred, that because they are Medicare Advantage instead of regular Medicare / Supplement, they must choose an undesirable situation or incur large additional costs. The Medicare Advantage facility can be one star, whereas the others are 5 star, in a given community. The lower ranked facilities have all the incentives to negotiate aggressively with Medicare Advantage to access their patients.

gasdoc
Can you be more specific on what I said that was incorrect? If you're saying that provider case managers have an incentive to watch costs for the member, please let us know how that is done.
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by AAA »

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...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.
You're saying your Medicare Advantage premium would come out of Social Security (in addition to the usual Medicare deduction)?
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montanagirl
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by montanagirl »

AAA wrote: Thu Oct 22, 2020 12:29 pm
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...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.
You're saying your Medicare Advantage premium would come out of Social Security (in addition to the usual Medicare deduction)?
Yes, because technically it's Medicare Part C.

I wish supps worked that way. I mean I can keep doing set-asides in checking. But direct at the source is much slicker.

But I decided to split the difference and applied for Plan N at Mutual of Omaha. Prices there are very competitive and their tech platform very up to date.
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by gasdoc »

PowderDay9 wrote: Thu Oct 22, 2020 12:07 pm
gasdoc wrote: Thu Oct 22, 2020 11:40 am
PowderDay9 wrote: Thu Oct 22, 2020 10:30 am
gasdoc wrote: Thu Oct 22, 2020 9:44 am My perspective is from being married to a case manager at our local medical center. She, and all the other case managers, despise Medicare Advantage. The reason- while it is possible to check to see if your favorite provider is on the panel, there is no way to check every possible occurrence. For example, say you break your hip and go to your favorite hospital. All is fine. And you see your favorite ortho doc. All is fine. Then they tell you to go to a nursing facility for rehab- not good because now you are into areas where they cut costs and nobody does research. So maybe the only facility you can go is the terribly run, filthy nursing facility that barely passes accreditation and the only people that go there are those with that medicare advantage plan because they have no choice. Then, when you need a specific kind of ambulation device, oh no, it is not covered! My wife would never allow me to purchase a medical advantage plan. She works with them every day. I hope this saves people some heartache.

gasdoc
Asking a provider case manager if they like Medicare Advantage is like asking a hedge fund manager if they want more transparency and reporting requirements on them. A case manager for a local medical center at best has no incentive to watch costs and at worst has an incentive to bill as much as possible. Of course they'd rather not have somebody (MA plan) oversee what they are recommending and ordering. If the practice charges and wastes too much then they get dropped from the network.

When you have any insurance you are part of a risk pool. If there are no controls on cost then members can get any test, procedure, special kind of ambulation device, even if it's not necessary or there's a similar less expensive option. This would be Med Supp and can be expensive. If you'd rather be a part of a risk pool that values monitoring what gets spent in hopes of avoiding waste then this would be Medicare Advantage.

I find it interesting that us Bogleheads really value getting the most bang for our buck and paying low costs but some don't find that same value in a health care product that attempts to do the same thing. I'd be curious to know why that is.
This is just not correct. I see where you are going, but she is not that kind of "case manager." The nurses in her department are responsible only for placement once a patient is ready to leave the hospital. Often, for various reasons, a patient cannot return to the situation where he/she resided before hospital admission. A common need is for rehab before going back home. The case managers in this situation help provide that liaison between the docs' requirements and the practical side of actual placement and securing an empty bed in a specific facility. It is not uncommon for her to be the person that has to tell the patients and their families, who are often to the point of tears when they find out how limited their choices are for the facility to which they must be transferred, that because they are Medicare Advantage instead of regular Medicare / Supplement, they must choose an undesirable situation or incur large additional costs. The Medicare Advantage facility can be one star, whereas the others are 5 star, in a given community. The lower ranked facilities have all the incentives to negotiate aggressively with Medicare Advantage to access their patients.

gasdoc
Can you be more specific on what I said that was incorrect? If you're saying that provider case managers have an incentive to watch costs for the member, please let us know how that is done.
I am saying that these case managers have as their only incentive to get the the patient out of the hospital efficiently and with good customer satisfaction; additional days in the facility are uncompensated. They are not the people that "manage care," or try to reduce costs or increase profits, except of course by limiting days in the hospital. In short, they are consulted when a patient needs a transfer to another facility. There are others that do as you are inferring, but my wife is not one of these people. Thus she is somewhat an expert on the various insurance plans when a patient needs an interim facility prior to discharge home, or when the patient needs medical equipment before they can be discharged home.

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

Post by beyou »

montanagirl wrote: Thu Oct 22, 2020 10:58 am
beyou wrote: Wed Oct 21, 2020 11:35 pm
FIREchief wrote: Wed Oct 21, 2020 8:50 pm
beyou wrote: Wed Oct 21, 2020 8:34 pm I just don’t see why one would voluntarily agree to reduce their choice of doctors and fight for care with insurance companies when they don’t need to.
Lower premiums?
Lowest premiums are having no insurance at all.
Why not take that option ?
Asset protection? Even MA limits your out of pocket expense.
Any insurance that has in and out of network options does not give you asset protection or limits as to cost. Out of network can be fully excluded OR included as % of customary and reasonable costs. What seems reasonable would be very different to your health insurer compared to a hospital. You may get some back on out of network but people have been bankrupted by out of network claims. And if you stay in network and can’t see who and where you prefer, then that is the reason to go to a more expensive policy with a more extensive “network” or covering all providers.
Last edited by beyou on Thu Oct 22, 2020 1:58 pm, edited 1 time in total.
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beyou
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by beyou »

Broken Man 1999 wrote: Thu Oct 22, 2020 8:09 am
beyou wrote: Wed Oct 21, 2020 8:34 pm I just don’t see why one would voluntarily agree to reduce their choice of doctors and fight for care with insurance companies when they don’t need to. I can’t wait to go on Medicare for these reasons alone.
I have seen my PCP and wound care doctor for over 20 years. During that time I have been with 4 different HMOs/PPOs/EPN. Never had to change doctors, or for that matter specialists.

I don't believe I have ever had to fight for services, and believe me I have consumed a bunch over the years. I'm not a profit center for any medical insurance I might have.

In Metro areas there is plenty of access, rural areas by neccesity have smaller networks. I certainly wouldn't use a MA plan in a rural area. Though, rural areas have other challanges for medical care than medical insurance.

Perhaps I have had good results because MegaCorp provides our retirement insurace. At any rate, our MA PPO plan is more than worth the money I pay for it, zero at the moment.

Broken Man 1999
Lucky for you that you pay zero and don’t need it due to redundant coverage. My employer plan is pretty good too, but most employers seem to not give you that coverage after retirement, so most of us have to look at ACA then Medicare. ACA plans in my area have ZERO out of network coverage so the networks are really important. Some options are much more extensive than others. When I get to Medicare, I will celebrate avoidance of relying on an insurer’s network.
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by Northern Flicker »

There is a trend in some areas for docs not to accept traditional medicare patients. I believe these are areas where the area-adjustment to medicare fees is not viewed as adequate by providers. While a narrow network can be a significant issue, I don't think it is in your interest for your providers to feel undercompensated for administering your care either. It can lead to shorter PCP visits and recommendations by specialists for the most aggressive care option that is consistent with standards of practice.

Of course, it you have traditional medicare (A, B, supplement, and drug plan) you can switch to MA at any open enrollment, but not generally in the other direction without medical underwriting for the supplemental plan. I've not been able to quantify the risk of not having a supplemental plan, so have to consider it mandatory to have one.
Risk is not a guarantor of return.
RetiredArtist
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by RetiredArtist »

pennywise wrote: Wed Oct 21, 2020 7:08 am
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.
Why does the government subsidize MA plans?
RetiredArtist
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by RetiredArtist »

My work-provided insurance was with United Healthcare. I could choose any provider who contracted with them.
Approval for small things ($100 orthopedic devices that i could buy online these days) to big things (cataract surgery) took months. And I experienced a few incorrect billing events that also took months to clear up. I was so happy to be done with them. Regular Medicare plus supplement plan has been hassle free.
Last edited by RetiredArtist on Thu Oct 22, 2020 5:47 pm, edited 1 time in total.
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montanagirl
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by montanagirl »

RetiredArtist wrote: Thu Oct 22, 2020 2:27 pm
pennywise wrote: Wed Oct 21, 2020 7:08 am
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.
Why does the government subsidize MA plans?
I recall that MA was sort of an experimental model of the direction some people wanted regular Medicare to go. Ie we would all be on MA if it worked out. The subsidies would end, and everything would be wonderful. :wink:
PowderDay9
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by PowderDay9 »

montanagirl wrote: Thu Oct 22, 2020 2:43 pm
RetiredArtist wrote: Thu Oct 22, 2020 2:27 pm
pennywise wrote: Wed Oct 21, 2020 7:08 am
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.
Why does the government subsidize MA plans?
I recall that MA was sort of an experimental model of the direction some people wanted regular Medicare to go. Ie we would all be on MA if it worked out. The subsidies would end, and everything would be wonderful. :wink:
The government doesn't subsidize Medicare Advantage. It's a capitated payment that is meant to be representative of the Part A and B cost that the Medicare eligible person would have received from enrolling in original Medicare.
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by Northern Flicker »

The higher cost to taxpayers for MA coverage does not include the fixed cost of Medicare administration. If enough peoole moved to MA plans, that fixed cost would start to come down and MA coverage would become cheaper for taxpayers. I think over the next 30-40 years in the US, we either will end up with single payer traditional medicare for all, or Medicare Advantage for all who qualify for medicare or medicare advantage for all.
Risk is not a guarantor of return.
Northern Flicker
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by Northern Flicker »

PowderDay9 wrote: Thu Oct 22, 2020 3:42 pm
montanagirl wrote: Thu Oct 22, 2020 2:43 pm
RetiredArtist wrote: Thu Oct 22, 2020 2:27 pm
pennywise wrote: Wed Oct 21, 2020 7:08 am
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.
Why does the government subsidize MA plans?
I recall that MA was sort of an experimental model of the direction some people wanted regular Medicare to go. Ie we would all be on MA if it worked out. The subsidies would end, and everything would be wonderful. :wink:
The government doesn't subsidize Medicare Advantage. It's a capitated payment that is meant to be representative of the Part A and B cost that the Medicare eligible person would have received from enrolling in original Medicare.
Except the MA payment is slightly higher on average, representing a de facto subsidy.
Risk is not a guarantor of return.
PowderDay9
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by PowderDay9 »

Northern Flicker wrote: Thu Oct 22, 2020 3:44 pm
PowderDay9 wrote: Thu Oct 22, 2020 3:42 pm
montanagirl wrote: Thu Oct 22, 2020 2:43 pm
RetiredArtist wrote: Thu Oct 22, 2020 2:27 pm
pennywise wrote: Wed Oct 21, 2020 7:08 am

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.
Why does the government subsidize MA plans?
I recall that MA was sort of an experimental model of the direction some people wanted regular Medicare to go. Ie we would all be on MA if it worked out. The subsidies would end, and everything would be wonderful. :wink:
The government doesn't subsidize Medicare Advantage. It's a capitated payment that is meant to be representative of the Part A and B cost that the Medicare eligible person would have received from enrolling in original Medicare.
Except the MA payment is slightly higher on average, representing a de facto subsidy.
CMS also keeps a portion of the rebate. The rebate is the savings that the insurance company can produce by offering actuarially equivalent benefits at a lower cost than the government.

I'm not sure if that would offset the cost that you mentioned but it's complicated to figure out if MA is indirectly subsidized in any way.
pennywise
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by pennywise »

PowderDay9 wrote: Thu Oct 22, 2020 3:42 pm The government doesn't subsidize Medicare Advantage. It's a capitated payment that is meant to be representative of the Part A and B cost that the Medicare eligible person would have received from enrolling in original Medicare.
Thank you PowderDay, I misspoke using 'subsidized'. As noted, the government is paying the insurance companies to take on the responsibilities/risks for each customer in the MA plan.
Kidneydoc
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Re: do doctors/hospitals HATE Medicare Advantage (as payers)

Post by Kidneydoc »

I am a physician and I do HATE Medicare Advantage (MA). Medicare Advantage is basically Medicare version of an HMO, (health maintenance organization), though PPOs will offer more flexibility.

The following are facts from Health Affairs:
"Medicare Has Lower Administrative Costs Than Private Plans (MA): According to the Kaiser Family Foundation, administrative costs in Medicare are only about 2 percent of operating expenditures. Defenders of the insurance industry estimate administrative costs as 17 percent of revenue.
Insurance industry-funded studies exclude private plans’ marketing costs ([i]editorial: MA definitely market their products[/i]) and profits from their calculation of administrative costs. Even so, Medicare’s overhead is dramatically lower. Medicare administrative cost figures include the collection of Medicare taxes, fraud and abuse controls, and building costs.

Medicare Advantage, which enrolls seniors in private health plans, has failed to deliver care more efficiently than traditional fee-for-service Medicare. Both the CBO and the Medicare Payment Advisory Commission (MedPAC), the commission which advises congress on Medicare’s finances, have calculated that Medicare Advantage plans covering the same care as traditional Medicare cost 12 percent more."

The only way that MAs can work financially by charging lower up front premiums and fringe benefits:
1. Increase the copays and deductibles of their insurance and medications.
2. Negotiate favorable contracts with narrow network of "health care providers", now increasing hospital employed physicians and advance practice nurse practitioners/physician assistants. Read: likely no out-of-state provider coverage and you might be out-of-network for specialty hospitals, ie. Memorial Sloan Kettering, Dana Farber etc. Now large hospital networks are getting into the MA market (Google "Braven Health", a joint venture between BCBS Horizon, Hackensack Meridian and RWJBarnabas). I do not think that these hospital networks are going into these markets to primarily serve their patient populations, but primarily to maintain their source of revenue.
3. Deny care that they feel is not medically necessary: subacute rehabilitation and medications (in my experience, MAs will deny subacute rehab more often than traditional Medicare). Please note that medical necessity is in the eye of the beholder. What you, the patient, feel is medically necessary is NOT what Medicare/CMS, or for the matter the for-profit medical director/administrator at MAs feel is medically necessary.

That being said, given increasing income inequality (I am trying not to be political here), the vast majority of American are poorly prepared for retirement (not the typical Bogleheads member), and likely in the future will opt for Medicare Advantage. The fact the MA's marketed like crazy on ads and telemarketers, and that Medigap policies are not should be a red flag. This is akin to the marketing of whole-life insurance products vs. term insurance: buyer beware. Can MAs be a value proposition? Yes, but selective plans.

I feel most MAs are "robbing Peter to pay Paul": Saving money up front with annual premiums will come at the expense of future out-of-pocket healthcare costs. For those who are healthy and considering MAs to save money: as a physician, I say you will definitely develop medical problems with age, as we all have 100% mortality, including myself. Switching from MA to Medigap after you develop a medical problem and want to see a super-specialist at a specialty hospital may not be as easy as you think as you may need to undergo medical underwriting after age 65 during annual open enrollment period (Keep in mind that during the six-month Medigap Open Enrollment Period at age 65 , you may apply with preexisting health condition with no additional costs).

My humble opinion
PowderDay9
Posts: 150
Joined: Fri Oct 12, 2018 12:29 pm

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

Post by PowderDay9 »

Kidneydoc wrote: Sat Oct 24, 2020 9:56 am The following are facts from Health Affairs:
"Medicare Has Lower Administrative Costs Than Private Plans (MA): According to the Kaiser Family Foundation, administrative costs in Medicare are only about 2 percent of operating expenditures. Defenders of the insurance industry estimate administrative costs as 17 percent of revenue.
Insurance industry-funded studies exclude private plans’ marketing costs ([i]editorial: MA definitely market their products[/i]) and profits from their calculation of administrative costs. Even so, Medicare’s overhead is dramatically lower. Medicare administrative cost figures include the collection of Medicare taxes, fraud and abuse controls, and building costs.

Medicare Advantage, which enrolls seniors in private health plans, has failed to deliver care more efficiently than traditional fee-for-service Medicare. Both the CBO and the Medicare Payment Advisory Commission (MedPAC), the commission which advises congress on Medicare’s finances, have calculated that Medicare Advantage plans covering the same care as traditional Medicare cost 12 percent more."
I think you're only highlighting one side of the story. Your "facts" above are from an opinion article from 9/20/11...
https://www.healthaffairs.org/do/10.137 ... 3390/full/
...that was in response to this article on 8/9/11 arguing the opposite. It actually states this in the first line of the article you quoted.
https://www.healthaffairs.org/do/10.137 ... 2862/full/

You are also leaving out important considerations that impact the cost of Original Medicare such as fraud. It's by far the biggest fraud in the country and estimated at $50-$60 billion. That would be almost 10% extra cost just right there. Then add on the cost of waste and abuse from paying every claim that comes in without any oversight of the providers. These things are complicated, not transparent, and very hard to calculate, which is why partisan opinion pieces are written on Original Medicare vs Medicare Advantage.

Kidneydoc wrote: Sat Oct 24, 2020 9:56 am The only way that MAs can work financially by charging lower up front premiums and fringe benefits:
1. Increase the copays and deductibles of their insurance and medications.
This is not true. CMS mandates through their actuarial filings that the overall plan benefits of the Medicare Advantage plan must be at least as rich as original medicare or richer. Often times the actual copays and deductibles are much richer. Original Medicare Part B is 20% cost share and many MA plans have many procedures at $0 copays.
Kidneydoc wrote: Sat Oct 24, 2020 9:56 am That being said, given increasing income inequality (I am trying not to be political here), the vast majority of American are poorly prepared for retirement (not the typical Bogleheads member), and likely in the future will opt for Medicare Advantage. The fact the MA's marketed like crazy on ads and telemarketers, and that Medigap policies are not should be a red flag. This is akin to the marketing of whole-life insurance products vs. term insurance: buyer beware. Can MAs be a value proposition? Yes, but selective plans.
I generally agree about marketing but there is a short enrollment window from Oct 15 to Dec 7 so the vast majority of marketing in concentrated around this time. There are also tons of CMS rules about how plans can sell their plans. For example, they aren't allowed to call you to solicit business if you aren't already a member.

About 44% of people are enrolled in Original Medicare, 36% in Medicare Advantage, and 20% in Original Medicare plus Medicare Supplement. The MA enrollment has been growing substantially in the last 10 years. The advertising is partly impacted by the size of the market up for grabs. Only a small portion of seniors can afford the expensive Med Supp policies and there is 44% of Original Medicare members out there that could switch to MA and receive richer benefits and maximum out of pocket protection that isn't available on Original Medicare. Lots of value there for those middle and lower income people.

If you don't like Marketing, I'm presuming you don't like commissions. Check out the huge commission percentages on Med Supp policies. It's not just a one-time up front cost either. Med Supp is regulated by the states so it can be the wild west depending on your state. I helped a family member shop for Med Supp a few years ago and was shocked at the commissions paid. I was also surprised why there was 30+ different carriers offering the same required plan but the rates varied widely. There is a lot of pricing gaming going on with Med Supp and it's impossible to predict what your premiums will be in as little as 5 or 10 years. I personally think there should be a federal law that prohibits UW on Med Supp for existing members so they can switch plans if their plan closes and turns into a death spiral with huge rate increases. Too many games going on in Med Supp.
Kidneydoc wrote: Sat Oct 24, 2020 9:56 am I feel most MAs are "robbing Peter to pay Paul": Saving money up front with annual premiums will come at the expense of future out-of-pocket healthcare costs. For those who are healthy and considering MAs to save money: as a physician, I say you will definitely develop medical problems with age, as we all have 100% mortality, including myself. Switching from MA to Medigap after you develop a medical problem and want to see a super-specialist at a specialty hospital may not be as easy as you think as you may need to undergo medical underwriting after age 65 during annual open enrollment period (Keep in mind that during the six-month Medigap Open Enrollment Period at age 65 , you may apply with preexisting health condition with no additional costs).

My humble opinion
"Robbing Peter to pay Paul" is by definition the fundamental concept of insurance. Since the actual benefits are at least as rich or richer than Original Medicare (with no Med Supp), then I would argue this plan is better for those that can't afford or don't value Med Supp. In general, I agree with your other points here. If you have the money, I'd start by looking at OM plus Med Supp (aka Medigap). My point has always been that it is very expensive for what you get but some people want complete piece of mind knowing they can go to any provider for care. In general, Medicare Advantage has a ton of value and is a great option as well.
toofache32
Posts: 2170
Joined: Sun Mar 04, 2012 6:30 pm

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

Post by toofache32 »

Surgeon here. I have not read through this thread but can give my view of the original question in the title. Medicare was the 2nd insurance I dropped after Medicaid. These are the lowest payors. What's to like about them?
Last edited by toofache32 on Sun Oct 25, 2020 12:49 pm, edited 3 times in total.
Rudy Tooty
Posts: 18
Joined: Fri Oct 09, 2020 11:39 pm

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

Post by Rudy Tooty »

An awful lot depends on where you live in the country. I'm enrolled in an MA plan. The greater the competition between networks - the more benefits for the enrollee. Big networks of docs - and I could change networks in any given month as many times as I want. Do not have to wait for open season. $0 premium. $0 copay for both PCP and specialists. $0 co-pay urgent care. $0 co-pay for ER if admitted to hospital. $0 co-pay outpatient surgery. $0 co-pay in-patient surgery. $1000 annual max out of pocket for medical services. If not, $85. Plan provides $80 per quarter of OTC products (big selection). $0 co-pay for MRI, x-rays. $0 co-pay for labs, diagnostic testing. $0 co-pay for PT. $0 co-pay eye or hearing exams. There are some co-pays for those who need psychiatric in or out-patient care. Every other year $250 credit for lenses and frames. $0 co-pay Acupuncture or Chiro treatments. No referral needed. Also, there's a dental plan for routine care $0 co-pay. Fillings, root canals, etc...available at discounted rates. PPO plans available at an extra cost. The included drug plan is pretty good unless you need the latest and greatest branded drugs. That can get expensive until you escape the donut hole. I get my long-term prescriptions through the VA - so not a problem.

So far so good. Haven't had any major surgeries, etc... through MA but have spoken to some who have. They were satisfied with the treatments and outcomes. I would pay an extra $175-$200/mo for a supplement plan - had I gone that route.

Location, location, location!
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