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I'll be turning 65 4/9 and I'm slowly starting my research into all the do's and don'ts, which providers to look for, but before you choose a plan, mostly likely it'll be an HMO, with limited choices, I'd like to know which providers I'll be stuck with.
I've been with Health Plan of NV, and have never had any reason to use them until a couple months ago, and, naively, I didn't realize there was only one Provider for Orthopedic Dr.'s: Nevada Orthopedic & Spine, which I had a negative experience with, and refuse to go back there. Aside from that, I plan to go car-less in my retirement years, and their 2 clinics are way, way out from where I live, hardly accessible by bus. There is a multi-Doctor, Orthopedic Clinic just walking distance from my house, and I'd like to find a plan whereas that clinic would be my provider, and providing they accept Medicare.
I would also like to know if there's any insurance plans that will reimburse you for seeking medical care outside the country. When I was with Blue Cross, years ago, I was able to go to Tijuana, get medical care there, pay for it with cash, and they'd reimburse me for it, showing the receipts.
Disgusted with the Orthopedic clinic, mentioned above, I'm going to the Angeles Hospital in Tijuana next week for a Baker's Cyst aspiration ($300) but Health Plan of NV will do no reimbursement for that, even though I'm saving them money!
So doing research, will these potential insurance carriers have a list of their providers? I have found, you can research these providers on Yelp, for the clinic, and Vitals.com for individual Dr.'s. I just want to make sure I pick the right one!
Your best bet is to choose your doctors and then call their billing people to see which plan they accept.
Provider lists from insurance companies - whether online or through customer service - can be unreliable. Often the insurance companies mail out contracts to providers, list them all on their provider lists - online and elsewhere, including their customer service rep lists - but don't bother to update those lists when the providers do NOT return the contracts. So, you can get wrong info from insurance company CS, as well.
It happens, a lot. You need to check BOTH ends.
Before committing to a Medicare Advantage HMO, you may want to consider this:
Which will give you flexibility to use any Medicare provider - anywhere. hd-F premiums are usually quite low, but you are responsible for the first $2,140 of the 20% Medicare doesn't pay.
Someone else may be able to address reimbursement for out-of-country services. There are plenty of Americans who have retired to Mexico. Not sure what they do.
Great idea! A life-saving idea, actually, to grill the billing people first off, given the unreliability of the lists provided by the insurance companies. Looking ahead, it will probably be orthopedic care I should concentrate on, and with this big orthopedic clinic, walking distance from my house, being able to go there? Perfect!
And there's Shepherd Eye Clinic, another walk from my house.
I will second that you cant go by the provider lists from the insurance company totally. I was just given incorrect information on my MA plan website and based most of my plan choice on that information. Getting information from the provider doesnt always work, either. You have to ask: 1) do they accept Medicare assignment? 2) are they IN-NETWORK with various MEDICARE plans 3) you have to specify that the plan is a Medicare plan because they may be in network with OTHER plans the insurance company sells, but not the Medicare plans.
Then go back to the Medicare plan(s) you are looking at and specifically ask about that provider or group over the phone. Dont go by any printed information or online information. Get the NAME and phone number of the person at the insurance company that tells you yes or no.
and, generally, only applies if you have a Medigap policy. There are participating providers who accept Medicare assignment, and there are nonparticipating providers who do not accept assignment but whose charges are allowed by Medicare. These nonparticipating providers are also allowed to charge an an excess/limiting charge of another 15%. Specialists are often nonparticipating providers. Medigaps will cover charges for both participating and nonparticipating providers.
If OP chooses a Medigap or is going out-of-network on an MA, the actual question to ask is "do you accept Medicare patients."
However, as I understand OP's post, he is initially looking at Medicare Advantage (HMO) plans,
Quote:
but before you choose a plan, mostly likely it'll be an HMO, with limited choices,
in which case assignment, participating and nonparticipating would be irrelevant, as OP would be limited to that plan's doctors.
The simplest thing - if you are considering an Advantage plan - as jzeig stated - is to ask which Medicare Advantage plans the doc accepts.
Medicare says on both pages above that "accepting assignment" is required for providers on regular Medicare, Supplement, and MA plans. It also says that you should ask the question of your providers. Also, my MA plan says to check EACH time you make a drs appt to make sure the doctor is still participating in-network with the particular plan you have.
That said, two of my providers office staff did not know what accepting assignment meant and never did answer the question.
Have only had Medicare for 20 days and it is a real pain in the neck!!! (whine, whine).
I'll be turning 65 4/9 and I'm slowly starting my research into all the do's and don'ts, which providers to look for, but before you choose a plan, mostly likely it'll be an HMO, with limited choices, I'd like to know which providers I'll be stuck with.
I've been with Health Plan of NV, and have never had any reason to use them until a couple months ago, and, naively, I didn't realize there was only one Provider for Orthopedic Dr.'s: Nevada Orthopedic & Spine, which I had a negative experience with, and refuse to go back there. Aside from that, I plan to go car-less in my retirement years, and their 2 clinics are way, way out from where I live, hardly accessible by bus. There is a multi-Doctor, Orthopedic Clinic just walking distance from my house, and I'd like to find a plan whereas that clinic would be my provider, and providing they accept Medicare.
I would also like to know if there's any insurance plans that will reimburse you for seeking medical care outside the country. When I was with Blue Cross, years ago, I was able to go to Tijuana, get medical care there, pay for it with cash, and they'd reimburse me for it, showing the receipts.
Disgusted with the Orthopedic clinic, mentioned above, I'm going to the Angeles Hospital in Tijuana next week for a Baker's Cyst aspiration ($300) but Health Plan of NV will do no reimbursement for that, even though I'm saving them money!
So doing research, will these potential insurance carriers have a list of their providers? I have found, you can research these providers on Yelp, for the clinic, and Vitals.com for individual Dr.'s. I just want to make sure I pick the right one!
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).
Medicare says on both pages above that "accepting assignment" is required for providers on regular Medicare, Supplement, and MA plans.
No, it doesn't say that accepting assignment is required - because it isn't. Finding a provider who accepts assignment is a means of keeping costs down:
Quote:
Keeping costs down with assignment
Assignment means that your doctor, provider, or supplier agrees (or is required by law) to accept the Medicare-approved amount as full payment for covered services.
- but accepting assignment it is not required in order to be a Medicare provider.
All that is required is that the provider either be
(1) participating (accepts assignment), or
(2) nonparticipating (does not accept assignment, can impose 15% higher limiting charge).
Relative to an MA, whether or not accepting assignment is required would be determined by the MA plan and what it requires of its network doctors, not Medicare.
Medigaps do pay the 20% Medicare copay for nonparticipating (do not accept assignment) providers - plus these Medigaps (F&G) also pay 15% limiting charge for the nonparticipating providers.
An example of a nonparticipating provider which does not accept assignment is Mayo Clinic.
Mayo will accept Medicare patients and provide services under Medicare - BUT - Mayo will NOT accept assignment because Mayo wants the ability to charge the additional 15% limiting charges.
This is how Mayo - a nonparticipating provider which does NOT accept assignment - handles the bills:
Quote:
Originally Posted by Robyn55
That isn't entirely correct. For example - the Mayo Clinic here (and an increasing number of providers all over the country) will see traditional Medicare patients. But it does not "participate" in Medicare or accept Medicare assignment.
It is therefore entitled to charge the patient 15% more than Medicare allowances. This extra 15% is called a Medicare Part B Excess Charge - and - in 2012 - it is only covered by Plans F and G (it was also covered by the since-discontinued plan J).
The way things work from a paperwork POV at Mayo is Mayo sends notice of your bills to Medicare and your Medigap carrier.
Mayo sends your bill to you - you have to pay your bill directly to Mayo -
and Medicare/your Medigap carrier send you reimbursement checks.
We haven't had any problems with Medicare and UHC/AARP Medigap with Mayo.
Medigaps are particularly useful if you routinely see providers who accept Medicare patients who do not accept assignment (nonparticipating), and are charging the extra 15%.
******
This is what the Medicare site says on participating providers (accepts assignment ) and nonparticipating (does not accept assignment) - both of which Medicare recognizes as providers:
Quote:
Make sure your doctor, provider, or supplier accepts assignment
Most doctors, providers, and suppliers accept assignment, but you should always check to make sure. Participating providers have signed an agreement to accept assignment for all Medicare-covered services.
Here's what happens if your doctor, provider, or supplier accepts assignment:
They agree to charge you only the Medicare deductible and coinsurance amount and usually wait for Medicare to pay its share before asking you to pay your share.
They have to submit your claim directly to Medicare and can't charge you for submitting the claim.
If your doctor, provider, or supplier doesn't accept assignment
Non-participating providers haven't signed an agreement to accept assignment for all Medicare-covered services, but they can still choose to accept assignment for individual services. These providers are called "non-participating." [the operative word here is CHOOSE - if provider does NOT CHOOSE - then provider can still provide services under Medicare but is allowed to charge the limiting charge (see below)]
Here's what happens if your doctor, provider, or supplier doesn't accept assignment:
You might have to pay the entire charge at the time of service. Your doctor, provider, or supplier is supposed to submit a claim to Medicare for any Medicare-covered services they provide to you.
They can't charge you for submitting a claim. If they don't submit the Medicare claim once you ask them to, call 1‑800‑MEDICARE.
In some cases, you might have to submit your own claim to Medicare usingForm CMS-1490S to get paid back.
They can charge you more than the Medicare-approved amount, but there's a limit called "the limiting charge." The provider can only charge you up to 15% over the amount that non-participating providers are paid. Non-participating providers are paid 95% of the fee schedule amount.
The limiting charge applies only to certain Medicare-covered services and doesn't apply to some supplies and durable medical equipment.
Apologies for beating this horse to death - but there has been and still remains a lot of confusion on this issue.
Asking whether provider accepts assignment only gets you a partial answer - particularly if your provider is Mayo or another nonparticipating provider.
What you are charged is totally dependent on whether that provider is participating or nonparticipating.
Charges from both participating and nonparticipating providers are reimburseable through Medicare - but the nonparticipating provider costs that patient, or its Medigap, the additional 15% limiting charge.
Last edited by Ariadne22; 06-20-2014 at 07:22 PM..
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).
This pretty much says it all. Either a full Medigap F/G or a high-deductible Medigap F, plus Part D, would be a better alternative to the gatekeeping and other restrictions of an MA. MAs are fine if one is healthy, not so good if dealing with chronic issues..
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Last edited by Ariadne22; 06-20-2014 at 06:27 PM..
The vast majority of Medicare Advantage plans are state-specific, you can't even use them outside your state let alone the country.
Back in the 1980's, I worked for 10 years for a big computer company in their Accounting Department, and our mission: Cost Containment!
This will always baffle me about insurance companies. Is the revenue stream so great the need not consider cost containment? Increasing profits?
14 years ago, I had a pimple on my face, turned out to be benign cancer. Dermatologist sliced it off, then told me I was to undergo a 7-hour procedure on the table, purpose to see that they "got it all", with cosmetic purposes as well. Procedure approved by BCBS! Me? Lay on a table for 7 hours?
At the time, I was in need of some dental work, in Tijuana, and while there, I decided to see a Dermatologist, we're looking at $30-35 to see a specialist. He put me under the light and told me it was gone! He guessed that this Dermatologist, in Las Vegas, was just trying to bilk BCBS out of 7 hours of unnecessary billing. 14 years later, no re-occurance!
So I saved BCBS a nice chunk of $$, and where's my reward?
Tomorrow, I'll be down there for an aspiration, out of my own $$, and will Health Plan of Nevada reimburse me a nickel of it? Heavens no! And, again, saving them a big chunk of $$!
I would think that these insurance companies would encourage you to even go to a neighboring state if it would save them some money, increase their profits, but no! Or reward you for finding someone to do some medical procedure, outside their provider system!
This all seems so screwy to me I just can't wrap my head around this! What am I missing here?
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