Medicare or Medicare Advantage: Will Doctors take new Patients? (costs, vs)

[john3232]

Regarding copays and Medicare Advantage. The below doesn't look too bad:

In 2023, the out-of-pocket limit for Medicare Advantage plans may not exceed $8,300 for in-network services and $12,450 for in-network and out-of-network services combined.
https://www.kff.org/medicare/issue-b...ces%20combined.

However, your provider needs to be in your "network" (HMO or PPO)

O.k.

Next you may need the medical procedure to be "pre-certified", meaning in some instances if your doctor orders say a MRI or a CAT scan or a hip or knee replacement the insurance company will have to give their o.k. If they say no.

You pay yourself.

[pathrunner]

Let's put it this way: If Medicare Advantage had denied my hospitalization and lung surgery back in 2011, I'd be dead. Think about that. Anything can happen at any time. Accidents, illnesses, chronic conditions, etc.

Also, if Medicare Advantage had decided that I didn't need a hip replacement (also in 2011) I'd be in a wheelchair. Kaiser Permanente in Oregon had previously denied my hip replacement for ridiculous reasons (you're too young - I was bone on bone with excruciating pain) and therefore denied it. all it takes is one crucial denial and you're toast.

And again, why would someone pay $7K to $14K out of pocket if they didn't have to? I pay $2748 per year (via monthly payments) and see whoever I want whenever I want - including major critical care specialists - without a referral*. I've never been denied ANY procedure or treatment at all.

*Only twice in 7 years have I needed a referral and both were for a critical care specialist.

[john3232]

Originally Posted by pathrunner

Let's put it this way: If Medicare Advantage had denied my hospitalization and lung surgery back in 2011, I'd be dead. Think about that. Anything can happen at any time. Accidents, illnesses, chronic conditions, etc.

Also, if Medicare Advantage had decided that I didn't need a hip replacement (also in 2011) I'd be in a wheelchair. Kaiser Permanente in Oregon had previously denied my hip replacement for ridiculous reasons (you're too young - I was bone on bone with excruciating pain) and therefore denied it. all it takes is one crucial denial and you're toast.

And again, why would someone pay $7K to $14K out of pocket if they didn't have to? I pay $2748 per year (via monthly payments) and see whoever I want whenever I want - including major critical care specialists - without a referral*. I've never been denied ANY procedure or treatment at all.

*Only twice in 7 years have I needed a referral and both were for a critical care specialist.

My guess is it's the very low monthly premium. They can't afford to pay more, or they can afford to pay more but don't understand the limitations of Medicare Advantage.

As was mentioned earlier in this thread they likely ask friends or family members who tell them their Advantage plan is great. Which I'm sure it is... until you're denied coverage.

[pathrunner]

I think the important thing to remember is that Medicare Advantage is a gamble.

[mborner]

Originally Posted by pathrunner

I think the important thing to remember is that Medicare Advantage is a gamble.

I prefer to think of it as a scam. Okay, fine line, I know, but the horror stories, oh my!

The commercials look fantastic. Great coverage, free!! The commercials don't flat out lie but I think there is some dishonesty in not telling the whole truth. There's so much they don't tell you. The main one being "actual" out of pocket costs. Others, like the benefits you see touted in the ads are available to very few beneficiaries, in a very limited select area. They don't lie, they just don't tell you the whole truth. Look, I know it sounds like I think Advantage plans are the Devil. The truth is, they could be good for some people, namingly healthy, broke people. For me, personally, I've worked hard my entire life and saved like a madman toward my financial future. I'm willing to pay dearly on healthcare premiums so that all of my hard work doesn't get wiped out on one or two medical necessities that my insurance wouldn't pay for. I want coverage, plain and simple. Original Medicare with a supplement. There really is no greater coverage than that. The Government did something right, for once.

[MN-Born-n-Raised]

Originally Posted by easy62

I became disabled when i 55 years old, i could not get a supplement Medicare plan. And when i turned 65, now I’m 68 all i can get now is an advantage plan. Can’t get a supplement plan because of my disability. So I’ve been with Aetna PPO advantage plan and have no issues with them.

Sorry for the paywall. But the title says it all: https://www.nytimes.com/2022/10/08/u...legations.html ‘The Cash Monster Was Insatiable’: How Insurers Exploited Medicare for Billions

Here's the math. If Atna got mice-nut premiums from you and defrauded the government, well, then they made money. So they covered you while getting close to no premiums. In 2016, "..diagnostic codes were also at the center of a lawsuit against Cigna, with the insurer agreeing to pay $172 million to resolve allegations that it submitting false Medicare Advantage diagnostic codes." https://www.benefitspro.com/2023/10/...20231014072447

Next, in 2022, "OIG audit targets Aetna’s Medicare Advantage plans as the government cracks down on fraud" https://www.healthcaredive.com/news/...ks-dow/604515/

This is just the tip of the iceberg. I bet the game is to charge cheap rates so that they can get customers. Later, to overcharge the bloated government for extras. Poof! They are suddenly profitable. Let's see how quickly they payout now with those cheap rate plans when they cannot rip off the government as easily.

It took me a minute to figure out how they could be charging so little. Econonomics are at play here. The writing is on the wall.

[pathrunner]

Originally Posted by mborner

I prefer to think of it as a scam. Okay, fine line, I know, but the horror stories, oh my!

The commercials look fantastic. Great coverage, free!! The commercials don't flat out lie but I think there is some dishonesty in not telling the whole truth. There's so much they don't tell you. The main one being "actual" out of pocket costs. Others, like the benefits you see touted in the ads are available to very few beneficiaries, in a very limited select area. They don't lie, they just don't tell you the whole truth. Look, I know it sounds like I think Advantage plans are the Devil. The truth is, they could be good for some people, namingly healthy, broke people. For me, personally, I've worked hard my entire life and saved like a madman toward my financial future. I'm willing to pay dearly on healthcare premiums so that all of my hard work doesn't get wiped out on one or two medical necessities that my insurance wouldn't pay for. I want coverage, plain and simple. Original Medicare with a supplement. There really is no greater coverage than that. The Government did something right, for once.

Oh it's definitely a scam. I've stated that many times on here in other threads.

The rest of your points are spot on. Unbelievably, many people on here will debate that and I really don't understand it, because like you said you worked long and hard to save and pay for things.

Why would anyone want their savings and other resources wiped out because they wanted "free" Medicare?

[john3232]

Originally Posted by MN-Born-n-Raised

Sorry for the paywall. But the title says it all: https://www.nytimes.com/2022/10/08/u...legations.html ‘The Cash Monster Was Insatiable’: How Insurers Exploited Medicare for Billions

Here's the math. If Atna got mice-nut premiums from you and defrauded the government, well, then they made money. So they covered you while getting close to no premiums. In 2016, "..diagnostic codes were also at the center of a lawsuit against Cigna, with the insurer agreeing to pay $172 million to resolve allegations that it submitting false Medicare Advantage diagnostic codes." https://www.benefitspro.com/2023/10/...20231014072447

Next, in 2022, "OIG audit targets Aetna’s Medicare Advantage plans as the government cracks down on fraud" https://www.healthcaredive.com/news/...ks-dow/604515/

This is just the tip of the iceberg. I bet the game is to charge cheap rates so that they can get customers. Later, to over charge the bloated government for extras. Poof! They are suddenly profitable. Let's see how quickly they payout now with those cheap rate plans when they cannot rip off the government as easily.

It took me a minute to figure out how they could be charging so little. Econonomics are at play here. The writing is on the wall.

And I'll bet you're correct.

O V E R P A I D B Y B I L L I O N S

By our estimate, and based on 2022 spending, Medicare Advantage overcharges taxpayers by a minimum of 22% or $88 billion per year, and potentially by up to 35% or $140 billion. By comparison, Part B premiums in 2022 totaled approximately $131 billion, and overall federal spending on Part D drug benefits cost approximately $126 billion. Either of these— or other crucial aspects of Medicare and Medicaid—could be funded entirely by eliminating overcharges in the Medicare Advantage program.

Medicare Advantage, also known as MA or Medicare Part C, is a privately administered insurance program that uses a capitated payment structure, as opposed to the fee-for-service (FFS) structure of Traditional Medicare or TM. Instead of paying directly for the health care of beneficiaries, the federal government gives a lump sum of money to a third party (generally a commercial insurer) to “manage” patient care.

Although private insurers have been involved in one form or another since the early days of Medicare, it is only since the establishment of Medicare Advantage in the Medicare Modernization Act of 2003 that such participation has grown significantly. Since 2007, the share of beneficiaries enrolled in MA has nearly tripled, and the program now manages the care of more than half of all eligible beneficiaries...
https://pnhp.org/system/assets/uploa...port_Final.pdf

Originally Posted by MN-Born-n-Raised

Let's see how quickly they payout now with those cheap rate plans when they cannot rip off the government as easily.

Exactly

[L00k4ward]

Originally Posted by john3232

…

It's my understanding you can change Plan D (drug plan) without problems but only this plan. However, you still need to join when you turn 65. If you decide to join at a later date you've be penalized. What penalty? Not sure but I was advised to join when I enrolled in Medicare.

…

Not that it matters to you anymore as you have already purchased plan D but it might help others to learn how they calculate penalty if one doesn’t join on time.

The size of the penalty will be changing every year as it is based on a national average of premiums calculated annually

Here is detailed explanation

https://www.medicare.gov/drug-covera...0Part%20D%20or

After reading you will be glad you don’t have to pay it.

[john3232]

Originally Posted by mborner

I prefer to think of it as a scam. Okay, fine line, I know, but the horror stories, oh my!

The commercials look fantastic. Great coverage, free!! The commercials don't flat out lie but I think there is some dishonesty in not telling the whole truth. There's so much they don't tell you. The main one being "actual" out of pocket costs. Others, like the benefits you see touted in the ads are available to very few beneficiaries, in a very limited select area. They don't lie, they just don't tell you the whole truth. Look, I know it sounds like I think Advantage plans are the Devil. The truth is, they could be good for some people, namingly healthy, broke people. For me, personally, I've worked hard my entire life and saved like a madman toward my financial future. I'm willing to pay dearly on healthcare premiums so that all of my hard work doesn't get wiped out on one or two medical necessities that my insurance wouldn't pay for. I want coverage, plain and simple. Original Medicare with a supplement. There really is no greater coverage than that. The Government did something right, for once.

Yes, and the commercials with Joe Namath are great. It's not surprising Medicare Advantage has 50% of the market. Get great health coverage and extra benefits all for the low price of $12 a month or better yet...free!

Medicare Advantage - the name itself is very deceptive and shouldn't be allowed but my guess is political donations will ensure the name stays.