High Denial Rates By Medicare Advantage Plans Harming Rural Hospitals and Patients (benefits, deductible)

[TheShadow]

The woman in the article from the OP didn't know she couldn't use her old doctor. That tells me she didn't read up on the coverage she was signing up for. Just like with any other purchase "Buyer Beware" is the watch word. All plans have booklets that detail what is covered and how to find out who is "in network" and who is "out of network" and if there is coverage or a different co-pay for "out of network" doctors or facilities. It's important to research your coverage prior to accepting a plan. These groups that call you and try to sign you up for a plan are getting some kind of a kick-back and aren't in it for the customer's best interest.

Personally, I don't really get a choice because it's being covered by my former employer, so there's no cost to me for the plan, other than what is deducted by Medicare from my SS. If I don't like my plan, I am free to select traditional Medicare and pay for supplemental coverage on my own dime, just like everyone else. After checking my coverage carefully under my "free" advantage plan, the coverage is just as good as my DH's supplemental plan. So I'll be taking the advantage plan. They actually call my plan an advantage plan, but it has all the same features as my current PPO plan, and it's run by the same mega-insurer, so I'm sure I'll be fine.

[TheShadow]

Originally Posted by moguldreamer

Half the population has an IQ below the median.

Can't rep you again right now, but this is one of my favorite sayings. The scariest thing is that the median is not particularly bright.

[TheShadow]

Originally Posted by ged_782

Unlike individual Advantage plans that are available to just anybody, with plan summaries available online, employer-sponsored Medicare Advantage plans are almost always customized group plans only available to those who meet the employer's eligibility rules to participate. Therefore, those plan benefit summaries may not be made available until such time as the retiree becomes eligible to enroll, and then the employer may give the retiree a restricted time limit (like maybe 30 days), to either enroll, or pass and forfeit future participation.

Given that employer or union Advantage plans are usually better than the individual Advantage plans that would be available to someone (plus the employer may also provide a premium subsidy), it may be worth enrolling and and giving it a trial run, then bail within the 12-month "Trial Right" period, and get original Medicare + Supplement + Part D, if the employer plan isn't working the way you hoped.

This is important to remember. If my employer-paid MA PPO plan is not at least as good as my current pre-Medicare non-advantage plan (a PPO), in practice, I will just pay for my own supplemental plan within that 12 month period. It's a real "gotcha" that they can require underwriting to those who try to switch to traditional plan with supplemental after that first 12 months.

[moguldreamer]

Originally Posted by TheShadow

Can't rep you again right now, but this is one of my favorite sayings. The scariest thing is that the median is not particularly bright.

Every now and then I have to visit my state's DMV (department of motor vehicles) in person. It is TRULY eye-opening.

[twinkletwinkle22]

I would never disparage anyone who has an Advantage Plan for several reasons:

1. For some people an Advantage plan is what they can afford

2. Choosing a supplement to Medicare is crazy hard to understand. Both I and my spouse have college and master's level education and it was intense trying to understand this stuff. Two of us dove in did months of research, got bamboozled on the first try (most 1st timers wouldn't know that happens) until we finally got it done. (Thanks Ariadne here on city-data).

3. Everyone is doing the best they can. When we know better we (try and) do better

4. For some people this may be the first time they've ever had (or taken care of this themselves) their own health insurance. This is true for some in my family, a lifetime of no health insurance until Medicare

[Mike from back east]

Originally Posted by Sand&Salt

Everything I hear about Medicare is appalling. So glad I don't have to get involved in it.

My sister in a well-to-do area of SoCal just got dropped by their Medicare HMO with no reason. Now they are panic-shopping for some other provider. Sheesh.

I had an HMO before I retired, Kaiser, and hated it. Totally micro-managed everything to the point of not being worth much to us as patients. Waited weeks or months for anything routine. Wife had to wait months to get on a waiting list just to make an appointment for a pap smear even more months out. I get anyone's unhappiness with HMOs.


I've been on Medicare for ten years, both Part A and Part B. I love it.

I also kept my BC/BS when I retired. Costs me $326/month and covers most drugs with a co-pay of $3 or $15 and also anything Medicare Part B may not cover. I carry Vision and Dental insurance too. My wife got invisilne teeth straightening, cost $5000 but we only paid $1500 and insurance got the rest. I get almost zero medical bills.

I pick doctors out of the phone book, no such thing as out of network or having to see an HMO gatekeeper.

I will never do any HMO again, nor use any commercial insurance medicare supplemental type deal, the for-profit firms make their money by NOT providing service.

Everyone 65 and up gets Medicare Part A automatically, at no cost, all they have to do is sign up for it on the Social Security website. Most people have paid into Medicare all their working lives. It's our money and we've every right to it. Medicare Part A covers hospital costs, not doctors. I opted to buy Medicare Part B which does cover the cost that doctors bill you for. We each pay $494.70 every three months and it's a bargain. I had robotic hernia surgery in May 2023 and paid ZERO for any of it. The doctor billed thousands of dollars for his service, Medicare Part B paid him. I paid zero out of pocket for pre/post visits, etc. I turned 65 in 2013; in 2014 I had a stent placed in my right coronary artery, never paid a cent despite billings over $25,000.

Back to rural hospitals. There are too few patients in rural areas to keep doctors and hospitals busy enough to make money, whether from Medicare or regular health insurance payments. Hospitals are usually owned by for-profit firms and if they can't make money they shut them down and walk away. Same for doctors, they need a steady stream of patients to make a living and pay off student loans; if business is slow they won't move to rural areas to start with, they stay in or move to metro areas where the money is. People want to blame Medicare when rural hospitals close but the payouts to hospitals and doctors are the same in rural areas or major metro areas, the culprit is the lack of reaching a critical mass of business to support a for-profit health care industry. IOW, we have met the enemy and it's toxic capitalism.

[Maddie104]

Originally Posted by twinkletwinkle22

I would never disparage anyone who has an Advantage Plan for several reasons:

1. For some people an Advantage plan is what they can afford

2. Choosing a supplement to Medicare is crazy hard to understand. Both I and my spouse have college and master's level education and it was intense trying to understand this stuff. Two of us dove in did months of research, got bamboozled on the first try (most 1st timers wouldn't know that happens) until we finally got it done. (Thanks Ariadne here on city-data).

3. Everyone is doing the best they can. When we know better we (try and) do better

4. For some people this may be the first time they've ever had (or taken care of this themselves) their own health insurance. This is true for some in my family, a lifetime of no health insurance until Medicare

Agree with this. Add to that these plans are being sold by brokers who get a nice commission for MA enrollments. I am of the opinion, no one can serve two masters. Who knows what this woman was told and some people are too trusting.

I have a professional background in healthcare plans so I knew what plan was best for me. I knew more than the broker. He kept asking whether I was sure I didn't want Medicare Advantage.

[2sleepy]

Originally Posted by Sand&Salt

Everything I hear about Medicare is appalling. So glad I don't have to get involved in it.

My sister in a well-to-do area of SoCal just got dropped by their Medicare HMO with no reason. Now they are panic-shopping for some other provider. Sheesh.

This is open enrollment, it's the time that some companies opt out and others decide to offer advantage plans, I really doubt if she will have trouble replacing her plan there. I don't like medicare advantage I think it's horrible but nonetheless it's not like if one plan drops out patients have to panic to find another there are dozens....https://www.medicare.gov/plan-compar...lang=en&page=1 If they can afford it they would do better to get a medicare supplement rather than an advantage plan

[JOinGA]

Originally Posted by Teacher Terry

I know 2 people only still alive because they could go out of state for care. A MA plan doesn’t let you go out of network. They are also allowed to do step therapy and by the time you get to the step you originally needed you may be dead or too ill for it.

Every Medicare Advantage plan is different. Because mine is sponsored by my former employer, I have coverage countrywide, even emergency coverage overseas, and can go to anyone that accepts original Medicare. I caution every individual to consider the details of THEIR choices. It can be very confusing.

[twinkletwinkle22]

I also want to add to this discussion: VOTE.
VOTE for your representatives who will not dismantle Medicare, Medicaid.
VOTE for those not being backed by big insurance who will continue to overbill the government (taxpayers) and deny necessary care to those who paid for this insurance with their work.