The Medicare Thread

[mcski]

As a friend of mine used to say...

You'll get your reward. In heaven.

Total consciousness

[fomofo]

Wasn't religious, but he did have a wicked dry sense of humor. Also liked a dry martini, as he was a hard-core alcoholic, and a drug addict. Like so many others with whom I crossed paths, wonder whatever became of him?

Back on topic, this can be a biggie...

You can get the lowest cost if your doctor or other health care provider accepts the Medicare-approved amount as full payment for a covered service. This is called “accepting assignment.” If a provider accepts assignment, it’s for all Medicare-covered Part A and Part B services.

https://www.medicare.gov/basics/cost...ccept-Medicare

I guess it's straightforward enough to clarify up front if your PCP accepts Medicare, and assignment, but what about Docs and perhaps other healthcare providers you might be treated by if you unexpectedly end in a hospital? Kinda hard to try and find out on the fly if someone in particular "accepts assignment", much less break off and go a different way if they don't.

I'll take an answer off air, and save my diatribe about how ridiculous/inefficient/corrupt the healthcare system has become for later.

[Cono Este]

Just about every hospital etc accepts medicare. It’s the most widely accepted insurance in the country x 10.

Yes, if your into Indian medicine or something, or need hair on your head, chew on viagra, you won’t get any.

Medicare is always a bit behind, the govt is slow. The new shingles shot is still not covered. That’s actually where advantage can be better. Part b medical supplies too, seems confusing, but every provider you show the red white and blue to should know what it’s worth. Like PT, you get so much every yr and the PT people know. Then you need a doctor to order more.

[fomofo]

Just about every hospital etc accepts medicare. It’s the most widely accepted insurance in the country x 10.

So does the granularity end at the hospital level, i.e., if you're admitted to General Hospital, and General Hospital accepts Medicare, and assignment, then everything that happens while you're there will be covered at assignment levels?

Or do you need to pay more attention to who exactly sees you, and what services/procedures they order, lest receive unpleasant surprises when the billing comes through?

[fomofo]

If you're in California, (and some other states - see link below), this could be of interest to you...

Medicare beneficiaries in California are allowed to enroll in a Medigap plan during the days leading up to their birthday and the days directly after their birthday. ... During this window, you cannot be denied for health conditions. There is one catch. You must already be enrolled in a California Medicare supplement in order to take advantage of the birthday rule. You can keep the same plan type or choose one of the California Medigap plans with lesser benefits. For example, you can go from Plan G to Plan G, or from Plan G to Plan N, but you can’t go from Plan G to Plan F.

https://boomerbenefits.com/medigap-underwriting




Good general info regarding Medigap (Medicare Supplements)

[fomofo]

OK, I guess everyone got through the week of shoving shit down their pie hole, and now it's (temporarily) back to more mundane matters. Like Medicare.

So, I have some questions about getting out of the gate with Medicare. After signing up for Medicare Parts A and B it appears one can initially sign up for Medicare Advantage, and within 12 months switch back to Original Medicare, with the option at that time to purchase a Medicare Supplement (Medigap) with no underwriting (health questions asked) as if you had signed up for Medigap in the first place.

The following screen dumps are from the Centers for Medicare and Medicaid Services (CMS) publication Choosing a Medigap Policy.





Basic Medicare Part B premium will be $165/month in 2023, and adding Medigap Plan G supplment and a minimal Part D Drug Plan will bring that up to about $300/month. Probably can find a Medicare Advantage plan with low or even $0 premium, (and perhaps even one that will pay all or part of the Part B premium), and that also offers other perks such as $1-2k compensation for dental work, etc.

My questions at this point are:

1) Did I get anything wrong in my summary above?

2) If I did initially go with an Advantage Plan, and while covered took advantage of some of the perks it offered, and then within 12 months switched back to Original Medicare and Medigap is there any "claw back" or other surprise that I would encounter?

[Bunion 2020]

Opinion
Medicare Advantage? More like Medicare Disadvantage.

By Helaine Olen

November 30, 2022 at 7:00 a.m. EST

When the annual enrollment period for Medicare ends on Dec. 7, analysts expect that, for the first time, more seniors will receive their 2023 health-care coverage from Medicare Advantage than the traditional program.
Sign up for a weekly roundup of thought-provoking ideas and debates

That’s not a good thing for either elderly Americans or federal coffers. And while seniors are well advised to approach these plans with caution, we should all be paying attention to what’s going on.

Medicare Advantage plans, which are private insurance plans for seniors paid for with federal dollars, originated as a government savings strategy, on the theory that the private sector could improve on government performance at a lower cost. But over the past two decades, it has become clear that Medicare Advantage does not result in improved care for less money. Instead, it will come as no surprise to Americans familiar with the health insurance industry that insurers found a way to turn it into yet another profit center, while putting bureaucratic roadblocks in the way of patients.


The problems are so pronounced that Reps. Ro Khanna (D-Calif.) and Mark Pocan (D-Wis.) — both advocates of Medicare-for-all — recently introduced little-noticed legislation that would ban private insurers from using the word “Medicare” in their names or advertisements.


“Medicare implies universal coverage. You can go to any doctor, you can get your claims reimbursed,” Khanna told me. “You shouldn’t be able to appropriate the trust and faith people have in Medicare to sell a private product for personal profit that doesn’t have the same rules.”

Insurers in Medicare Advantage are paid a flat fee by the government, based on the enrollee’s health. These insurance companies often want their members to appear as ill as possible — at least as far as the Feds are concerned. They might “upcode,” in doctor speak, maximizing the amount of money they receive. (The federal government calls that practice “fraud” and has sued several of the largest insurers in federal court for it, including Anthem and Cigna, in cases still ongoing.)

As a result, multiple studies have found that seniors on Medicare Advantage cost the government more than those in the traditional program, exactly the opposite of what is intended. A government advisory panel recently estimated the overpayment was $12 billion in 2020.

This flood of money is fattening the bottom line of the health insurance giants even as they’re increasing pressure on the Medicare Hospital Insurance Trust Fund, which is projected to run out of funds in 2026. And Congress is loath to crack down, thanks to the combined power of health insurance lobbying and the program’s popularity with cash-strapped seniors.

Meanwhile, it’s not like seniors are getting better care for the money the federal government is spending — in fact, it can be worse. A research brief posted on the National Bureau of Economic Research website found picking the right plan could literally be a matter of life or death.

It’s “widespread” for Medicare Advantage plans to initially deny coverage for doctor-advised care, according to a report released this year by the Department of Health and Human Services. Plans erect roadblocks to treatment by demanding prior authorization for services traditional Medicare covers without questions. Plans can — and sometimes do — refuse to cover necessary prescription drugs. There are increasing complaints that private insurers rush patients out of skilled nursing and rehab facilities.

So why do people sign up? Traditional Medicare is not simple. It’s a complicated stew of different parts — for hospitalization, for doctors and for prescriptions. Seniors might feel they have to purchase supplemental coverage known as Medigap, which helps cover the co-pays and deductibles that Medicare does not cover.

Many Medicare Advantage plans eliminate or significantly reduce these out-of-pocket costs, as long as beneficiaries stay within their approved network. The private policies also frequently offer vision and dental coverage, not to mention gym memberships, something not on offer in Medicare itself.

These extras have an appeal. But a streamlined plan that can end up costing seniors more is no bargain — and Medicare Advantage sometimes relies on deceptive marketing to get them in the door. A report issued earlier this year by the Senate Finance Committee’s Democratic majority found that unscrupulous insurance agents — who are paid significantly more to sign up seniors for Medicare Advantage plans than for the traditional offering — will sometimes be misleading about networks and benefits, and even pursue seniors suffering from dementia. Ads featuring celebrities claim the plans will put more money in seniors’ pockets.

Medicare Advantage defenders are quick to point out that surveys show their enrollees are more likely to receive such preventive health and wellness services as monitoring of high blood pressure than those with the traditional program. But it’s usually when someone gets seriously ill that Medicare Advantage’s weaknesses become clear.

What would be best would be to fix Medicare, to make it more generous to enrollees and less generous to insurers. That’s unlikely to happen. But we can at least insist on calling it out for what it is: Try Medicare Disadvantage.

FWIW and perhaps CE can chime in but I see the supplements as the cheap way to have some work done now that I have been putting off and biting the bullet with the premium costs. Then later down the road looking at an advantage plan when I stop working and go in SS.

Market place aside, 300 a month for full coverage is pretty cheap.

[BFD]

funny this just goy bumped. Just got off the phone with United Health. Had this thread open when I was talking with them. I just went with the 0 premium medical advantage plan. Have no idea if this is the right move but looks like it will cover drugs. But like Bunion mentions I could of bought a supplement plan and been in for around $300 a month. Would of been cheap compared to over $1000 a month I have been paying. Oh well see how it goes.

[whipski]

Have you pcp order meds here, All the way from India. Pennies on the dollar. Expect up to 4 weeks for delivery.
https://www.alldaychemist.com/

[Cono Este]

funny this just goy bumped. Just got off the phone with United Health. Had this thread open when I was talking with them. I just went with the 0 premium medical advantage plan. Have no idea if this is the right move but looks like it will cover drugs. But like Bunion mentions I could of bought a supplement plan and been in for around $300 a month. Would of been cheap compared to over $1000 a month I have been paying. Oh well see how it goes.

It’s a great choice, heck of a deal, just know that if you started medicare at the month you turned 65, then you have a 12 month trial period where if you change your mind you can still apply for a supplement without answering health questions.

[Cono Este]

FWIW and perhaps CE can chime in but I see the supplements as the cheap way to have some work done now that I have been putting off and biting the bullet with the premium costs. Then later down the road looking at an advantage plan when I stop working and go in SS.

Market place aside, 300 a month for full coverage is pretty cheap.

I see that a lot.

I’ll tell everyone to go with their gut. I over sold a lot of supplements to people who now have trouble paying for them. And when I switch them to mapd i feel I could have saved them money just doing that in the beginning.

Also, if you live at 10,000 feet somewhere, with Mtn vistas out your back door, I envy you, but, Probably not a lot of doctors near by and a traditional supplement will work better.

But if youre a cheap bastard or simply broke from a life a women and wine, then go with a high deductible G. They are like 50 bucks a month.

Also, for those of you buying supplements, aarp gives you the silver sneakers you usually only get on the mapd plans. That’s worth whatever your gym premium is.

[fomofo]

Wait, there are some things you need to know about that Medicare Advantage Plan...

[Cono Este]

For those buying supplements, go with an established brand. I sold a lot of smaller companies years ago, they’ve done their job, but when they no longer offer supplements it can present problems.

Someone mentioned the birthday rule above etc. there are several rules that still offer you guaranteed coverage like when you’re new to medicare, but if your current company is not issuing new supps, and you have to go to a new company, they can fuck you for more $$. happened to a client of mine just recently.

Aarp unh (u get gym membership)
Mutual of Omaha
Bcbs
Etc.

If anyone wants a quote just pm me. I only sell Mo/IL but I can see them all. I’ll get back to you in a week if not right away.

Don’t forget about the high deductible G. Agents make shit on them because they’re like 50$ . so you’ll never be pitched one. I thinks it’s an awesome choice.

[Cono Este]

FYI Biden wants big cuts to Medicate advantage on the table.

You may have seen the PAC ad on TV with the guys in the billowing alley says Medicare advantage is medicare too. Call your congressman etc.

Med adv benefits like dental gym memberships will be the first to go. Those have only recently been added too. Co pays higher, maybe a monthly premium etc.

Med adv has always cost the medicare trust 10-15%% more per beneficiary than original, so something had to give.

Again, start on original medicare first and buy a supp.

[Bunion 2020]

^^^ Getting shoulder surgery next week, I went traditional medicare with the UHC Supplement through the AARP after starting out on a LASSO MSA. Glad I made the change. The 3K provided by LASSO in the MSA would not have cut it.

[Cono Este]

If the cuts run deep, people with pre existing conditions will be screwed. There is no special enrollment period that will guarantee people a traditional supplement.

I’m going to get a lot of angry people calling me, but I know I told them all the same thing.

Don’t be greedy.

[Cono Este]

^^^ Getting shoulder surgery next week, I went traditional medicare with the UHC Supplement through the AARP after starting out on a LASSO MSA. Glad I made the change. The 3K provided by LASSO in the MSA would not have cut it.

Aarp is the only supplement that give you a gym membership. That’s worth 1/3 the cost of the supp. Then with a G, add 200 bucks in the part B deductible and in most states a 65 yr old is only out 1000-1500 for supplemental. Plus drug co pays.

I’m some shitty rural states. The g’s are 90 bucks a month at 65. In illinois the aarp is 120 with gym benefit.

It’s the way to go. Even though I make 2x as much selling an adv plan, I’m going to focus on traditional supps with the threat of them being defunded and the bullshit compliance I have to follow selling advantage. I already got “randomly” audited with this call recoding shit. It’s not even complaint based.

[old goat]

These "benefits" like dental, gym membership, etc. are not Medicare benefits. They are sweeteners some insurnce companies use to induce healthier people to sign up becuase the insurers are making so much money from these people. Some people are also able to sign up for MA plans with zero premiums. As a reminder--Medicare Advantage means the insurer gets so much per month from Medicare for each insured body from which the insurer pays for all care the person needs.
Because Medicare Advanatage has been so lucrative it would seem ripe for cuts. That might end the extra benefits and zero premiums. However CMS is not currently planning cuts but some adjustments in how a patient's risk is determined, which in turn determines how much the govt pays for that patient.
Here's what Kaiser Family Foundation (which has nothing to do with Kaiser Health Plan and Hospitals) says on the subject. https://www.kff.org/policy-watch/is-...are-advantage/

If you want to sign up for MA I would look at the Medicare rating for the plan and not automaticaly go with the lowest orzero premium or the benefits. I would want to be confident that the plan would not restrict my care to save money. (With traditional medicare I would want to know my doctor isn't giving me unnecessary care to make money.)

This is not something I know much about but I believe there are automatic cuts in a few years if the trust fund is going bust. Biden wants o increase taxes on people who make more than 400K to keep the fund solvent.

[Bunion 2020]

RE: AARP & Gym memberships.

Bozeman has very limited options for participating gyms. I use the local YMCA. It wasn't the primary motivator but it did help.

[old goat]

One of the changes in MA the CMS is proposing is how they audit and charge back insurers who falsely elevate the patient risk factors that allow them to get more per month from Medicare for those patients. Whie that doesn't directly affect patient care to me it is a red flag for a company that is greedy enough to withhold care. Do your research.

[Cono Este]

If you’re in an Advantage plan, read your Notices of changes for 2024. My phone is lighting up. I’ve only gotten anthem and a smaller local plan so far, but the maximum out of pockets went up. People are calling mostly about UHC,

Seems these “changes in accounting” , or what constitutes cuts, and how they get paid, might be as bad as I thought.

Then call Harry.

[oftpiste]

New to this thread and 9 months into medicare coverage. And I'm a complete idiot about this stuff.

Have UHC and what I think is a decent broker. Reading the changes didn't seem like they were heinous. Slightly higher co pays and out of pocket limits. Is that what people are calling about or....?

School me....

[Bunion 2020]

^^^ Do you have a UHC supplement ( Part G)? Or a UHC Advantage plan?

Vast differences.

[oftpiste]

it appears to be an advantage plan. Get's a different name next year."AARP Medicare Advantage Choice Plan 2"

[Bunion 2020]

OK got it. Not an expert in this at all. If he will chime in and is sober perhaps CE would like to explain.