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I had Coventry which gave me a runaround about getting an epidural since last summer (I never got it). Twice before, I called my Family Dr. and she ordered the epidural, which lasts me 1-2 years. With Coventry, I had to get a consult with a Neurologist first, who ordered an MRI that Coventry wouldn't approve. They also dropped Nexium as a formulary drug. They also wanted me to pay a monthly premium, which I wouldn't mind doing if they weren't so awful.
This behavior is very common with MA's - which is why I will not consider an MA. I just plain don't trust them. I have ZERO tolerance for this game playing, and sure as heck don't want to be dealing with the games should something serious develop.
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Originally Posted by gentlearts
My husband is shopping for the first time for a Medicare Advantage plan, so I am not sure which one he will choose, but I'll be interested is seeing what kind of experience he has with it.
So, in spite of your experiences, neither of you will consider a Medigap, instead? You wouldn't have any problems whatsoever with Original Medicare and a Medigap and Part D. Yes, there is the premium cost for a Medigap and Part D - but, unless you are undergoing a procedure not approved by Medicare - your costs pretty much end with your premium and drug copays. Issues of referrals, approval, nonpayment, blah, blah, blah - none of that occurs if it is Medicare-approved procedure.
Better to buy a high-deductible Medigap F for a very low premium ($60/mo), and pick up the odd 20% charge here and there yourself. Worst case, should disaster befall, most you have to pay on that 20% in any one year is $2,180, after which Medigap pays 100%. Meanwhile, patient/doctor is in control - NOT the insurance company.
Once again, a good thread on the cost-effectiveness of a high-deductible Medigap F.
Are you sure about that? I've never heard of being able to disenroll from a plan after the enrollment period ends (after January 1st) until the following open enrollment period of December 7th. I may be wrong,
You are. Did you read carefully the quote and check out the link in that quote? The information is directly from Medicare.gov website. Here it is again:
Quote:
If you're in a Medicare Advantage Plan, you can leave your plan and switch to Original Medicare.
If you switch to Original Medicare during this period, you'll have until February 14 to also join a Medicare Prescription Drug Plan to add drug coverage. Your coverage will begin the first day of the month after the plan gets your enrollment form.
I don't agree that Medicare Advantage plans are always a bad idea, however. They can be very helpful to Medicare recipients. You just have to choose the right Advantage plan, just like any other.
This is true. Like I said - Advantage plans are like a box of chocolates - you never know what you're gonna get. Some plans in some areas work great - never an issue. Others, fraught w/problems, misinformation, and deceit. Read this about problems w/Humana in MN - and not corrected:
There is very little recourse if one has trouble with an Advantage provider.
And, the following - note this is from a different source - is very common behavior, not only with Humana. I had similar experience with United Health Care:
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Swanson's letter includes 25 affidavits from patients and medical providers that not only support Swanson's claims but also paint a picture of what Dawn Kern, business office manager at Bigfork Valley Hospital described as "frivolous denials...and lengthy and often fruitless appeal process."
Swanson's letter says two years after Humana preauthorized Medicare-covered home care services for two Bigfork patients, Bigfork Valley has yet to receive any payment for these services, despite appealing Humana's denials with over 50 phone calls, letters, emails and supporting documentation.
It never ends with some carriers. They figure the longer they drag it out, the less likely they'll have to pay.
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Originally Posted by Scooby Snacks
Traditional Medicare can end up costing OP a lot more because of that 20% OOP he/she will be responsible for, whereas Advantage plans are on a straight copay system. My Advantage plan has a $0 copay for Primary Care Doctor visits, for example. Also, OP wouldn't have to pay for a separate prescription part D.
Hunky dory when you're well. It's when serious illness occurs, that problems develop.
Read these - carefully:
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Originally Posted by ocnjgirl
The vast majority of Medicare Advantage plans are state-specific, you can't even use them outside your state let alone the country.
My Mom had Blue Cross of Pa plan, and when I brought her here to NJ (she was being D/C'd from rehab and couldn't return home alone) her plan paid for nothing here.
We had to pay out of pocket for her to get a physical for ALF placement, no reimbursement. From the minute she set foot in NJ, she basically was uninsured until I could get her disenrolled from Pa to NJ Blue Cross (they are run completely separately, you can't switch just from one to the other) and it took weeks to complete the change. She would have been covered for ER only in NJ under the Pa Blue Cross Plan.
As a rehab therapist who's worked in geriatric health care for 18 years, I would scrimp so I could get traditional Medicare and a supplemental. If you ever get sick or need rehab, your co-pays are going to be astronomical with any HMO Medicare plan, and your choices of places to go for rehab may be limited as well.
You will also have to get re-approved for rehab every few days to a week, while under traditional with a supplemental, you can get up to 100 days of rehab after a 3-day hospitalization (as long as you're still making progress and have goals you haven't met yet).
My Mom had about $7000 total co-pays for that illness, including ambulance, hospital and rehab (about 2-3 weeks). I switched her to traditional as soon as open enrollment came, and now if she had the same illness and went to the same rehab, she'd have zero in co-pays. She thought her plan was great, no premiums, what could be better??
Better is a plan that covers everything, and without begging (her plan wanted to cut her after the first week, even though she couldn't walk by herself yet but had been living alone independently prior to getting sick).
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Originally Posted by ocnjgirl
My mother had a Medicare Advantage Plan and I switched her to regular Medicare with a supplemental as soon as she would agree.
She had to go to a rehab facility for about 4 weeks under the advantage plan and her co-pays were over $5000.00.
With traditional Medicare and the supplemental they would have been zero.
With the Advantage plan, the facility was also required to give them therapy updates every 3 days, and I had to fight to prevent her from being cut.
Even then, it only paid 100% for the first week or so, then the percentage they paid progressively decreased every few days after that.
This doesn't happen with traditional Medicare - as long as the person is making weekly progress, Medicare pays 100% for the 1st 20 days and 80% for days 20-100, with the supplemental picking up the other 20%. There is no need to get approval to continue the stay/beg for continued services.
The $5000 was only her co-pay for the rehab, the ambulance was another couple hundred and the hospital was several hundred, too.
In our experience, Advantage Plans are great when you're healthy, but nickel and dime you to death if you get sick.
The foregoing from a health professional. The internet is rife with stories on MA's not delivering or presenting enormous obstacles before they will approve and/or pay for care. And then, even if approved, they won't pay - or deny approving in the first place.
Some (far too many, actually) MA's can be very bad actors - and far too often you don't know if you've signed up with one until you start to use it.
The underlying reason for this bad behavior is profit. MA's are for-profit. Original Medicare is not. Profit and healthcare are oxymorons in my opinion and shouldn't be allowed in the Medicare world - at all - nor outside it, either.
Kaiser Advantage is an exception in CA - because Kaiser owns its hospitals and employs its doctors - so all "profit/revenue" is kept in-house. No game-playing, there.
Better to buy a high-deductible Medigap F for a very low premium ($60/mo), and pick up the odd 20% charge here and there yourself. Worst case, should disaster befall, most you have to pay on that 20% in any one year is $2,180, after which Medigap pays 100%. Meanwhile, patient/doctor is in control - NOT the insurance company. Also, fwiw, my hd-F is w/Physicians Mutual which provides unlimited preventive benefits not subject to deductible - even when Medicare won't pay - like the mammogram or colonoscopy outside of its set schedule, vaccinations, biopsies, vision tests/refractions, etc.
Once again, a good thread on the cost-effectiveness of a high-deductible Medigap F.
Hey Ariadne22 we spoke several times a couple of months ago about Medicare. I did go with traditional Medicare with a supplemental plan (Blue Cross) plus a prescription plan.
You did the right thing. What are your premiums? As I recall, premiums in MA are community-rated.
Last edited by Ariadne22; 01-11-2015 at 10:11 PM..
Gentleheart, you can still switch if any of these apply to you: you get "extra help" from SS, you are under 65 and disabled, if you are already on medicare due to disability and you turn 65, and other special circumstances which are outlined on the medicare.gov site.
Ariadne 22 is correct in that you can end your membership in a plan at anytime and go back to original medicare plus a drug plan if you do so before Feb 14.
Check it out and good luck.
PS Medicare Advantage Plans have alot of surprises that are not readily outlined in their sales and policy outline information imo. Dont knock yourself over the head. You could study this stuff for hours and still be dped. I did and was duped also.
Thanks, but none of those things apply. I am keeping my fingers crossed that there are no further issues in the coming year. One thing I will do is file a complaint with Medicare. This is how ratings are arrived at for the Advantage plans. The one other time I filed one, I was pleasantly surprised at how SS followed up on my complaint.
Gentleheart, you can still switch if any of these apply to you: you get "extra help" from SS, you are under 65 and disabled, if you are already on medicare due to disability and you turn 65, and other special circumstances which are outlined on the medicare.gov site.
Thanks, but none of those things apply.
Whether or not you fit the above criteria has absolutely no bearing on your right to disenroll from Advantage and go back to Original Medicare by February 14th.
All Advantage enrollees have the right to drop their MA plan during the annual Medicare Advantage Plan Disenrollment Period. This year that period ends February 14.
Again, per Medicare.gov:
Quote:
Medicare Advantage Disenrollment Period.
If you're in a Medicare Advantage Plan, you can leave your plan and switch to Original Medicare.
If you switch to Original Medicare during this period, you'll have until February 14 to also join a Medicare Prescription Drug Plan to add drug coverage. Your coverage will begin the first day of the month after the plan gets your enrollment form.
One thing I will do is file a complaint with Medicare. This is how ratings are arrived at for the Advantage plans. The one other time I filed one, I was pleasantly surprised at how SS followed up on my complaint.
Those CMS ratings mean very little when the rubber meets the road. You're sick, they won't approve in a timely manner and/or pay for a Medicare authorized treatment. By the time you fight your way through the mess, it may be too late.
No matter CMS acknowledged your complaint. A complaint doesn't do much good when you're in the middle of a crisis. And, why, in heaven's name, should any MA enrollee have to resort to complaints to get these companies to deliver Medicare benefits?
CMS admits it has problems:
Quote:
CMS has its own difficulties
Medicare regulations state that CMS can inspect “or otherwise evaluate the quality, appropriateness and timeliness of services” offered by Medicare Advantage plans.
But the agency has reported its own difficulties keeping tabs on the fast-growing program.
In a little noticed proposal in March, CMS officials said they were “constrained in the number of program audits we can conduct each year, due to limited resources.”
The agency is only able to audit about 30 Medicare Advantage companies a year — about one in 10 — of the 300 operating.
CMS proposed that health plans conduct and pay for self-audits with the goal that each organization would be looked over at least every three years. But in May CMS backed off in the face of industry protests. [The tail is clearly wagging the dog.]
“Ensuring that Medicare beneficiaries receive high quality care and timely services while enrolled in a Medicare Advantage plan is a top priority for CMS,” an agency spokesman wrote in an email. He said the agency “may finalize this proposal at a future date.”
Interestingly, Humana is no longer listed on the Medicare.gov website as offering MA's in Minnesota - although the Humana website itself is still pushing the product
You did the right thing. What are your premiums? As I recall, premiums in MA are community-rated.
I took Blue cross "Core" medigap supplemental. It's $95 per month.
I took United American Essential prescription plan. It's 23.60 per month.
You are correct my state is community rated.
In MA on your supplemental plan you get a discount the first three years you are on a Medicare supplemental plan. 1st year 15%, second year 10%, 3rd year 5%.
With Blue cross, if I do direct withdraw from my checking account I get a free gym membership.
Also I'm covered outside the USA in case I'm traveling.
I had Coventry which gave me a runaround about getting an epidural since last summer (I never got it). Twice before, I called my Family Dr. and she ordered the epidural, which lasts me 1-2 years. With Coventry, I had to get a consult with a Neurologist first, who ordered an MRI that Coventry wouldn't approve. They also dropped Nexium as a formulary drug. They also wanted me to pay a monthly premium, which I wouldn't mind doing if they weren't so awful.
My husband is shopping for the first time for a Medicare Advantage plan, so I am not sure which one he will choose, but I'll be interested is seeing what kind of experience he has with it.
I have regular medicare with J gap coverage (J no longer available). When my doctor suggested I have a epidural, Medicare had no problem with it. It was me who did, and chickened out just prior to procedure.
It's not only the less hassle issue with government Medicare, it's also that you can go to most any doctor you want both in your area and in any state. You wouldn't have had the problems you did with the physical therapist. You could have gone to any physical therapist you wanted to.
So unless money is that tight, or you can belong to a group like Kaiser, you would be so much happier I think with regular Medicare. Sounds like your area might not be the ideal area for the Advantage plan.
I took Blue cross "Core" medigap supplemental. It's $95 per month.
I took United American Essential prescription plan. It's 23.60 per month.
You are correct my state is community rated.
In MA on your supplemental plan you get a discount the first three years you are on a Medicare supplemental plan. 1st year 15%, second year 10%, 3rd year 5%.
With Blue cross, if I do direct withdraw from my checking account I get a free gym membership.
Also I'm covered outside the USA in case I'm traveling.
Yes, the F plans cover foreign travel - around here up to $50k, although I don't see a $$ limit in your plan description (I downloaded off website). The gym membership is a nice perk. It appears you do have exposure on the Part A deductible should you be faced with multiple hospitalizations in multiple benefit periods in a year. While you're young and healthy, it's not a big concern.
More importantly, your Part B copays are covered. You'll probably get some part of your premium back each year in copays alone. Your $95 (actually $80 this year) is well spent. My hd-F premium is $74 (plus I get a few add'l bucks back b/c I pay for it on a cashback Visa), but it pays for nothing (except preventive) until I reach the $2,180 deductible. I would definitely spring for the $95 ($80) if that plan was available here.
Great thing about Massachusetts, too, is you can always switch to the Bronze plan if it appears more cost-effective should a serious health issue develop - because - you're in a guaranteed issue state. Hopefully, you'll be in great health for the duration and won't need to do that.
Thanks for that update. It's always interesting to compare the states and nuances of the plans which can differ, in some cases substantially, state-by-state.
I have regular medicare with J gap coverage (J no longer available). When my doctor suggested I have a epidural, Medicare had no problem with it. It was me who did, and chickened out just prior to procedure.
It's not only the less hassle issue with government Medicare, it's also that you can go to most any doctor you want both in your area and in any state. You wouldn't have had the problems you did with the physical therapist. You could have gone to any physical therapist you wanted to.
So unless money is that tight, or you can belong to a group like Kaiser, you would be so much happier I think with regular Medicare. Sounds like your area might not be the ideal area for the Advantage plan.
Unfortunately when I tried this with regular Medicare found out that there were very few doctors that will accept 'new' medicare patients ... even though the Medicare website listing for doctors still included that they do accept Medicare patients. I got tired of looking after a few hours and just gave up.
Unfortunately when I tried this with regular Medicare found out that there were very few doctors that will accept 'new' medicare patients ... even though the Medicare website listing for doctors still included that they do accept Medicare patients. I got tired of looking after a few hours and just gave up.
Acceptance of new Medicare patients is very much dependent on area. Around here, it is never a problem.
Website info on providers is often erroneous or incomplete - both from the insurance companies and medicare.gov. As an example, there are insurers offering Medigaps in WI not listed on the govt. website which I located through the WI Insurance Commissioner website. Quite a surprise to me.
What you need to do is locate the physicians (either through the Medical Society or hospitals) in your area you want to see, and call them. Years back we could use the yellow pages.
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