Pitfalls of Medicare Advantage Plans

Likkmee

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Pitfalls of Medicare Advantage Plans

“Although Mom saw her MA premiums increase significantly over the years, she didn’t have any real motivation to disenroll until after she broke her hip and required skilled care in a nursing facility. After a few days, the nursing home administrator told her that if she stayed there, she would have to pay for everything out of her own pocket. Why? Because a utilization review nurse at her MA plan, who had never seen or examined her, decided that the care she was receiving was no longer ‘medically necessary.’ Because there are no commonly used criteria as to what constitutes medical necessity, insurers have wide discretion in determining what they will pay for and when they will stop paying for services like skilled nursing care by decreeing it ‘custodial.’”

Snip


here are some details of in-network services from a popular Humana Medicare Advantage Plan in Florida:

  • Ambulance—$300
  • Hospital stay—$175 per day for the first 10 days
  • Diabetes supplies—up to 20% copay
  • Diagnostic radiology—up to $125 copay
  • Lab Services—up to $100 copay
  • Outpatient x-rays—up to $100 copay
  • Therapeutic radiology—$35 or up to 20% copay depending on the service
  • Renal dialysis—20% of the cost
Medicare Advantage Plans as a physician. Here's how he describes them:

  • Care can actually end up costing more, to the patient and the federal budget, than it would under original Medicare, particularly if one suffers from a very serious medical problem.
  • Some private plans are not financially stable and may suddenly cease coverage. This happened in Florida in 2014 when a popular MA plan called Physicians United Plan was declared insolvent, and doctors canceled appointments.11
  • One may have difficulty getting emergency or urgent care due to rationing.
  • The plans only cover certain doctors, and often drop providers without cause, breaking the continuity of care.
  • Members have to follow plan rules to get covered care.
  • There are always restrictions when choosing doctors, hospitals, and other providers, which is another form of rationing that keeps profits up for the insurance company but limits patient choice.
  • It can be difficult to get care away from home.
  • The extra benefits offered can turn out to be less than promised.
  • Plans that include coverage for Part D prescription drug costs may ration certain high-cost medications.
Snip

Switching Back to Original Medicare

While you can save money with a Medicare Advantage Plan when you are healthy, if you get sick in the middle of the year, you are stuck with whatever costs you incur until you can switch plans during the next open season for Medicare.3 At that time, you can switch to an Original Medicare plan with Medigap. If you do, keep in mind that Medigap can may charge you a higher rate than if you had enrolled in a Medigap policy when you first qualified for Medicare.8

Most Medigap policies are issue-age rated policies or attained-age rated policies. This means that when you sign up later in life, you will pay more per month than if you had started with the Medigap policy at age 65. You may be able to find a policy that has no age rating, but those are rare.

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Just for your information.
Move to Panama,no problem
 
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Penelope

Penelope

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Pitfalls of Medicare Advantage Plans

“Although Mom saw her MA premiums increase significantly over the years, she didn’t have any real motivation to disenroll until after she broke her hip and required skilled care in a nursing facility. After a few days, the nursing home administrator told her that if she stayed there, she would have to pay for everything out of her own pocket. Why? Because a utilization review nurse at her MA plan, who had never seen or examined her, decided that the care she was receiving was no longer ‘medically necessary.’ Because there are no commonly used criteria as to what constitutes medical necessity, insurers have wide discretion in determining what they will pay for and when they will stop paying for services like skilled nursing care by decreeing it ‘custodial.’”

Snip


here are some details of in-network services from a popular Humana Medicare Advantage Plan in Florida:

  • Ambulance—$300
  • Hospital stay—$175 per day for the first 10 days
  • Diabetes supplies—up to 20% copay
  • Diagnostic radiology—up to $125 copay
  • Lab Services—up to $100 copay
  • Outpatient x-rays—up to $100 copay
  • Therapeutic radiology—$35 or up to 20% copay depending on the service
  • Renal dialysis—20% of the cost
Medicare Advantage Plans as a physician. Here's how he describes them:

  • Care can actually end up costing more, to the patient and the federal budget, than it would under original Medicare, particularly if one suffers from a very serious medical problem.
  • Some private plans are not financially stable and may suddenly cease coverage. This happened in Florida in 2014 when a popular MA plan called Physicians United Plan was declared insolvent, and doctors canceled appointments.11
  • One may have difficulty getting emergency or urgent care due to rationing.
  • The plans only cover certain doctors, and often drop providers without cause, breaking the continuity of care.
  • Members have to follow plan rules to get covered care.
  • There are always restrictions when choosing doctors, hospitals, and other providers, which is another form of rationing that keeps profits up for the insurance company but limits patient choice.
  • It can be difficult to get care away from home.
  • The extra benefits offered can turn out to be less than promised.
  • Plans that include coverage for Part D prescription drug costs may ration certain high-cost medications.
Snip

Switching Back to Original Medicare

While you can save money with a Medicare Advantage Plan when you are healthy, if you get sick in the middle of the year, you are stuck with whatever costs you incur until you can switch plans during the next open season for Medicare.3 At that time, you can switch to an Original Medicare plan with Medigap. If you do, keep in mind that Medigap can may charge you a higher rate than if you had enrolled in a Medigap policy when you first qualified for Medicare.8

Most Medigap policies are issue-age rated policies or attained-age rated policies. This means that when you sign up later in life, you will pay more per month than if you had started with the Medigap policy at age 65. You may be able to find a policy that has no age rating, but those are rare.

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Just for your information.
Move to Panama,no problem
I'm not moving, I hope a lot of you move if Biden gets elected. Don't let the door hit you in the a..
 
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Penelope

Penelope

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When they get rid of Medicare and they will, then Medicare Advantage plans will take off and then we will not have Medicare so there goes you

hospital of $96,000 was $1475 ,

That seems strange that all you had to pay was 1475 since your OOP is 6500.
Did you get a discount for working for them?

So your all for underwriting, well they do it for Medicare.
Max out of pocket is the cumulation of co pays and any percentages you may to pay. My plan called for a $295 a day co pay days 1 through 5 after 5 nothing.

They do not underwrite for Medicare they do for a supplement if you don't get one when you are eligible.

Insurance company employee's don't get discounts.
Some plans underwrite for Medical Advantage and they sure will when they dc Medicare which they will in the future.

I read they want to get rid of plan B meds too.

I'm researching for my husband but I think he would be Plan G and a Medicare prescription plan, as he has no issues now just an occ kidney stone.

I don't want Medicare Advantage plans, as they change copays , OOP max, deductibles annually and they sure will when they (republicans) get rid of Medicare, then the prices will really go up.

Then all plans will have underwriting. See now they want everyone to sign up for Part C plans(Medicare Advantage) and then they will slowly do away with the medigap plans and Medicare as we know it.
No plans to my knowledge underwrite for MAPD plans. If you are referring to end stage renal disease they cannot deny any longer beginning in 2021.

Yes, the current administration want to limit some in hospital administered part B drugs.

In your previous post you mentioned one plan in Michigan, there are many. You also mentioned DME and each plan treats this differently to some degree except I know of no plans that make you pay a thing for diabetic supplies because they are covered under Part B regardless if you're on an MAPD.

Yes, many plans change co pay annually.

If you want an agent in Michigan I suggest you go to this forum and ask, there are a couple of very truthful agents here: Senior Insurance Forum
I'm will to look on a Senior forum but I'm getting my husband a Medigap plan.

the plans offered in MI pay a copay of 20% for DME. I don't trust any Plan C.
 

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