Medicare Advantage EGWP vs. Public MA Plans

[tallguy3891]

I ask the moderators to please not fold this thread into any other thread and thanks up front.

There is a current thread going back and forth about Medicare Advantage Plans versus Medigap with some liking one or the other.

I think a separate thread would be helpful to clarify which Medicare Advantage (MA) plans people are liking, or if there is any difference.

There are publicly offered Medicare Advantage plans as seen on tv, etc. There are also Employer Sponsored EGWP (Employer Group Waiver Plans) Medicare Advantage plans from where one worked. These are designed for the employer offering them.

I think it would be helpful if those on these two types of MA plans could share their experiences with these two MA options. Employer MA plans appear to offer different coverage (zero cost for almost everything and in some cases zero out of pocket max)) in comparison to public MA plans with copays/coinsurance, etc.

Do these two types of MA plans differ in their handling of the prior approval or authorization issue which seems to be the big issue (or any other areas)?

This way, the thread can focus just on MA issues and leave Medigap out of it. So, any comments on experiences with these two types of MA plans? Please mention whether it is a public MA plan or an employer MA plan.

I will start with a couple of situations I know about. One had a public MA plan and commented how they continually had out of pocket costs. The other had a retiree employer MA plan and rarely had anything out of pocket except for a very small copay for hospitalizations and ambulance. These were both MA plans but with a huge difference.

[OpenMinded1]

The following is an excerpt from a Consumers' Checkbook article pertaining to MA plans available to current federal employees and federal annuitants thru the Federal Employee Health Benefits Program (FEHB). I made the first sentence bold because it appears to indicate that he thinks that, in the case of this employer's MA EGWP, the benefits are superior to public MA plans. I also provide a link to the entire article.

We've found that these new MA plans have better benefits than virtually all existing FEHB and MA plans. For example, the APWU, UnitedHealthcare, GEHA, MHBP, Compass Rose, Rural Carrier, and Aetna MA plans charge $0 for any inpatient or outpatient benefit and have no out-of-pocket maximum for healthcare expenses other than prescription drugs. They promise you'll pay nothing (subject, of course, to the usual restrictions on paying only for medically necessary care). Moreover, they also charge nothing for using non-network providers, so long as they participate with Medicare and accept the plan. The Kaiser MA plans do not let you go out-of-network and the cost-sharing benefits are not as generous as you would find with the other MA options. For example, with Kaiser High Medicare Advantage 2 in the D.C. area, you'll pay a $5 copay to see your primary care doctor or $15 to see a specialist.

https://help.checkbook.org/article/71-e ... -advantage

Added: I saw a couple examples of actual problems that people had with the FEHB MA EGWP on the Government Employee Retirement Planning Blog a couple months ago, but now can't locate the article that contained them. Not sure how credible this source is anyway. One example was someone that had been referred for surgery for a skeletal and/or muscular problem. The FEHB MA plan wouldn't approve the surgery until the person underwent physical therapy. According to the person recounting the incident, they obviously needed the surgery, and during PT the condition got much worse. The PT and wait caused a lot of needless suffering.

[tallguy3891]

The following is an excerpt from a Consumers' Checkbook article pertaining to MA plans available to current federal employees and federal annuitants thru the Federal Employee Health Benefits Program (FEHB). I made the first sentence bold because it appears to indicate that he thinks that in the case of this employer's MA EGWP the benefits are superior to public MA plans. I also provide a link to the entire article.

We've found that these new MA plans have better benefits than virtually all existing FEHB and MA plans. For example, the APWU, UnitedHealthcare, GEHA, MHBP, Compass Rose, Rural Carrier, and Aetna MA plans charge $0 for any inpatient or outpatient benefit and have no out-of-pocket maximum for healthcare expenses other than prescription drugs. They promise you'll pay nothing (subject, of course, to the usual restrictions on paying only for medically necessary care). Moreover, they also charge nothing for using non-network providers, so long as they participate with Medicare and accept the plan. The Kaiser MA plans do not let you go out-of-network and the cost-sharing benefits are not as generous as you would find with the other MA options. For example, with Kaiser High Medicare Advantage 2 in the D.C. area, you'll pay a $5 copay to see your primary care doctor or $15 to see a specialist.

https://help.checkbook.org/article/71-e ... -advantage

There is that wording again---"medically necessary care." Is that the MA plan controlling it, deciding if the care gets approved, which is the concern in other threads? Hopefully others with MA plans will also comment on their experiences with prior approval/authorization for care of various types.

[tallguy3891]

The following is an excerpt from a Consumers' Checkbook article pertaining to MA plans available to current federal employees and federal annuitants thru the Federal Employee Health Benefits Program (FEHB). I made the first sentence bold because it appears to indicate that he thinks that, in the case of this employer's MA EGWP, the benefits are superior to public MA plans. I also provide a link to the entire article.

We've found that these new MA plans have better benefits than virtually all existing FEHB and MA plans. For example, the APWU, UnitedHealthcare, GEHA, MHBP, Compass Rose, Rural Carrier, and Aetna MA plans charge $0 for any inpatient or outpatient benefit and have no out-of-pocket maximum for healthcare expenses other than prescription drugs. They promise you'll pay nothing (subject, of course, to the usual restrictions on paying only for medically necessary care). Moreover, they also charge nothing for using non-network providers, so long as they participate with Medicare and accept the plan. The Kaiser MA plans do not let you go out-of-network and the cost-sharing benefits are not as generous as you would find with the other MA options. For example, with Kaiser High Medicare Advantage 2 in the D.C. area, you'll pay a $5 copay to see your primary care doctor or $15 to see a specialist.

https://help.checkbook.org/article/71-e ... -advantage

Added: I saw a couple examples of actual problems that people had with the FEHB MA EGWP on the Government Employee Retirement Planning Blog a couple months ago, but now can't locate the article that contained them. Not sure how credible this source is anyway. One example was someone that had been referred for surgery for a skeletal and/or muscular problem. The FEHB MA plan wouldn't approve the surgery until the person underwent physical therapy. According to the person recounting the incident, they obviously needed the surgery, and during PT the condition got much worse. The PT and wait caused a lot of needless suffering.

Some articles:
https://www.healthcaredive.com/news/uni ... ls/699834/

https://www.cms.gov/newsroom/fact-sheet ... cms-4201-f

https://kffhealthnews.org/morning-break ... e-denials/

[tallguy3891]

Very interesting. The lack of responses about Medicare Advantage plans, either Employer offered or public, could be taken a variety of ways: perhaps fewer people have them on the group than Medigap, or have no comments on experiences either way, or, or...

But, I do find it interesting no one to date commented on their experiences with them. That is a comment itself, in my opinion, and very helpful.

[2pedals]

I don’t think they have been around for very long time, so not enough track record to be meaningful. My retiree employer sponsored plan is going to new next year for us. I will say Aetna has a lot of procedures that require pre-authorization. Much more so than the BCBS traditional medical insurance we are currently using.

[tallguy3891]

I don’t think they have been around for very long time, so not enough track record to be meaningful. My retiree employer sponsored plan is going to new next year for us. I will say Aetna has a lot of procedures that require pre-authorization. Much more so than the BCBS traditional medical insurance we are currently using.

Thanks for your comments. This is the kind of stuff which is very helpful. Can you give more details on what you said about Aetna? Was it a Medicare Advantage Plan?

[skp]

Is this what you want???
My Public MA plan. Never seen this plan advertised TV, but it is a "regular" public Advantage plan and is not affiliated with a company's retirement plan. It was recommended to me by an insurance broker affiliated with the hospital from which I retired (retired RN). My husband and I have an Aetna HMO/POS plan. It is zero premium (after regular Medicare charges) We've only had it a year and I am healthy. My husband does have a few medical problems. Our HMO POS covers any provider that takes Aetna anywhere in the country. All our prior physicians, eye dr, and dentist were already on the plan. I didn't have to change any providers. If I so desired, I live one hour east of Cleveland and could go to the Cleveland Clinic and my insurance would cover it. We own a hunting camp in PA, and I am covered there. I don't intend to do a lot of international traveling so that is not an issue. Being an RN who worked in the area, I checked any "good" physician I would be interested in seeing is on the registry, so I don't foresee any provider limitations.
Our co pays are $0 for PCP. $35 for specialists. We've both seen the PCP once. My husband due to his medical problems, has seen 2 specialists this year. So, $70 copays for that.
Prescriptions. I am on no meds, he's on one. His one med is free.
Labs. We've both have had lab work done- me once he twice. Lab work was free.
Extras. We've both had teeth cleaned twice and Xray's- we paid zero.
We both had our eyes checked and new glasses. Exam was zero, glasses were a lot but my choice- I get progressives with the works and so does he so they are costly. We each received $200 towards their purchase. But still spent $1000 on glasses.
We have Silver Sneakers which I don't use. I've bought a few things from our CVS OTC benefits but donate the rest to a free Clinic where I volunteer, so I guess I am using them.
Preauths. He need a CT scan with contrast. It required a preauth but that took less time than it took to get it scheduled. It did cost us $200.
Preventive. I've had a mammogram, dex scan, cologaurd test, flu shot, shingles shot, and an in-home visit from a NP which the insurance company paid ME for.

Very interesting. The lack of responses about Medicare Advantage plans, either Employer offered or public, could be taken a variety of ways: perhaps fewer people have them on the group than Medigap, or have no comments on experiences either way, or, or...

But, I do find it interesting no one to date commented on their experiences with them. That is a comment itself, in my opinion, and very helpful.

I wrote this in the prior thread and didn't answer here because I didn't want to be repetitive. I am only responding to this one based on this comment. Perhaps other people aren't responding for the same reason. I'm sure I'm going to hear that my experiences don't count because I am healthy.

[2pedals]

I don’t think they have been around for very long time, so not enough track record to be meaningful. My retiree employer sponsored plan is going to new next year for us. I will say Aetna has a lot of procedures that require pre-authorization. Much more so than the BCBS traditional medical insurance we are currently using.

Thanks for your comments. This is the kind of stuff which is very helpful. Can you give more details on what you said about Aetna? Was it a Medicare Advantage Plan?

Yes, the company sponsored plan is moving from a supplement plan approx $350/mo to an advantage plan. The EGWP Aetna advantage plan has more benefits silver sneakers, dental, vision and hearing zero premiums and includes a very good drug benefit but when you read the fine details many procedures require pre authorization and it’s a PPO. Similar to commercial Advantage plans they are squeezing the medical benefits via PPO pricing management and controlling your access to procedures that they may determine to be not medically necessary whatever that means to them not necessarily to you or your doctor. It seems to have lower deductibles, maximum out of pocket levels but the Aetna plan is essentially a commercial advantage plan.

[OpenMinded1]

I don't intend to do a lot of international traveling so that is not an issue.

For those that travel to other countries for up to a few weeks per year, travel insurance would probably be a cost effective way to compensate for the lack of coverage in other countries by most MA plans.

[OpenMinded1]

I don’t think they have been around for very long time, so not enough track record to be meaningful. My retiree employer sponsored plan is going to new next year for us. I will say Aetna has a lot of procedures that require pre-authorization. Much more so than the BCBS traditional medical insurance we are currently using.

Thanks for your comments. This is the kind of stuff which is very helpful. Can you give more details on what you said about Aetna? Was it a Medicare Advantage Plan?

Yes, the company sponsored plan is moving from a supplement plan approx $350/mo to an advantage plan. The EGWP Aetna advantage plan has more benefits silver sneakers, dental, vision and hearing zero premiums and includes a very good drug benefit but when you read the fine details many procedures require pre authorization and it’s a PPO. Similar to commercial Advantage plans they are squeezing the medical benefits via PPO pricing management and controlling your access to procedures that they may determine to be not medically necessary whatever that means to them not necessarily to you or your doctor. It seems to have lower deductibles, maximum out of pocket levels but the Aetna plan is essentially a commercial advantage plan.

Thanks for your input. You don't seem to think its being a PPO is a good thing. Would you mind explaining in a little more detail how PPOs are "squeezing the medical benefits via PPO pricing management....."?

My limited research gives me the impressions that PPOs tend to have more providers in network than HMOs, and their networks generally cover larger areas. That's a positive for someone like me with a sketchy, local healthcare system.

[tallguy3891]

Is this what you want???
My Public MA plan. Never seen this plan advertised TV, but it is a "regular" public Advantage plan and is not affiliated with a company's retirement plan. It was recommended to me by an insurance broker affiliated with the hospital from which I retired (retired RN). My husband and I have an Aetna HMO/POS plan. It is zero premium (after regular Medicare charges) We've only had it a year and I am healthy. My husband does have a few medical problems. Our HMO POS covers any provider that takes Aetna anywhere in the country. All our prior physicians, eye dr, and dentist were already on the plan. I didn't have to change any providers. If I so desired, I live one hour east of Cleveland and could go to the Cleveland Clinic and my insurance would cover it. We own a hunting camp in PA, and I am covered there. I don't intend to do a lot of international traveling so that is not an issue. Being an RN who worked in the area, I checked any "good" physician I would be interested in seeing is on the registry, so I don't foresee any provider limitations.
Our co pays are $0 for PCP. $35 for specialists. We've both seen the PCP once. My husband due to his medical problems, has seen 2 specialists this year. So, $70 copays for that.
Prescriptions. I am on no meds, he's on one. His one med is free.
Labs. We've both have had lab work done- me once he twice. Lab work was free.
Extras. We've both had teeth cleaned twice and Xray's- we paid zero.
We both had our eyes checked and new glasses. Exam was zero, glasses were a lot but my choice- I get progressives with the works and so does he so they are costly. We each received $200 towards their purchase. But still spent $1000 on glasses.
We have Silver Sneakers which I don't use. I've bought a few things from our CVS OTC benefits but donate the rest to a free Clinic where I volunteer, so I guess I am using them.
Preauths. He need a CT scan with contrast. It required a preauth but that took less time than it took to get it scheduled. It did cost us $200.
Preventive. I've had a mammogram, dex scan, cologaurd test, flu shot, shingles shot, and an in-home visit from a NP which the insurance company paid ME for.

Very interesting. The lack of responses about Medicare Advantage plans, either Employer offered or public, could be taken a variety of ways: perhaps fewer people have them on the group than Medigap, or have no comments on experiences either way, or, or...

But, I do find it interesting no one to date commented on their experiences with them. That is a comment itself, in my opinion, and very helpful.

I wrote this in the prior thread and didn't answer here because I didn't want to be repetitive. I am only responding to this one based on this comment. Perhaps other people aren't responding for the same reason. I'm sure I'm going to hear that my experiences don't count because I am healthy.

Thank you for posting this again. Very helpful and very much appreciate you taking the time to do so.

[2pedals]

OpenMinded1,

I’m not an expert in the field, I turn 65 next year. From what I know PPO can be better than HMOs. Still the problem becomes how many doctors will be willing to accept payment from any given Advantage plan. One Advantage plan may work in one community but not in another. If your company sponsors a plan you don’t get to choose unless you want to leave, if you leave, you and your spouse gets dropped. From time to time the sponsor will shop your plan and you may end up with a plan that doesn’t work very well in your community. After I leave the sponsored plan I and my wife can never get back on the sponsored plan. You don’t get to shop your sponsored plan the company does this for you.

They can even have lower payment rates than original Medicare. Many doctors and medical systems are not exactly pleased dealing with some advantage plans and their pre-authorization policies. This could be more troubling in smaller communities than larger. Some retirees living in different communities are finding it difficult to keep or even find a PCP and specialist. Doctors and medical providers can and do drop advantage networks for various reasons.

[OpenMinded1]

OpenMinded1,

I’m not an expert in the field, I turn 65 next year. From what I know PPO can be better than HMOs. Still the problem becomes how many doctors will be willing to accept payment from any given Advantage plan. One Advantage plan may work in one community but not in another. If your company sponsors a plan you don’t get to choose unless you want to leave, if you leave, you and your spouse gets dropped. From time to time the sponsor will shop your plan and you may end up with a plan that doesn’t work very well in your community. After I leave the sponsored plan I and my wife can never get back on the sponsored plan. You don’t get to shop your sponsored plan the company does this for you.

They can even have lower payment rates than original Medicare. Many doctors and medical systems are not exactly pleased dealing with some advantage plans and their pre-authorization policies. This could be more troubling in smaller communities than larger. Some retirees living in different communities are finding it difficult to keep or even find a PCP and specialist. Doctors and medical providers can and do drop advantage networks for various reasons.

Thanks for the response. My former employer, the federal government, is probably different that most private companies. It offers numerous regular plans to current and former employees, and recently began offering a significant number of Medicare Advantage plans . Some of the plans, both MA and regular plans, offer nationwide coverage. Most often those are listed as PPOs. However, it's of course not that simple. Some plans are listed as both PPO and HMO. Others are listed as PPO and FFS. They don't make things easy.

I am having a tough time deciding between the regular and MA plans. The MA plans appear to offer big saving, but I'm concerned with some of the things you bring up: more pre-approvals, the MA plan having too much influence over my healthcare, providers dropping out because of all the extra steps, etc.

Again, thanks for the input.

[2pedals]

OpenMinded1,

I’m not an expert in the field, I turn 65 next year. From what I know PPO can be better than HMOs. Still the problem becomes how many doctors will be willing to accept payment from any given Advantage plan. One Advantage plan may work in one community but not in another. If your company sponsors a plan you don’t get to choose unless you want to leave, if you leave, you and your spouse gets dropped. From time to time the sponsor will shop your plan and you may end up with a plan that doesn’t work very well in your community. After I leave the sponsored plan I and my wife can never get back on the sponsored plan. You don’t get to shop your sponsored plan the company does this for you.

They can even have lower payment rates than original Medicare. Many doctors and medical systems are not exactly pleased dealing with some advantage plans and their pre-authorization policies. This could be more troubling in smaller communities than larger. Some retirees living in different communities are finding it difficult to keep or even find a PCP and specialist. Doctors and medical providers can and do drop advantage networks for various reasons.

Thanks for the response. My former employer, the federal government, is probably different that most private companies. It offers numerous regular plans to current and former employees, and recently began offering a significant number of Medicare Advantage plans . Some of the plans, both MA and regular plans, offer nationwide coverage. Most often those are listed as PPOs. However, it's of course not that simple. Some plans are listed as both PPO and HMO. Others are listed as PPO and FFS. They don't make things easy.

I am having a tough time deciding between the regular and MA plans. The MA plans appear to offer big saving, but I'm concerned with some of the things you bring up: more pre-approvals, the MA plan having too much influence over my healthcare, providers dropping out because of all the extra steps, etc.

Again, thanks for the input.

Seems like a good problem to have. I don’t know of any company that offers more than one Medicare plan. Many mega corps that do are transitioning into a EGWP plan. They don’t have to offer anything.

[Padlin]

Without reading all the above…
Company retirement medical benefit provides something like $1500 towards premiums at their chosen insurer. They require me to use United Healthcare, I think, their plans do not cover my 2 highest priced drugs, to the tune of about 6k, a month. So I pass on the benefit and choose my own plan from other companies.

I have a Tuft’s HMO plan, I must use docs from their list and get referrals for specialist's. While all my regular Drs are in the plan going to a good specialist via the referral process is proving a to be a stumbling block. I’m changing to their PPO plan for next year. My wife, who’s in great health is fine with the HMO. Cost differences between the 2 plans are minuscule so not a factor.

Medigap also does not cover my drugs so that’s out.

[OpenMinded1]

OpenMinded1,

I’m not an expert in the field, I turn 65 next year. From what I know PPO can be better than HMOs. Still the problem becomes how many doctors will be willing to accept payment from any given Advantage plan. One Advantage plan may work in one community but not in another. If your company sponsors a plan you don’t get to choose unless you want to leave, if you leave, you and your spouse gets dropped. From time to time the sponsor will shop your plan and you may end up with a plan that doesn’t work very well in your community. After I leave the sponsored plan I and my wife can never get back on the sponsored plan. You don’t get to shop your sponsored plan the company does this for you.

They can even have lower payment rates than original Medicare. Many doctors and medical systems are not exactly pleased dealing with some advantage plans and their pre-authorization policies. This could be more troubling in smaller communities than larger. Some retirees living in different communities are finding it difficult to keep or even find a PCP and specialist. Doctors and medical providers can and do drop advantage networks for various reasons.

Thanks for the response. My former employer, the federal government, is probably different that most private companies. It offers numerous regular plans to current and former employees, and recently began offering a significant number of Medicare Advantage plans . Some of the plans, both MA and regular plans, offer nationwide coverage. Most often those are listed as PPOs. However, it's of course not that simple. Some plans are listed as both PPO and HMO. Others are listed as PPO and FFS. They don't make things easy.

I am having a tough time deciding between the regular and MA plans. The MA plans appear to offer big saving, but I'm concerned with some of the things you bring up: more pre-approvals, the MA plan having too much influence over my healthcare, providers dropping out because of all the extra steps, etc.

Again, thanks for the input.

Seems like a good problem to have. I don’t know of any company that offers more than one Medicare plan. Many mega corps that do are transitioning into a EGWP plan. They don’t have to offer anything.

Just to be clear, Medicare Advantage EGWPs are the only MA-type plans available to current federal employees and annuitants thru their former employer, the federal government.

[tallguy3891]

OpenMinded1,

I’m not an expert in the field, I turn 65 next year. From what I know PPO can be better than HMOs. Still the problem becomes how many doctors will be willing to accept payment from any given Advantage plan. One Advantage plan may work in one community but not in another. If your company sponsors a plan you don’t get to choose unless you want to leave, if you leave, you and your spouse gets dropped. From time to time the sponsor will shop your plan and you may end up with a plan that doesn’t work very well in your community. After I leave the sponsored plan I and my wife can never get back on the sponsored plan. You don’t get to shop your sponsored plan the company does this for you.

They can even have lower payment rates than original Medicare. Many doctors and medical systems are not exactly pleased dealing with some advantage plans and their pre-authorization policies. This could be more troubling in smaller communities than larger. Some retirees living in different communities are finding it difficult to keep or even find a PCP and specialist. Doctors and medical providers can and do drop advantage networks for various reasons.

Thanks for the response. My former employer, the federal government, is probably different that most private companies. It offers numerous regular plans to current and former employees, and recently began offering a significant number of Medicare Advantage plans . Some of the plans, both MA and regular plans, offer nationwide coverage. Most often those are listed as PPOs. However, it's of course not that simple. Some plans are listed as both PPO and HMO. Others are listed as PPO and FFS. They don't make things easy.

I am having a tough time deciding between the regular and MA plans. The MA plans appear to offer big saving, but I'm concerned with some of the things you bring up: more pre-approvals, the MA plan having too much influence over my healthcare, providers dropping out because of all the extra steps, etc.

Again, thanks for the input.

Seems like a good problem to have. I don’t know of any company that offers more than one Medicare plan. Many mega corps that do are transitioning into a EGWP plan. They don’t have to offer anything.

Just to be clear, Medicare Advantage EGWPs are the only MA-type plans available to current federal employees and annuitants thru their former employer, the federal government.

I was hoping, due to their what I consider hefty premium costs, these FEHB MA plans would be without the "issues" so many mention about "public" MA plans. However, it sounds like it can vary by company, by location, by HMO vs PPO, etc. So, it is difficult to make a decision. It sounds like there might be issues in particular with MA plans with Skilled Nursing (SNF) approval for extended days, which makes sense due to the cost of the service in general.

Then again, I saw a public MA plan last year which was zero premium, covered all my providers, and had a $2900 yearly out of pocket max (each). Changed a little this year but still great. It reminded me in specifics so much of a certain well known FEHB plan which has a premium over $500 per month (self+one), and the zero premium plan actually is better in SNF coverage than the FEHB plan! Go figure.

[tallguy3891]

The following is an excerpt from a Consumers' Checkbook article pertaining to MA plans available to current federal employees and federal annuitants thru the Federal Employee Health Benefits Program (FEHB). I made the first sentence bold because it appears to indicate that he thinks that, in the case of this employer's MA EGWP, the benefits are superior to public MA plans. I also provide a link to the entire article.

We've found that these new MA plans have better benefits than virtually all existing FEHB and MA plans. For example, the APWU, UnitedHealthcare, GEHA, MHBP, Compass Rose, Rural Carrier, and Aetna MA plans charge $0 for any inpatient or outpatient benefit and have no out-of-pocket maximum for healthcare expenses other than prescription drugs. They promise you'll pay nothing (subject, of course, to the usual restrictions on paying only for medically necessary care). Moreover, they also charge nothing for using non-network providers, so long as they participate with Medicare and accept the plan. The Kaiser MA plans do not let you go out-of-network and the cost-sharing benefits are not as generous as you would find with the other MA options. For example, with Kaiser High Medicare Advantage 2 in the D.C. area, you'll pay a $5 copay to see your primary care doctor or $15 to see a specialist.

https://help.checkbook.org/article/71-e ... -advantage

Added: I saw a couple examples of actual problems that people had with the FEHB MA EGWP on the Government Employee Retirement Planning Blog a couple months ago, but now can't locate the article that contained them. Not sure how credible this source is anyway. One example was someone that had been referred for surgery for a skeletal and/or muscular problem. The FEHB MA plan wouldn't approve the surgery until the person underwent physical therapy. According to the person recounting the incident, they obviously needed the surgery, and during PT the condition got much worse. The PT and wait caused a lot of needless suffering.

You mentioned concerns about prior approvals for the MA plan but if you look at Section 3 of the FEHB brochure you can see that MHBP Std requires approvals for things as well. The issues I see the most about MA plans in general are providers, SNF extended days, and physical therapy before surgeries, scans, etc. I'm sure there are others.

You also mentioned savings versus the regular Std plan. I'm not sure how much this would apply if being on Medicare A and B since when on them the combo of the plan and Medicare usually covers 100% or almost. We have not paid a penny oop other than for Rx since being on various FEHB plans and A/B for years. However, the Skilled Nursing days could be a big factor to consider since MHBP Std offers zero at this time for those on A/B while the MA plan covers up to 100.

Also, FEHB offers, at least for some of their MA plans, the ability to opt out anytime during the year one wants. I would triple verify this with MHBP, and how quickly the regular plan resumes, and if true, at least you know you could try the MA option and opt out if necessary/desired.

[Artful Dodger]

Hello,

We have an employer sponsored group retiree MA plan. Medical coverage is 85% after a $110 deductible with a $1300 annual out of pocket limit. Prescriptions are covered similar to a regular Part D plan with $10-$30-$60 copays. The first two years we had UHC as the plan administrator. This past January, they switched to Aetna. It is a PPO plan with the vast majority of local hospitals and physicians participating. Both plans covered out of network providers at the same level but we’ve never encountered a non-network situation. We’ve had numerous tests, procedures, etc. with no problems.

Keep in mind, there is no traditional Medicare RX plans so if you’re on Medicare and have a RX plan it is a private plan. Also, medical necessity comes into play whether you’re on traditional Medicare or a Medicare Advantage plan. I’m not saying there won’t be any difference in the approval process but the services still have to be medically necessary.

Just like other MA plans we receive some extra services like Silver Sneakers.

I did want to add a quick edit. Earlier this year I had a cardiac calcium test. It was not covered and I was informed of that prior to receiving it. But, it was a screening test and would not have been covered by traditional Medicare either.

[OpenMinded1]

The following is an excerpt from a Consumers' Checkbook article pertaining to MA plans available to current federal employees and federal annuitants thru the Federal Employee Health Benefits Program (FEHB). I made the first sentence bold because it appears to indicate that he thinks that, in the case of this employer's MA EGWP, the benefits are superior to public MA plans. I also provide a link to the entire article.

We've found that these new MA plans have better benefits than virtually all existing FEHB and MA plans. For example, the APWU, UnitedHealthcare, GEHA, MHBP, Compass Rose, Rural Carrier, and Aetna MA plans charge $0 for any inpatient or outpatient benefit and have no out-of-pocket maximum for healthcare expenses other than prescription drugs. They promise you'll pay nothing (subject, of course, to the usual restrictions on paying only for medically necessary care). Moreover, they also charge nothing for using non-network providers, so long as they participate with Medicare and accept the plan. The Kaiser MA plans do not let you go out-of-network and the cost-sharing benefits are not as generous as you would find with the other MA options. For example, with Kaiser High Medicare Advantage 2 in the D.C. area, you'll pay a $5 copay to see your primary care doctor or $15 to see a specialist.

https://help.checkbook.org/article/71-e ... -advantage

Added: I saw a couple examples of actual problems that people had with the FEHB MA EGWP on the Government Employee Retirement Planning Blog a couple months ago, but now can't locate the article that contained them. Not sure how credible this source is anyway. One example was someone that had been referred for surgery for a skeletal and/or muscular problem. The FEHB MA plan wouldn't approve the surgery until the person underwent physical therapy. According to the person recounting the incident, they obviously needed the surgery, and during PT the condition got much worse. The PT and wait caused a lot of needless suffering.

You mentioned concerns about prior approvals for the MA plan but if you look at Section 3 of the FEHB brochure you can see that MHBP Std requires approvals for things as well. The issues I see the most about MA plans in general are providers, SNF extended days, and physical therapy before surgeries, scans, etc. I'm sure there are others.

You also mentioned savings versus the regular Std plan. I'm not sure how much this would apply if being on Medicare A and B since when on them the combo of the plan and Medicare usually covers 100% or almost. We have not paid a penny oop other than for Rx since being on various FEHB plans and A/B for years. However, the Skilled Nursing days could be a big factor to consider since MHBP Std offers zero at this time for those on A/B while the MA plan covers up to 100.

Also, FEHB offers, at least for some of their MA plans, the ability to opt out anytime during the year one wants. I would triple verify this with MHBP, and how quickly the regular plan resumes, and if true, at least you know you could try the MA option and opt out if necessary/desired.

According to Consumers' Checkbook the MHBP Aetna Advantage Plan offers significant savings versus the MHBP Standard Plan for couples with high healthcare usage when both are on Medicare A and B, and not subject to IRRMA. For couples such as this, the estimated cost for the MHBP Advantage Plan is $2200 less per year, or $183.33 per month. (The estimate is $2100 less per year for couples such as this with average healthcare usage.) Not sure where the savings come from. Part of it may be due to the fact that the Advantage option offers an $1800 reimbursement - $900 per person. Also, as you mention, maybe it in part has to do with the difference in coverage for skilled nursing facility days. Also, the most the couple could pay in a year with the MHBP Advantage Plan is $11220. In contrast, it would be $21020 with MHBP Standard.

[tallguy3891]

The following is an excerpt from a Consumers' Checkbook article pertaining to MA plans available to current federal employees and federal annuitants thru the Federal Employee Health Benefits Program (FEHB). I made the first sentence bold because it appears to indicate that he thinks that, in the case of this employer's MA EGWP, the benefits are superior to public MA plans. I also provide a link to the entire article.

We've found that these new MA plans have better benefits than virtually all existing FEHB and MA plans. For example, the APWU, UnitedHealthcare, GEHA, MHBP, Compass Rose, Rural Carrier, and Aetna MA plans charge $0 for any inpatient or outpatient benefit and have no out-of-pocket maximum for healthcare expenses other than prescription drugs. They promise you'll pay nothing (subject, of course, to the usual restrictions on paying only for medically necessary care). Moreover, they also charge nothing for using non-network providers, so long as they participate with Medicare and accept the plan. The Kaiser MA plans do not let you go out-of-network and the cost-sharing benefits are not as generous as you would find with the other MA options. For example, with Kaiser High Medicare Advantage 2 in the D.C. area, you'll pay a $5 copay to see your primary care doctor or $15 to see a specialist.

https://help.checkbook.org/article/71-e ... -advantage

Added: I saw a couple examples of actual problems that people had with the FEHB MA EGWP on the Government Employee Retirement Planning Blog a couple months ago, but now can't locate the article that contained them. Not sure how credible this source is anyway. One example was someone that had been referred for surgery for a skeletal and/or muscular problem. The FEHB MA plan wouldn't approve the surgery until the person underwent physical therapy. According to the person recounting the incident, they obviously needed the surgery, and during PT the condition got much worse. The PT and wait caused a lot of needless suffering.

You mentioned concerns about prior approvals for the MA plan but if you look at Section 3 of the FEHB brochure you can see that MHBP Std requires approvals for things as well. The issues I see the most about MA plans in general are providers, SNF extended days, and physical therapy before surgeries, scans, etc. I'm sure there are others.

You also mentioned savings versus the regular Std plan. I'm not sure how much this would apply if being on Medicare A and B since when on them the combo of the plan and Medicare usually covers 100% or almost. We have not paid a penny oop other than for Rx since being on various FEHB plans and A/B for years. However, the Skilled Nursing days could be a big factor to consider since MHBP Std offers zero at this time for those on A/B while the MA plan covers up to 100.

Also, FEHB offers, at least for some of their MA plans, the ability to opt out anytime during the year one wants. I would triple verify this with MHBP, and how quickly the regular plan resumes, and if true, at least you know you could try the MA option and opt out if necessary/desired.

According to Consumers' Checkbook the MHBP Aetna Advantage Plan offers significant savings versus the MHBP Standard Plan for couples with high healthcare usage when both are on Medicare A and B, and not subject to IRRMA. For couples such as this, the estimated cost for the MHBP Advantage Plan is $2200 less per year, or $183.33 per month. (The estimate is $2100 less per year for couples such as this with average healthcare usage.) Not sure where the savings come from. Part of it may be due to the fact that the Advantage option offers an $1800 reimbursement - $900 per person. Also, as you mention, maybe it in part has to do with the difference in coverage for skilled nursing facility days. Also, the most the couple could pay in a year with the MHBP Advantage Plan is $11220. In contrast, it would be $21020 with MHBP Standard.

I'm guessing they might use the out of pocket yearly max in the calculation, which makes sense, and as a correction to my previous post about Medicare A and B mitigating those costs at least somewhat, the out of pocket yearly max would still have to be factored in for Rx out of pocket costs as well--which could be considerable for expensive meds. The new MPDP Part D option or MA plan Rx could lessen that somewhat due to the lower yearly oop max. Maybe these things factor into the much lower oop max for the MA plan.

[quantAndHold]

Neither of us has access to an EGWP plan. My wife is on a public MA plan that is the same HMO as her employer plan when she was working. All of the docs she had before are covered. $0 premium, $0 or very low copays, $2300 OOP max that she has never come close to hitting, despite being hospitalized a couple of times. She used her Silver and Fit to get a free membership at the same gym I pay $65/month for, and we can’t use up all of the free CVS stuff she gets. She has dental insurance that she hasn’t really used, since we already have a dentist we like that isn’t covered by her insurance.

I’m not old enough for Medicare yet, but I’m on an ACA plan that’s working well for me, despite needing $173k worth of medical care this past year. When I hit 65, I’ll switch to the MA plan offered by the same HMO. I fully expect it will be the same as what I have now, except much cheaper.

[OpenMinded1]

The following is an excerpt from a Consumers' Checkbook article pertaining to MA plans available to current federal employees and federal annuitants thru the Federal Employee Health Benefits Program (FEHB). I made the first sentence bold because it appears to indicate that he thinks that, in the case of this employer's MA EGWP, the benefits are superior to public MA plans. I also provide a link to the entire article.

We've found that these new MA plans have better benefits than virtually all existing FEHB and MA plans. For example, the APWU, UnitedHealthcare, GEHA, MHBP, Compass Rose, Rural Carrier, and Aetna MA plans charge $0 for any inpatient or outpatient benefit and have no out-of-pocket maximum for healthcare expenses other than prescription drugs. They promise you'll pay nothing (subject, of course, to the usual restrictions on paying only for medically necessary care). Moreover, they also charge nothing for using non-network providers, so long as they participate with Medicare and accept the plan. The Kaiser MA plans do not let you go out-of-network and the cost-sharing benefits are not as generous as you would find with the other MA options. For example, with Kaiser High Medicare Advantage 2 in the D.C. area, you'll pay a $5 copay to see your primary care doctor or $15 to see a specialist.

https://help.checkbook.org/article/71-e ... -advantage

Added: I saw a couple examples of actual problems that people had with the FEHB MA EGWP on the Government Employee Retirement Planning Blog a couple months ago, but now can't locate the article that contained them. Not sure how credible this source is anyway. One example was someone that had been referred for surgery for a skeletal and/or muscular problem. The FEHB MA plan wouldn't approve the surgery until the person underwent physical therapy. According to the person recounting the incident, they obviously needed the surgery, and during PT the condition got much worse. The PT and wait caused a lot of needless suffering.

You mentioned concerns about prior approvals for the MA plan but if you look at Section 3 of the FEHB brochure you can see that MHBP Std requires approvals for things as well. The issues I see the most about MA plans in general are providers, SNF extended days, and physical therapy before surgeries, scans, etc. I'm sure there are others.

You also mentioned savings versus the regular Std plan. I'm not sure how much this would apply if being on Medicare A and B since when on them the combo of the plan and Medicare usually covers 100% or almost. We have not paid a penny oop other than for Rx since being on various FEHB plans and A/B for years. However, the Skilled Nursing days could be a big factor to consider since MHBP Std offers zero at this time for those on A/B while the MA plan covers up to 100.

Also, FEHB offers, at least for some of their MA plans, the ability to opt out anytime during the year one wants. I would triple verify this with MHBP, and how quickly the regular plan resumes, and if true, at least you know you could try the MA option and opt out if necessary/desired.

According to Consumers' Checkbook the MHBP Aetna Advantage Plan offers significant savings versus the MHBP Standard Plan for couples with high healthcare usage when both are on Medicare A and B, and not subject to IRRMA. For couples such as this, the estimated cost for the MHBP Advantage Plan is $2200 less per year, or $183.33 per month. (The estimate is $2100 less per year for couples such as this with average healthcare usage.) Not sure where the savings come from. Part of it may be due to the fact that the Advantage option offers an $1800 reimbursement - $900 per person. Also, as you mention, maybe it in part has to do with the difference in coverage for skilled nursing facility days. Also, the most the couple could pay in a year with the MHBP Advantage Plan is $11220. In contrast, it would be $21020 with MHBP Standard.

I'm guessing they might use the out of pocket yearly max in the calculation, which makes sense, and as a correction to my previous post about Medicare A and B mitigating those costs at least somewhat, the out of pocket yearly max would still have to be factored in for Rx out of pocket costs as well--which could be considerable for expensive meds. The new MPDP Part D option or MA plan Rx could lessen that somewhat due to the lower yearly oop max. Maybe these things factor into the much lower oop max for the MA plan.

Here's what they say about how they calculate high healthcare useage:

Our High Cost year estimates the out-of-pocket amounts you are likely to pay for a major hospital visit along with heavier use of primary care and specialist physicians, outpatient services, drugs, and dental care. It also includes premium (adjusted for the benefits of premium conversion if eligible), applicable health savings accounts in Consumer Driven and High Deductible plans. It is calculated on expenses of $30,000 or more. The percent chance (% chance) refers to the likelihood (probability) that someone like you (or your family) will experience a High Cost year based on your age, family size, and health expense category.

[OpenMinded1]

Without reading all the above…
Company retirement medical benefit provides something like $1500 towards premiums at their chosen insurer. They require me to use United Healthcare, I think, their plans do not cover my 2 highest priced drugs, to the tune of about 6k, a month. So I pass on the benefit and choose my own plan from other companies.

I have a Tuft’s HMO plan, I must use docs from their list and get referrals for specialist's. While all my regular Drs are in the plan going to a good specialist via the referral process is proving a to be a stumbling block. I’m changing to their PPO plan for next year. My wife, who’s in great health is fine with the HMO. Cost differences between the 2 plans are minuscule so not a factor.

Medigap also does not cover my drugs so that’s out.

My former employer's MA plan that I am considering does not require referrals.

[tallguy3891]

Without reading all the above…
Company retirement medical benefit provides something like $1500 towards premiums at their chosen insurer. They require me to use United Healthcare, I think, their plans do not cover my 2 highest priced drugs, to the tune of about 6k, a month. So I pass on the benefit and choose my own plan from other companies.

I have a Tuft’s HMO plan, I must use docs from their list and get referrals for specialist's. While all my regular Drs are in the plan going to a good specialist via the referral process is proving a to be a stumbling block. I’m changing to their PPO plan for next year. My wife, who’s in great health is fine with the HMO. Cost differences between the 2 plans are minuscule so not a factor.

Medigap also does not cover my drugs so that’s out.

My former employer's MA plan that I am considering does not require referrals.

In my research of some FEHB MA plans, I saw that (at present anyway) one can opt in anytime during the year, and I was told by a rep for MHBP that one can opt out and back into their regular plan at any time during the year as well, although doing so in the latter case does involve some amount of paperwork. Nice to know it apparently isn't restricted to Open Season if need be. Of course, I would double check all of this.

[OpenMinded1]

Without reading all the above…
Company retirement medical benefit provides something like $1500 towards premiums at their chosen insurer. They require me to use United Healthcare, I think, their plans do not cover my 2 highest priced drugs, to the tune of about 6k, a month. So I pass on the benefit and choose my own plan from other companies.

I have a Tuft’s HMO plan, I must use docs from their list and get referrals for specialist's. While all my regular Drs are in the plan going to a good specialist via the referral process is proving a to be a stumbling block. I’m changing to their PPO plan for next year. My wife, who’s in great health is fine with the HMO. Cost differences between the 2 plans are minuscule so not a factor.

Medigap also does not cover my drugs so that’s out.

My former employer's MA plan that I am considering does not require referrals.

In my research of some FEHB MA plans, I saw that (at present anyway) one can opt in anytime during the year, and I was told by a rep for MHBP that one can opt out and back into their regular plan at any time during the year as well, although doing so in the latter case does involve some amount of paperwork. Nice to know it apparently isn't restricted to Open Season if need be. Of course, I would double check all of this.

Thanks. I also talked to a MHBP rep today about that. Actually I asked two separate reps the same questions about opting in and out just to be sure. What they told me agrees with what you stated above. Also, they said that the switch back to the MHBP Standard Plan generally occurs on the first day of the month following the month the request to switch back is made in.

[tallguy3891]

Without reading all the above…
Company retirement medical benefit provides something like $1500 towards premiums at their chosen insurer. They require me to use United Healthcare, I think, their plans do not cover my 2 highest priced drugs, to the tune of about 6k, a month. So I pass on the benefit and choose my own plan from other companies.

I have a Tuft’s HMO plan, I must use docs from their list and get referrals for specialist's. While all my regular Drs are in the plan going to a good specialist via the referral process is proving a to be a stumbling block. I’m changing to their PPO plan for next year. My wife, who’s in great health is fine with the HMO. Cost differences between the 2 plans are minuscule so not a factor.

Medigap also does not cover my drugs so that’s out.

My former employer's MA plan that I am considering does not require referrals.

In my research of some FEHB MA plans, I saw that (at present anyway) one can opt in anytime during the year, and I was told by a rep for MHBP that one can opt out and back into their regular plan at any time during the year as well, although doing so in the latter case does involve some amount of paperwork. Nice to know it apparently isn't restricted to Open Season if need be. Of course, I would double check all of this.

Thanks. I also talked to a MHBP rep today about that. Actually I asked two separate reps the same questions about opting in and out just to be sure. What they told me agrees with what you stated above. Also, they said that the switch back to the MHBP Standard Plan generally occurs on the first day of the month following the month the request to switch back is made in.

I have been looking also at the GEHA MA and SAMBA MA plans. It seems like you mentioned elsewhere why you wanted to stay with MHBP but GEHA Standard seems to get good ratings from others as a secondary with A/B and is cheaper than MHBP Std. Perhaps that would work for your spouse as employer secondary coverage if you went into their MA option? It would require verification that one spouse can be in MA and one not. The reason I mention it is because I found that several of the FEHB MA plans did not include our providers but GEHA MA and SAMBA MA both use UnitedHealthcare, which does include all of our providers while some other FEHB MA plans did not.

[OpenMinded1]

Without reading all the above…
Company retirement medical benefit provides something like $1500 towards premiums at their chosen insurer. They require me to use United Healthcare, I think, their plans do not cover my 2 highest priced drugs, to the tune of about 6k, a month. So I pass on the benefit and choose my own plan from other companies.

I have a Tuft’s HMO plan, I must use docs from their list and get referrals for specialist's. While all my regular Drs are in the plan going to a good specialist via the referral process is proving a to be a stumbling block. I’m changing to their PPO plan for next year. My wife, who’s in great health is fine with the HMO. Cost differences between the 2 plans are minuscule so not a factor.

Medigap also does not cover my drugs so that’s out.

My former employer's MA plan that I am considering does not require referrals.

In my research of some FEHB MA plans, I saw that (at present anyway) one can opt in anytime during the year, and I was told by a rep for MHBP that one can opt out and back into their regular plan at any time during the year as well, although doing so in the latter case does involve some amount of paperwork. Nice to know it apparently isn't restricted to Open Season if need be. Of course, I would double check all of this.

Thanks. I also talked to a MHBP rep today about that. Actually I asked two separate reps the same questions about opting in and out just to be sure. What they told me agrees with what you stated above. Also, they said that the switch back to the MHBP Standard Plan generally occurs on the first day of the month following the month the request to switch back is made in.

I have been looking also at the GEHA MA and SAMBA MA plans. It seems like you mentioned elsewhere why you wanted to stay with MHBP but GEHA Standard seems to get good ratings from others as a secondary with A/B and is cheaper than MHBP Std. Perhaps that would work for your spouse as employer secondary coverage if you went into their MA option? It would require verification that one spouse can be in MA and one not. The reason I mention it is because I found that several of the FEHB MA plans did not include our providers but GEHA MA and SAMBA MA both use UnitedHealthcare, which does include all of our providers while some other FEHB MA plans did not.

Thanks. It does appear that yearly cost for various levels of healthcare usage would be slightly less (about $1000) for GEHA versus MHBP. That's for a couple like us with one on Med and the other not. It also assumes GEHA would let me be on their MA plan, and my wife on their standard plan. I'm sure MHBP allows this. But maximum OOP per year is considerably more for GEHA. For a couple like us It's more than twice as much - approx. $21K versus $10K. I think part of this may be because MHBP has better prescription drug coverage. I noticed that GEHA MA requires 33% copay for specialty drugs versus a 15% for MHBP MA. Not sure if there is a $2K max OOP or not.

Unfortunately, I've got a lot going on right now with the holidays and a trip overseas in about a week. If it weren't for those things, I would spend more time researching some other plans before the end of open season. I don't think I will switch from MHBP Standard this open season. After the holidays, I will probably switch to MHBP Standard with Aetna MA. Wife will stay on MHBP Standard and her cheap employer insurance. But I will definitely do some more provider research before switching to MHBP MA. The savings might be worth it even if one of my doctors doesn't accept the MA plan. I know they all accept Medicare.