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I have a medicare advantage PPO plan. I can go out of my network if I choose to and I can pay up to the policy limits if I need to. And its my plan, in a serious situation I would do so.
And not to criticize but you do have resources that others who might choose an Advantage plan don’t
So those options are not ones they have/can use to provide services the Advantage plan does not
Some Advantage plans work for those who need them
Some who are happy might not be with a change in their medical circumstances
And not to criticize but you do have resources that others who might choose an Advantage plan don’t
So those options are not ones they have/can use to provide services the Advantage plan does not
Some Advantage plans work for those who need them
Some who are happy might not be with a change in their medical circumstances
True that. I use a concierge MD who accepts my medicare advantage PPO plan. I pay a monthly fee to MDVIP that is same or less than a supplement plan and provides excellent immediate referrals. Just saying that there are options within the advantage plans.
My wife had cataract surgery this morning and she has regular Medicare and a plan N supplement. So when she checked in nothing needed to be paid up front because everything would be covered.
While I was waiting for her, another very elderly lady came in for cataract surgery. When she checked in, she was told that with her insurance, she had a copay of $1100 that would need to be paid up front. She said that she didn't have that much money, so they worked it out to pay 1/2 down and the rest in payments.
Makes me really appreciate the Medicare insurance we have.
maybe she was having different lenses put in than your wife. medicare does not pay for all lenses.
maybe she was having different lenses put in than your wife. medicare does not pay for all lenses.
Question—what lenses are not covered?
My ophthalmologist told me that my cataracts were not serious enough infringement on my vision to get Medicare to cover the surgery—but if there was an “impingement factor” he could ask for special permission—meaning if the cataracts caused an infringement on my normal quality of life—
They do—because I have bad night halos==but I only have true vision in my right eye because of amblyopia and I don’t want to risk losing sight by botched cataract surgery—-
(I know 3 people who lose vision in one eye when they had cataract surgery and I am more cautious than most I guess)…
Or maybe her plan had a deductible she had not met
Low monthly premium is not the only reason to choose a plan
No referrals necessary doesn't matter if treatments aren't approved. Again, note the story upthread - i.e., docs needed approval to remove cancerous pituitary gland - Advantage plan would only allow removal of one-half the gland. How stupid and dangerous is that? A second surgery will almost certainly eventually be necessary to remove the other half. Meanwhile, almost certain likelihood of metastasizing to who knows where in her body at a later date. Friend of mine is currently undergoing radiation treatment on her lungs, ribcage, and pelvis because of a cancer she had 30 years ago on her thyroid, so the doctors have told her. These cells float around in the body and eventually cause issues elsewhere should immune system weaken. Leave half a gland, which no doubt has already been infected, to fester? Geez.
Rest assured, that plan will act as gatekeeper. Most plans require immediate notification when you are hospitalized. Locate that plan's Explanation of Benefits and Coverage. It will state when approvals on services are necessary - which is the most critical issue. Query providers in the plan's network on their experience with preapprovals. Yes, one may be able to see in and out-of-network providers without referrals, but preapprovals for lengthy and expensive services is another matter entirely.
All Advantage plans eventually become gatekeepers when large sums of money are involved. Some are worse than others. A NJ nurse reported constant surveillance when her mother was in a nursing home for rehab. Advantage insisted mother be discharged weeks before she was ready. Nurse moved mother to another state, bought a Medigap, and hasn't had issues since and has saved money because neverending Advantage copays for mom's situation exceeded $5k.
Yes, all have gatekeepers. I don't know if I would call it "constant surveillance", what they do is require updates, usually once a week but sometimes every few days. We (therapy) fill out a form saying how much help they need for toileting, dressing, how far they are walking, etc. There are certain benchmarks they will use to cut people, either if they aren't making progress or if they made "too much" progress, such as walking 100 feet. We will sometimes hold back on progress reporting if the person needs to continue rehab (for instance many homes at the shore are raised and have 20-some steps to get to the front door. So the fact that the person can walk 100 feet isn't enough to make them independent. But lack of progress gets a cut too, even though elderly often make much slower progress. I will say the cuts are coming after shorter stays now even vs just a few years ago.
My mother was living alone and independent when she spent a week in the hospital for cellulitis of her leg. After only a week in rehab, her Advantage plan (Blue Cross/Blue Shield of Pennsylvania) tried to cut her, saying "we think it is unlikely your mother will be able to walk again". Are you kidding me???? Why would a leg infection, now healed, render her unable to ever walk again?? We appealed and she was allowed to stay, but she had over $5000 in co-pays after only a few weeks.
I switched her to traditional with supplemental as soon as I was able.
Yes, all have gatekeepers. I don't know if I would call it "constant surveillance", what they do is require updates, usually once a week but sometimes every few days. We (therapy) fill out a form saying how much help they need for toileting, dressing, how far they are walking, etc. There are certain benchmarks they will use to cut people, either if they aren't making progress or if they made "too much" progress, such as walking 100 feet. We will sometimes hold back on progress reporting if the person needs to continue rehab (for instance many homes at the shore are raised and have 20-some steps to get to the front door. So the fact that the person can walk 100 feet isn't enough to make them independent. But lack of progress gets a cut too, even though elderly often make much slower progress. I will say the cuts are coming after shorter stays now even vs just a few years ago.
My mother was living alone and independent when she spent a week in the hospital for cellulitis of her leg. After only a week in rehab, her Advantage plan (Blue Cross/Blue Shield of Pennsylvania) tried to cut her, saying "we think it is unlikely your mother will be able to walk again". Are you kidding me???? Why would a leg infection, now healed, render her unable to ever walk again?? We appealed and she was allowed to stay, but she had over $5000 in co-pays after only a few weeks.
I switched her to traditional with supplemental as soon as I was able.
Serious question as I am not yet on Medicare. I have until June to decide between employer group Medicare advantage or original Medicare.
Doesn’t Medicare also monitor and determine what services people are eligible to? Doesn’t Medicare also try to get people out of facilities asap- or deny their coverage altogether?
Serious question as I am not yet on Medicare. I have until June to decide between employer group Medicare advantage or original Medicare.
Doesn’t Medicare also monitor and determine what services people are eligible to? Doesn’t Medicare also try to get people out of facilities asap- or deny their coverage altogether?
No. There are no gatekeepers with traditional Medicare. Technically people have to show progress to continue therapy, but no one looks at it unless the chart is audited, and that would be many months or even years later. If an audit found the person should have been cut after 2 months, it would be the nursing home on the hook to pay back the money, never the patient. It rarely happens, the vast majority of audits are for long term care patients on Medicare Part B, who were dependent for care yet getting therapy for months anyway.
With traditional Medicare, as long as therapy feels you are making progress but still not at your prior level of function, you can get up to 100 days of therapy (with Medicare part A paying 100% of the first 20 days, then 80% of the rest, and the supplemental policy picking up the other 20%. I have never had an Advantage patient get 100 days, even after traumatic injuries such as major stroke or spinal cord injury.
Bottom line summary, with traditional Medicare, your direct care team decides how long you get therapy. With Advantage plans, a 3rd party gatekeeper decides.
No. There are no gatekeepers with traditional Medicare. Technically people have to show progress to continue therapy, but no one looks at it unless the chart is audited, and that would be many months or even years later. If an audit found the person should have been cut after 2 months, it would be the nursing home on the hook to pay back the money, never the patient. It rarely happens, the vast majority of audits are for long term care patients on Medicare Part B, who were dependent for care yet getting therapy for months anyway.
With traditional Medicare, as long as therapy feels you are making progress but still not at your prior level of function, you can get up to 100 days of therapy (with Medicare part A paying 100% of the first 20 days, then 80% of the rest, and the supplemental policy picking up the other 20%. I have never had an Advantage patient get 100 days, even after traumatic injuries such as major stroke or spinal cord injury.
Bottom line summary, with traditional Medicare, your direct care team decides how long you get therapy. With Advantage plans, a 3rd party gatekeeper decides.
medicare is the gatekeeper. they pay if they want to, they dont pay if they dont want to. been there on the crappy side of medicare. some people have great luck, some of us wish we had never signed up for it. its an ins co and it behaves like all ins cos.
medicare is the gatekeeper. they pay if they want to, they dont pay if they dont want to. been there on the crappy side of medicare. some people have great luck, some of us wish we had never signed up for it. its an ins co and it behaves like all ins cos.
I've been in rehab 25 years, never saw Medicare refuse to pay for patient's stay.
What about just going A,B,D and skip the Advantage plan? At the moment I don't go to the doctor often. If something serious comes up, though, which way is better? I only ask here because of the warning in the OP about Advantage plans.
I will try to research more myself, but just curious about your view.
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I have Medicare advantage with Kelsey ,it only serves TX .
They have their own doctors and medical facilities,so far I have no need to go outside their network.
I have seen some of their GP and specialists and find them to be competent .
But there is one prescription drug I use,it went from brand to generic ,and switch from one generic to another as it is cheaper,unfortunately it is not so good(it is from India).
So I order brand name off shore,it turns out to be the cheapest with free shipping.
You have to do your own research,if y ou live in a small town,your choices would be limited,also one does not know what illness we could have -cancer,heart,kidney,liver ,who know?
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