Anything and I do mean anything promoted by republicans on health care is designed to hurt the consumer who is in the medicare pool. The promote the flexibility but the key sentence in the story is "pushing the expenses to the private insurance companies such as Humana and United. For someone who is in that pool will find their benefits greatly capped or limited pool of doctors. This is a thinly veiled attempt to model our terrible private insurance which does the same thing with its in-network vs out of network where the consumer suffers.
44
One thing worth considering is signing up for ‘regular’ Medicare without a supplemental plan (Medigap) but with part D (drug coverage).
This necessitates paying 20% of your medical bills, however compare that with the high cost of many supplemental plans, especially when they also impose a deductible. If you’re careful and thoughtful about planning, this can save money - even if you’re faced with hospitalization. Remember that supplemental plans pay out only for care that is approved by Medicare - otherwise, supplements pay nothing (and you’re still on the hook for monthly premiums).
9
@Lenore M Yes, I am sometimes amazed by how low my 20% is for office visits -- $15, $20, $25.
I have a Medicare supplement, but it is High Deductible Plan F, which has the same coverage as Plan F (the most comprehensive supplement) except that it doesn't pay anything at all until I have paid about $2300 out of pocket for Medicare Parts A & B deductibles and coinsurance. In New York this plan costs more than $200 a month less than a regular Plan F. I pay about $70 a month for it.
In a normal year my High Deductible Plan F pays nothing on my behalf as my medical expenses are pretty low -- like a total of maybe $400 or $500 out of pocket after Medicare A & B pay their benefits. However, with all the money I save on premiums I have an extra $1500 - $2000 for things like dental, vision, etc., plus there are some medical expenses that aren't covered at all by Medicare, so I have this money for that. In a bad year, like last year when an accident left me hospitalized for a couple of days, I hit the $2300 and after that my Medicare supplement kicks in and everything is covered 100%. After 6 years on Medicare I have had 5 "good" years and just the one "bad" year.
Interestingly, AARP's "approved" healthcare insurer, United Healthcare, refuses to offer High Deductible Plan F. and, as far as I have seen after many years of AARP membership, AARP doesn't even acknowledge its existence in numerous articles in its monthly publications about "how to keep health care costs down."
26
Thanks for this information.
I agree with the several MDs who have commented here and suggested that we do Medicare for all - like most other civilized countries. We need healthy citizens - since few of us have the resources, not to mention the desire, to completely isolate ourselves from any contact at all with others.
37
I would be wary of joining Medicare Adv. just to get a grab bar & someone to come for an hour 2 x a week to help you shower. Being eligible for Medicaid is best way to get home care in NY, as the bene is quite generous here. Alternatively, pay for it yourself. But don't expect meaningful help thru Medicare.
I have original Medicare, plus a Medigap supplement & a Part D plan. Even in that type of plan I can see I am getting less than my late mother did under original Medicare & Medigap 10-15 years ago. They may not have actually eliminated payments for TYPES of services they cover, but they are finding more & more ways of reducing the $$ of benes you get. I learned this first hand last fall when I had accident that required emergency surgery for an open unstable fracture & subsequent outpatient rehab. Hospitals & other providers are under enormous pressure from Medicare & Medicaid to accept reduced payments, resulting in reduced services, especially in places like NYC, where there are so many on Medicare & Medicaid (not to mention extremely generous Medicaid package offered in NY).
My likely solution is to move to a state where I can live near a univ. medical center, enjoy a high quality of life, a lower cost of living (incl. health ins. premiums for Medigap half what they are in NY), with a healthier, younger population making fewer demands on Medicare/Medicaid. Not to mention the prospect of home assistance, if I need it, that is less expensive than here.
6
I am disabled and was this year switched by my company to a Medicare Advantage- I only had the choice of an HMO type plan or the PPO type plan (the PPO option being the one most like the plan it was replacing) but they are both eerily familiar of the era when HMO’s began their frightening stranglehold on the healthcare scene. It wasn’t about what they covered but mostly about what they didn’t cover.
As I’m not yet old enough to be considered to retired, I don’t think I have many other options - with disability I am very locked into my company and it’s benefits. I also realize I am fortunate to have any benefits at all. I have previously been bankrupted (see previous paragraph!) by earlier policies that did not cover medications that I had no choice but to pay for out of pocket. It got pricey.
In these seven months of 2018 I get constant wasteful mailings to my home, annoying “wellness” phone calls from the insurance company (I don’t answer, they leave voicemails!) and I can no longer afford to see many of my caregivers because of high copays. My monthly premium for the non Medicare portion of my insurance is about the same as it was last year.
The plan change was presented in the welcome materials as “cost saving” to me. Maybe. Whatever it used to cost for me to go see caregivers for treatment is saved because I cannot see these providers anymore. It’s just too expensive now.
Don’t get sick people. Yes, I know, ironic. But I’m saying, pre-retirement.
12
@Colleen Sorry to hear this happened to you, though, as you say, you are probably lucky to have any coverage at all.
I am on regular old-age Medicare and am always amused every year when I receive open enrollment materials and see what kind of copays apply under Medicare Advantage plans. $20, $30, $40 even $50. I am on original Medicare with a Medicare supplement (High Deductible Plan F). What I am left paying after a doctor visit under Part B, assuming I haven't yet met the deductible under my supplement, is not large -- $15, $20, $25. Original Medicare reimbursements are low (so low more and more docs refuse to take it) that 20% of them is also low, even for specialists. Plus, you generally have a greater choice of docs, so I have trouble seriously considering one of these adv plans, esp. when their reputation on some benes, like length of hospital & rehab stays, is so poor. But the insurance cos. make a fortune off them. In fact, the insurer of my Medigap plan (Blue Cross) no longer sells Medigap in NY state, preferring to stick to the high profits of "advantage" plans.
13
The free counseling from the State Health Insurance Assistance Programs was proposed to be eliminated in the President’s budget this year. If you have benefited from this help with Medicare enrollment and changes, please let your federal representatives know and ask them to support it.
24
Second part -
I was in Medicare Advantage Plan for one year. through corporate retiree coverage. Then premium shot up and with co-pays, co-insurance and network changes it was not such a favorable plan.
BECAUSE I was changing from a MAP after only one year and from a corporate plan -- many variables- I was eligible for a supplemental plan also by UHC through AARP WITHOUT MEDICAL UNDERWRITING.
Otherwise changing from a MAP to Original Medicare + Part D and a supplement - the supplement coverage would be subject to medical underwriting and exclusions for pre-existing conditions and higher premiums if I was accepted at all. I looked at many supplements and some didn't even give benefit that I was coming from corporate plan - still would have had medical underwriting and might have been ineligible for many supplements.
The answer to questions posed is MAP may look good in the beginning of your hunt for information but be wary about them- you may not be able to change in the future.
I suggest start or stay with Original Medicare + Part D and a supplement. I am an AARP member and had access to their supplement and received wonderful help from their agents on the telephone. From my research this is the best choice for me (and many family members and friends).
I have no connections to UHC.
I am very happy I changed from a MAP when I had the chance. The window was open for me only once-- during enrollment for 2018. Do your research now. Call for advice.
8
@joyce After several years of AARP membership & 6 years on Medicare, I have to tell you I am very skeptical of the AARP insurance scheme, though am happy to hear you are pleased with it.
Did you know there is a version of the most generous Medicare supplement (Plan F) that is much less expensive -- more than $200 a month less in premiums where I live -- because it has an annual deductible of about $2300? In other words, Medicare Parts A & B pay their benefits, but the Medicare supplement doesn't kick in until you have paid out of pocket for $2300 or so in Medicare deductibles & coinsurance. For a pretty healthy person like me, who in a normal, accident-free year pays only $400 -$500 out of pocket, the supplement pays nothing, but there is huge savings in premiums, which can be applied to things like dental implants & eyeglasses. In a bad year, like last year, when I had an accident and had to go to the hospital, the plan kicks in at $2300 & covers everything 100%.
But guess what? AARP/UHC don't offer this Medicare supplement (at least not in NY) on their menu, presumably because it doesn't offer enough profit for them. Not only have my premiums for HIgh Ded. Plan F not increased in the past 6 yrs,. they have gone down, as required in NY when claims don't justify premiums.
8
Buy Medicare Advantage to save money, then get a cancer diagnosis and try to get treatment at a renowned center, such as Memorial Sloan-Kettering or Dana Farber. Sorry, you’ll be told, try the mom-and-pop hospital down the block that’s in-network. The interns will take good care of you. Hey, it’s only your life at stake.
You get what you pay for. Sometimes, not even that.
35
Very important as Medicare Advantage gains more popularity, and should be the subject of a separate article:
In a dispute with my MA insurer over the arbitrary dropping of my primary care physician (and their suggestion that I might use the city health department as an alternative - honest) it became apparent that MA had become an extension of the same problems we had with for profit insurers before ACA - problems we had thought we had finally left behind as a reward for reaching Medicare eligibility.
When I took our problem to our State Corporation Commission, which regulates insurance, I was told that while Medicare could be held to some account as a federal program (and does not use arbitrary provider networks) MA had been set up to be out of the reach of regulation. The SCC, and no one else really, could deal with consumer issues with these insurers. I was urged to write to my representative, etc.
So correct me if I've got this imprecisely, but MA is the same old same old when it comes to health insurance. The insurance industry wins again, and I'm paying more to visit my out of network PCP because the insurer felt that he had been referring his patients to specialists that were too expensive - the stated reason for dropping him. Honest.
20
I commented briefly on what was better explained by
vacciniumovatum
Seattle8h ago
In my state, it appears that if you sign up for a Medicare Advantage plan, you cannot switch to a Medicare Supplemental Plan without passing a health exam so per-existing conditions that seniors tend to have will virtually always disqualify you from leaving your Advantage Plan (unless you can find another Advantage Plan that you like). The only exception appears to be if you are a retiree and your former employer has Supplemental Plan (usually it's like Supplemental Plan F) that is open only to their eligible retirees.
And
Rachel Kreier
Port Jefferson, NY18m ago
Yes -- the rules for Medigap vary from state to state. By FEDERAL law, everyone has the right to sign up for Medigap without underwriting (health exam to screen for pre-existing conditions) when they first become eligible for Medicare. If you instead go for a Medicare Advantage plan, then, depending on the state in which you live, switching back 10 years down the line may be either impossible, or very expensive. One of the sad things is that people sometimes discover AFTER they have developed an expensive health condition that the doctors and other providers who are good at treating that condition are not in the Advantage plan's network -- so they want to go back to Original Medicare, but can't get a Medigap suppleental plan to go with it.
17
It is obvious from all these comments that Advantage plans have pros & cons, and many promoters & detractors. The subject of this article, enhancements for Advantage plans, is a relatively small side issue to the bigger issue: are Advantage plans a good choice for seniors, and when?
Paula, I hope you and your editors are listening. Our government has failed time and again on health insurance. Rather than truly analyze these issues, Congress band-aids and curries favor with large donors. On the issue of types of Medicare coverage the NYTimes and you have the opportunity to talk to experts and provide a real public service by helping to truly answer this question, ‘are Advantage plans a good choice for seniors, and when?
27
I think the Times is not in the business of making judgements that only you personally can make.
There are private companies, I use Senior Enrollment Solutions, that help sort out advantages and disadvantages based on the client’s personal information. For example, the meds I take and Drs. I use, and then make recommendations, but even they are not telling me what is “best” for me because in the end it’s a subjective decision. This also means that no AI system can make it either.
5
@Michael Kelly Have to agree Times is not in the business of making these judgements. That's why I specified "...talk to experts and provide a real public service by helping to truly answer this question..." The media can provide a great service by speaking to experts, perhaps many experts to get at the real issue and provide real information it may be difficult to find.
On a local basis I understand a private company or even the volunteer organizations can be a great help; I have an agent who has been very helpful and have talked to our local volunteers. If you've spent some time reading these comments, you know there are a variety of opinions here....and surely this is the tip of the iceberg. Better understanding through quality journalism.
1
I am a little confused on Medicare Advantage. I have BCBS C plus - is that part of it?
Yes -- you are getting your Medicare benefits through a private insurer (Blue Cross/Blue Shield), a Medicare Advantage plan. The government pays a premium to the insurer on your behalf (you probably pay a bit extra, too).
1
Let us in how much out-of-pocket and deductibles cost, please.
Straight Medicare won’t pay for these “special services.” Nothing like the government promoting corporate insurance companies by changing the rules “in favor of” these corporations.
12
My Medicare Advantage plan states that it covers up to $2500 each ear for hearing aids, but then would only pay 25% of that. They don't say why. They state that they cover diabetic shoes and insoles, but give no guidance to help me figure out how. In short, they can promise the moon and pay nothing. They are, however, pretty good at turning down claims for the promised benefits.
26
In my state, it appears that if you sign up for a Medicare Advantage plan, you cannot switch to a Medicare Supplemental Plan without passing a health exam so per-existing conditions that seniors tend to have will virtually always disqualify you from leaving your Advantage Plan (unless you can find another Advantage Plan that you like). The only exception appears to be if you are a retiree and your former employer has Supplemental Plan (usually it's like Supplemental Plan F) that is open only to their eligible retirees.
7
Yes -- the rules for Medigap vary from state to state. By FEDERAL law, everyone has the right to sign up for Medigap without underwriting (health exam to screen for pre-existing conditions) when they first become eligible for Medicare. If you instead go for a Medicare Advantage plan, then, depending on the state in which you live, switching back 10 years down the line may be either impossible, or very expensive. One of the sad things is that people sometimes discover AFTER they have developed an expensive health condition that the doctors and other providers who are good at treating that condition are not in the Advantage plan's network -- so they want to go back to Original Medicare, but can't get a Medigap suppleental plan to go with it.
8
@vacciniumovatum
You can sign up for a Plan F when you enroll in Medicare. No restrictions allowed. Has nothing to do with a former employer or anything other than being able and willing to pay the extra money for more and more flexible coverage.
4
@Rachel Kreier Slightly off point, but one thing to keep in mind is Medicare Supplement known as High Deductible Plan F. AARP/UHC refuse to offer because not enough profit in it, but costs more than $200 a month less than regular Plan F where I live.
1
Fine for now but Medicare in general is unsustainable. The baby boomers by their sheer numbers are skewing the system. And the uneducated, minimum wage worker who is not contributing enough money into the system is not helping.
4
@Jan It's not the baby boomers that are skewing the system. It's all the younger disabled people in their 40s, 50s and 60s coming into Medicare on account of their disabilities/chronic illnesses that are skewing the system.
I am 71 and have been on Medicare plus the Medicare Supplement known as High Deductible Plan F for 6 years. though my Medicare premiums have gone up, my premiums for High Deductible Plan F have gone down, as is required under NY insurance law when claims don't justify premiums.
3
Many doctors ask you to sign a waiver from Medicare or Medicare Advantage that you will pay additional amounts for their higher costs out of pocket...or they do not accept Medicare payments at all.....nice...very nice...
8
Medicare is being killed off slowly and no one seems to be paying attention. In NYC many doctors have opted out. Medicare doesn't reimburse sufficiently.
16
Medicare Advantage programs were developed to destroy traditional Medicare and support private insurance companies. The "advantage" is theirs alone, no matter how many sales gimmicks they invent.
76
@Jean M
Absolutely spot-on. Another private market, that elders are supposed to 'shop' each year, until they fall over. It's ridiculous.
Vancouver sounds very, very good from here :)
22
@jazz one I have been on Medicare for 6 years. I have the Medicare supplement known as High Deductible Plan F, which costs at least $2500 a year less in NY State than regular Plan F. My insurer, Blue Cross, stopped selling this plan, and all other Medicare supplements, the year after I enrolled, apparently preferring the high profits of "advantage" plans, which they continue to offer. I believe it's state law that requires them to continue people like me who were already enrolled.
Note that the AARP "preferred" insurer, United HealthCare, refuses to offer High Deductible Plan F and AARP lets them get away with it.
1
This is simply more corporate welfare for the medical complex at all levels.
The home modifications they suggest Medicare cover should simply be tax write-offs.
Medicare advantage programs are a sham because much of the cost is borne by the "customer" - the patient. A friend of mine had to go to emergency because of a damaged disk in her back and got a bill for $12,000 that her "advantage" program didn't cover. The amount of the shocking bill and the non-coverage are both Preposterous!
OUR elected officials should be concentrating on persecuting Medicare/Medicaid corporate fraud and developing a national health program that covers ALL citizens instead of feeding more to the Robber Barons.
Smart people will choose original, regulated Medicare Supplement programs like Plan F and G. They cost a little more in premiums but cover almost all medical costs. Humana offers a Medicare D prescription plan through WalMart that is only about $20 a month and saves me hundreds of dollars. Shopping for the best, truly most cost efficient program is more important than ever.
SIBA programs at State Insurance Commissioner offices are a big help in sorting through the propaganda.
35
Most Minnesota Medicare Cost plans will be phased out next year and seniors will be offered (pushed into) Advantage plans. According to a Wharton School of Business study, Advantage plans are give-away programs to insurance companies. See L.A.Times article by Michael Hiltzik noted below. Has Congress does anything to address these problems?
New evidence that Medicare Advantage is an insurance industry scam
March 26, 2014 | By Michael Hiltzik
A big part of the argument made by enemies of the Affordable Care Act that the Act is hurting Medicare applies to a category of health plan known as Medicare Advantage. New evidence has just come in showing that Medicare Advantage is a ripoff that fattens the health insurance industry while scarcely helping its enrollees , all at public expense. Medicare Advantage plans differ from traditional Medicare by offering its enrollees ostensibly better care and sometimes broader services--free eyeglasses, even gym memberships--in return for reimbursements from the government that are 14% higher than traditional Medicare reimbursements, or more.
22
As your article says, "Any increased costs will be borne by the plans and their enrollees, not the federal budget." Advantage plans have varying premiums that range from zero to several hundred dollars monthly. They include Pard D drug coverage with wildly varying drug formularies. Unless you have a crystal ball (not covered by Medicare, by the way) you cannot predict what your medical needs or drugs prescribed in the future will be. Since Advantage plans are year-by-year, next year the plan you are now on could go away completely, come with a different provider network and different drug formulary, or require a higher premium. Any increased costs will be passed along to the consumer. This is a sneaky Republican way of privatizing Medicare with minimal political costs, but with huge tax cuts for the wealthy and increases in military spending, the money must come from somewhere and that translates to you-know-who.
36
Allowing private, for profit insurance companies to add additional "perks" to their lineup of Medicare Advantage plans for their enrollees (but cannot not offered to traditional Medicare beneficiaries) is just another "setup" and strategy by the GOP to terminate and end the Medicare program.
As the article states, "You can see why it’s played out this way. Funding for Medicare Advantage programs is capped: C.M.S. provides a set amount, which private insurers can use to provide whichever supplemental benefits they choose, theoretically stoking competition. Any increased costs will be borne by the plans and their enrollees, not the federal budget.
“Republicans have always been some of Medicare Advantage’s biggest boosters,” Mr. Gorman noted. “In effect, you’re shifting deficits onto the private sector.”
And the "private sector" will shift these deficits onto their enrollees. Don't fall for this gimmick !
42
@Abbey Road
A problem with adding perks to traditional Medicare is that Medicare keeps its overhead low by paying all bills without review. If it will pay for three cataract surgeries during a thirty day window, it will pay for a new grab bar for a shower every month for the next three years, even if it seems implausible that you are using 36 different showers. Medicare admits that 30% of its payments are erroneous.
1
I am nearly 82, in good health, active, and working part-time. Over the past 12 years, we traveled and worked overseas for five and finished up with the past seven years of full time RVing for a total of 12 years on Medicare Advantage while home and abroad.
We needed to have a a PPO to cover our travel lifestyle rather than an HMO for those who travel less than three months a year. Our experience with Medicare Advantage Healthnet PPO (Oregon) has been excellent, including one time when I had a heart event in Alaska, needed a helicopter transfer ($26,000) to Anchorage hospital, for a stent operation. (About $100,000 for everything). Our out of pocket cost was under $1000 as I recall.
About a month later in British Columbia, getting ready to canoe camp for several days on Bowron Lake, I started to pee blood (and we rushed (three hours drive) to a local hospital. I spent overnight in emergency room and they couldn't stop it totally, so had to drive to Prince George to a larger hospital where a urologist operated to cauterize my bladder. I had outstanding servce and care for two days in BC. Paid $10,000 with credit card over six months, which included everything (about a tenth of the cost of the USA). Healthnet, with my PPO, reimbursed me for nearly everything over the six months, due to emergency. My bladder problem was caused by the combo of aspirin and blood thinner. Got off all meds after a year and stayed off them.
5
Just a question: did your MD know you were taking a blood thinner AND aspirin which is also a blood thinner? Did your MD tell you to take aspirin or did you decide to do so because you heard it was a good idea for older people? This Public Health RN advises everyone to tell every MD they see ALL the meds they are taking even OTC and supplements/herbals to avoid this kind of interaction...and also go to Alaska if you can: I hear it is amazing!
20
I would be very skeptical about this so-called benefit. A relative changed from Traditional Medicare to a Medicare Advantage program (Anthem Blue Cross-Blue Shield) and found having a lack of choice of competent doctors and getting claims paid in a timely manner, or paid at all was problematic.
She switched back to traditional Medicare and purchased a supplementary program to cover deductibles and the 20% Medicare does not cover. It works much better. She can choose a competent doctor and know what the benefits are and not have the unpleasant surprise of a doctor or hospital being "out of network" and not covered.
48
Am reading so many conflicting comments that my head is spinning. So here goes: in eastern PA my husband and I have Advantage plans through Geisinger. Our current plan has $0 monthly premium, no referrals, in and out- of network are same cost. I created a little spreadsheet with certain assumptions: number of office visits, MRI costs, 1 hospitalization/yr, medications, etc. Each year I review maybe 5 different plans and pick the cheapest. So far, we are pleased. We are both in good health. At some point I will have to assume more care, then we will change. I originally picked an Advantage plan because it was most like my former work plan and I felt comfortable with it. All the scare stories are not true.
4
@Camilla Mallonee: The "scare stories" may not be true for YOU right now, if you & your husband are in relatively good health. But as another commenter pointed out, one's health can change in a matter of seconds, literally.
I hope your timing is good, so that you won't have your own "scare stories" - but please respect that those commenting here who've have bad experiences with Advantage plans are *not* making up those bad experiences out of thin air!
The last thing you want when you're unwell is to have to fight with your insurer over coverage/approval.
32
I am about to turn 65 and I am inundated with mail circulars and phone calls (which I never answer). Reading the comments to this article has been the most informative thing I have done. Thank you to everyone who wrote in, and to the NYT for starting the conversation.
47
I see this as an opportunity to privatize traditional Medicare, which Republicans have been doing little by little. It started with Bush's Medicare D drug insurance, through private insurers, and these private insurers not only raise rates they also keep changing what drugs will be covered, changing tiers and thereby also increasing copays. And, as with most insurers, they make the verbiage so confusing that most of the insured do not understand what they are signing up for.
There is no reason that Traditional Medicare cannot provide the same services at lower prices. The Republican Congress just does not want this to happen. One more step towards complete privatization of our Medicare insurance. The Republicans, little by little are taking away our Medicare and Social Security benefits that we pay for and paid for all of our working lives.
They need to keep their hands off of Social Security and Medicare
These Republicans sure are sneaky. They are even shafting their own voters.
113
The reason that Medicare Advantage plans can offer additional benefits is that government payments to the MA plans are higher than the cost would be if the patients were enrolled in original Medicare. Despite the impending (2026) deficit in the Part A trust fund, Congress is handing a multi-billion subsidy to the health insurance companies. It should be a given that the government premium payments for MA plan enrollment should be no more than the expected cost under original Medicare. If the insurers truly can save money through efficiencies, as they claim, and can offer services that are in addition to the legislated ones, great. If we think that it's important for beneficiaries to get additional services, like eyeglass coverage or home modifications, then they should be made available for all Medicare beneficiaries, not just those in MA plans.
42
As a semi-retired, 73 year-old journalist and marketing copywriter, I still find most insurance information difficult to understand; always have. Fortunately I have led a very healthy lifestyle with plenty of exercise and (for the most part) a proper diet.
But ailments are starting to creep into my life. With limited income, I remain fearful of the co-payments and deductibles should the need arise for a knee replacement.
With the primary focus of private health insurance providers on shareholder value and executive compensation packages, I am not very hopeful about real Medicare reform. And as much as I promote the idea of Medicare for All, I suspect I will not see it in my lifetime. This is not simply a case of political will. This will require a massive sea change — a tsunami — in public discourse and debate over the needs of a healthy society overall, versus profits for the few.
When Louisiana Congressman Billy Tauzin (D-LA) killed the bill to negotiate the prices of medication for Medicare, he "retired" to become the CEO of the industry lobbying firm, PhRMA. This is the revolving door problem in our government and has been for decades. Industry shills are appointed or elected to federal offices where they do the bidding of their former employers before going back to the industry. Tauzin was a "blue-dog Democrat" who worked for the industries he was supposed to oversee.
Will Medicare change? Will the Advantage plans? It's all about the money flowing in and out.
95
@David Ohman With the way things are going now, with the type of government we have now, I think things will change for the worse. Although traditional Medicare law hasn't changed much in the past 10-15 years, I see Medicare cutting back a lot on what it will reimburse for many covered benefits, with the result that people are getting reduced services from hospitals, doctors, etc. , at least in large urban areas with many Medicare and Medicaid recipients.. I am comparing the experience of my late mother with my own more recent experience -- both under original Medicare and a good Medicare supplement.
2
Thank you all for taking the time to comment. It has been very insightful to me as I am a recent retiree who is still covered by my employer plan. I must make my Medicare Part B choice by Sept. 1, and, although I’ve been reading and researching for some time, the difference between the Advantage and Supplemental plans is confusing. Your comments here have helped solidify my decision to go with a Supplemental plan. But it shouldn’t be so confusing to find the right plan. MAGA and get universal health care for the U. S.
29
1. Studies have shown that Advantage plans (HMOs) have disturbing rates of disenrollment for the sickest.
2. GAO reports show these plans actually spend more than comparable Fee for Service Medicare.
3. MedPAC reports show they have gamed risk assessments to cost taxpayers more. Whistleblower lawsuits have alleged the same.
4. Virtually no actual patient outcomes for survival and long term outcomes are available in public databases on these patients. Things like acute MI and heart failure. We have to rely on the industry's claim based data.
5. Congress and the courts have made them very hard to sue for negligent actions against vulnerable members.
6. Published rates of mammograms for breast cancer patients are not good.
38
@Brant Mittler, MD JD - Assuming Dr. Mittler's points are correct, they strongly support the need for the same federal regulation of Medicare Advantage that the government has always provided for original Medicare. And Part F Medigap insurance shouldn't require much regulation because it's mandate is to cover everything Medicare does not cover, no more, no less. Original Medicare is the best implementation of the KISS principle.
21
I worked in health care for >30 years. I have an advanced degree. English is my first language. I have time to do research and have easy access to information. And yet, despite every possible advantage, I struggle to make sense of my options.
What happens to those who are not as fortunate as I? Too often, for-profit insurance companies, beholden only to their shareholders, fill the gap. Their strategic marketing saturates the airways and the electronic media with "helpful", lovely to watch, easy to understand ads. And, based upon the obscenely high profits these companies have, and continue to make, the tens of millions of dollars they spend on advertising (not health care) is money well spent.
We need a single-payer, not-for-profit system of universal healthcare now!
211
@D. Lieberson Specifically we need HR 676, which would not only expand Medicare but improve it. For instance, dental and vision care would be included. You can find and read the bill for yourself and find the list of 123 co-sponsors, which is about 25 percent of the current Congress. Then we have to insist that anyone representing our district must support 676. Everyone would be covered from birth to death.
45
@sherry and who will be paying for all this coverage?
@Jake For one thing, it eliminates employer provided health insurance completely, and institutes an excise tax on payroll.
We're still tinkering with a beat-up jalopy, while the rest of the world has adopted fuel efficiency. It ***is*** rocket science everywhere else.
27
My Medicare Supplemental plan is currently provided by my former employer. They have a fairly high threshold of a deductible for full coverage to kick in, though sometimes, for reasons I can't understand, they do pay something.
But one thing is very clear: the drug coverage for certain maintenance drugs under the supplemental plan has far lower copayments than those in the Medicare Advantage plan my former employer offers. Two generic drugs I now take have copays of $32 per month in the supplemental plan; in the parallel Medicare Advantage plan the copays run $200 per month for the same two generic drugs. Message: private insurers running Medicare Advantage plans don't want patients with chronic conditions.
If, as threatened, my employer dumps all retirees into their one Medicare Advantage plan, I will be forced to change physicians and to change to a brand name medication that will cost $100 in copayments. Instant result: $68 more per month in health-care costs.
19
What we’ve come to accept as normal in this country is beyond absurd. I’m an intelligent, educated woman in my 40s, but reading articles like this makes my head spin. Premiums, supplements, caps, part B, part D, Medicare vs Medicare Advantage, and on and on and on. Whaaaaa.....????
I happen to be staying at the home of my French friend right now. She shook her head when I showed her the article. In France-and other European nations- you just go to your doctor when you need to.
Single-payer, universal healthcare now!
235
@PM
Well said. It's part of the problem that many Americans never travel abroad to see how some things can be done better, such as health coverage and public infrastructure like airports and mass transit.
These are the things that have enormous impacts on our daily lives, but here we allow our tax dollars to be poured down endless military rat holes while being told we can't afford universal health coverage or decent mass transport etc.
83
@PM I agree with your final point, but don't be scared off by the article. Within 6 months of turning 65 (from 3 before to 3 after), you enroll in Medicare, which is easy and painless. Have questions? Give them a call and you will get straight answers. Then, get a Supplemental (Medigap) policy, part F or G, either through Medicare or a good insurance broker, which covers the 20 percent not covered by Medicare. Pick one with a lower price, as all Medicare plans of the same level have to cover the same things by law. Then enroll in Part D for prescriptions - again, easy to do online.
22
@PM Ah, but thats Socialism !! (This said with tongue in cheek as I actually support UHC)
1
Another commenter pointed out a very important clarification ( I have worked in healthcare 40 years as a P.T.):
1) Medicare is available to Americans over 65 OR who ar
e permanently disabled ( like a friend who has been paralyzed since she was 28).
2) Medicaid is not Medicare ( it is really unfortunate the names are so similar!). Medicaid eligibility is based on having a very low income with few exceptions (like severely handicapped children)
3) Regular Medicare ( the white card with the red and blue stripe at the top) and Medicare Advantage Are Not the same thing. And you cannot have both.
4) A person who enrolls in a Medicare Advantage gives up their regular Medicare, but hundreds of my patients were misled by the insurance company to think they are keeping regular Medicare and just adding a Medigap (OR
may be called a Medicare supplement).
5) Medicare Advantage plans are run by insurance companies who need to make profits for their shareholders.
6) Every state has a SHIP Office which can provide unbiased info and help to citizens to pick the best plan for them.
61
They keep sweetening the Advantage plans. I consider them lobster pots. You can get in, but you can't get out.
62
A major difference between traditional Medicare and Medicare Advantage plans involves behavioral health benefits. In this region, many Medicare Advantage providers (e.g., United Healthcare) significantly restrict the number of clinicians they accept in their network. People in Medicare Advantage plans may be hard pressed to find an in-network clinician within reasonable driving distance.
Then there are the high co-pays and/or deductibles.
No one can claim that managed care discriminates on the basis of age. Many managed health care plans in this region- whether they are targeted to the under-65 or Medicare population - provide behavioral health "benefits" that for all intents and purposes, are inaccessible to people who are suffering.
7
@beth--If the Advantage plan includes a PPO, out of network docs that take regular Medicare also treat Advantage patients. The co-pay for the patient is slightly higher ($50 as opposed to $35 for an in network specialist). For my United Healthcare plan I have no deductible and a $5 co-pay for my primary, with many other benefits, e.g. a $50 quarterly credit for OTC items, for which they provide a catalog. I love it.
2
@kanecamp: I would say that if United Healthcare can afford to print & send everyone a catalog, you can only *imagine* the amount of $$$ they are raking in to pay for that. And money spent on the catalog is money NOT spent on reimbursing patients.
3
@beth I don't know what type of clinician you're talking about, but at least where I live practically no psychiatrists take original Medicare either.
1
Medicare already covers 80% of part B. So, how about the government taking another $40/month or so from me and cover the remaining 20%? This way I wouldn't have to go through the headache of selecting all those options from the various insurance companies and having to deal with the paperwork of a secondary company when I have to make claims.
23
That would be nice. How about the government covers the $50 copays I pay to see a doctor and the $70-$100 I pay to see specialist under my private employer based insurance plan? Maybe the government can reimburse the $360 I pay per month just to have the plan that covers myself and my two children. No one should have $0 cost to access health care - because they will often use it without care about expense. A family member of mine covered by Medicare and a union based supplement once went to the ER because she was “itchy” at zero cost to her. Meanwhile, I’m working myself ragged paying for my own and yours too.
8
@Bb
>>>they will often use it without care about expense
Most people avoid going to medical facilities unless they really need it. They don't want to take off from work or whatever, travel to and fro, sit for hours in a waiting room(even if they arrived on time for their scheduled appointment) and they don't like to be prodded and stuck with needles. So they self limit the times they go see a professional.
For those, who show up repeatedly for things that are of no consequence, the physicians should direct them to social workers or psychologists.
Meanwhile, your relative's itch should have been looked at least once by a professional to make sure it is not the symptom of something more serious.
I am already paying the government for 80%, why can't I pay them to cover the remaining 20%?
5
@Bb: Uh, it was your family member who mis-used the ER when it's very likely there were far less expensive options available. Don't blame the rest of us for that! Maybe you should have a word with your family member.
Most people avoid the ER if they possibly can, if only because you're likely to be there for 6-14 hours.
BTW, I and millions of others have worked ourselves ragged to afford the coverage we had in the past, and the coverage we now have. You're NOT the only one paying through the nose (now or in the past) for high health insurance premiums.
1
Do your research and due diligence, that's all I would advise.
10-12 years ago, husband got switched from regular Medicare to a Medicare Advantage Plan by a 'senior insurance agent.' Better commission for the agent, I get that.
Fortunately,that was not a big medical year for my husband.
The next sign-up period, I felt uneasy about all the ins & outs of the 'Advantage' plan, and we switched his coverage back, to 'traditional' Medicare + a supplement.
Good thing. He had a terrible reaction to a vaccine, and had to go to many different providers over several months to get the proper diagnosis and treatment. Dedicated, intense follow-up and complete recovery took two years. So we now bump along, each year since, just keeping what he has -- straight-up Medicare.
Despite knowing husband's history and our past experiences, at enrollment time two years ago, agent again pitches an Advantage plan. Husband in an absent-minded moment, says, 'ok.' I'm sitting there, and ask: what if he doesn't like this coverage, can he switch back to 'traditional Medicare' next year at this time?
Nope, agent says, you get ONE TIME to go off of it and return. We had used up that 'turn.' I immediately had agent rip up the Advantage application and kept checking and re-checking that we were making NO change to husband's coverage.
Until Congress totally guts it, and makes everyone shop for what is essentially private insurance in one's dotage, we're holding pat.
Do your research.
98
@jazz one
The agent was lying. You can change plans every year if you want.
2
I know it might be different areas of the country, but here in New York City there are many doctors who do not even accept original Medicare. They have oped out of Medicare of any kind and charge whatever they can for what they call "Conceriege service" . The patient pays through the nose for what ever the market will bear. In this enviornment Medicare can be second class healthcare. (pardon the spelling).
12
I am pushing 70 and have Medicare.
Luckily, I have never had to use it plus I have the ability to pay for any medical procedures.
Yet, I think removing this bright line between medical emergency and not needing emergency care in the first place - is a good idea.
I can forsee in my case requiring home care as I am single with no family to speak if.
Finally, someone below has made a comment about 49th parallel and how complex our medical care is for consumers.
I dare say that more consumers are aware of choices and trade offs between expenses and convenience - we are all better off.
Experimentation in delivery of medical care needs to be applauded.
2
@Neil
If you are willing to live with 20% co-pays and no out of pocket maximum, go with traditional Medicare.
1
Many doctors and hospitals do not accept Medicare Advantage so the hospital's ER you plan to use in your town may not accept it!
12
A recent article in Jrn. of Health Services found private insurers offering Medicare Advantage plans have four strategies that make them more costly than the traditional Medicare program.
1. Private plans cherry pick healthier beneficiaries who cost less to care for, guaranteeing larger profits. Although private plans must accept all seniors who choose to enroll, they cherry-pick by selectively recruiting the healthiest seniors through advertising, office location, etc. They induce sicker ones to disenroll by making expensive care inconvenient.
2. They recruit otherwise healthy seniors with very mild , inexpensive cases of sometimes serious conditions, automatically triggering higher premiums for these beneficiaries from the risk-adjustment scheme implemented in 2004, but escaping payments for expensive care. E.G., many seniors have very mild cases of arthritis, heart failure & bronchitis that require little or no treatment.
3. They enroll patients who get most of their care free at the Veterans Administration.
4. They heavily lobbied Congress to raise their reimbursement & induced Congress and the Bush administration to add bonus payments to Medicare Advantage premiums beginning in 2003. They continued this in 2017/18.
The industry has received a 3.3% increase in payments for Medicare Advantage plans from CMS, reversing a planned cut of 2.2 % in reimbursement rates. Stock prices then soared creating a bonanza for Wall Street investors , Big Insurance/Big Pharma.
56
@F.Douglas Stephenson, LCSW, BCD
And yet, even adjusted for health status, Medicare Advantage plans provide more effective care for fewer dollars than traditional Medicare. Who'd a thunk it?
Perhaps the 30% that Medicare admits to in excess payments has something to do with it.
Gee, drug companies have raised their prices at 2.4 times the rate of inflation since Obamacare instituted new regulations, and hospitals increased their charges 3.3 times the rate of inflation.
Inflation was 2% Medicare Advantage had to pay drug companies 4.8% more than last year and had to pay hospitals 6.6% more, all of their other costs went up 2% but you think their payments should have been cut 3.3%.
This will come as a shock to you. When Obamacare said that it was going to defund Medicare to the tune of $0.8 trillion dollars by reducing payments to providers, it was a budgetary trick intended to create the illusion that Obamacare was not going to add $2 trillion to the national debt.
Similar to the 1990s Medicare law that asserted medical costs would inflate at the rate of normal inflation rates despite massive government money flowing to cronies, no rational person ever believed that the costs would actually be reduced. Remember the "doc fixes" that had to be corrected every December or else reimbursement rates would be cut in half?
Paula, doesn't Medicare already cover "palliative care at home for the terminally ill", aka hospice?
4
A traditional plan will cover a person under palliative/hospice care as long as the provider justifies it in a recertification period. As a former hospice employee, I’ve had people under hospice/palliative care for 2 years. It all comes down to the provider knowing the ropes of justification.
9
It absolutely does. Hospice coverage is not an exclusive benefit of Medicare Advantage plans over traditional Medicare. Nor is the aide service that covers bathing and dressing - the traditional plan covers 1-2 aide visits per week for 1-2 hours per visit - the advantage plans follow that. What Advantage plan recipients can enjoy - a layer of people approving or denying your hospital stay, your access to skilled nursing care and acute rehab and a third party insurance case manager deeming that your needs are custodial (aka - you’re not going to get better so you can be discharged from the hospital now even if you can’t use the right side of your body). I work as an acute rehab case manager and am responsible for delivering the bad news from your “Advantage” plan. These plans often require me to submit 50 pages of clinicals to justify your stay. Advantage plans are great if you don’t get sick. If you want to roll the dice - go for it. Just don’t shoot the messenger.
20
@A Reader
Hospice care is for the terminally ill who have declined treatment expected to cure them of whatever they are dying from.
I've been practicing law for almost 40 years and in my opinion this column reflects how unnecessarily complicated and confusing for profit healthcare is. It's like playing Jenga but with peoples lives. Especially for us seniors.
117
@prn007
Licensed insurance brokers exist to explain the options to you. As an accountant, I contact a lawyer when I need legal advice, since I have not been all knowing since I was about 19 years old.
Professionals exist for a reason.
Although it may be appealing to those who like to rely on authority to provide a single solution to complex situations, there are people who prefer choices. What is optimum for you may not be optimum for me.
Personally, the fact that traditional Medicare has no out of pocket maximum makes it an undesirable choice.
1
@prn007 I am a former lawyer (actually, a former ERISA/benefits lawyer) and agree with you.
5
Sure, I would like a policy that costs less, covers more, and has few restrictions. But this is not Fantasyland. So to get me to switch from traditional Medicare plus supplement, the Advantage planners would have to provide a clear and complete item-by-item comparison of benefits and let me continue with my current doctors. For now, I'm satisfied with what I have.
26
Wow! I would love to know where Kaiser found Medicare Advantage premiums for $36 per month. If you look on the Medicare Webpage, most Medicare Advantage programs run closer to $300 per month. Big difference.
11
@joanna I have a Medicare Advantage plan with Kaiser in the Washington D.C. area and pay a $20 per month premium. (Doctor visits run $25 per visit for primary care and $40 for specialists.) Have been satisfied with Kaiser over these past nine years. Not much problem getting appointments. Kaiser really does push preventative care from my experience.
3
@joanna I pay $66 a month in Massachusetts for my Advantage plan including drug coverage. Co-pays are $10 for my primary care physician, $40 for a specialist. A hospital stay would cost me $275 a day for the first five days, $0 after that. Maximum out of pocket cost is $3400. So far (14 years) it's worked for me.
3
@joanna--I pay $0 premium above what is deducted from my SS for my Med Ad plan from United Healthcare. Primary co-pay is $5, specialist $35 co-pay, and I can go to an out of network specialist for a $50 co-pay if he/she takes regular Medicare. My plan includes drugs, and I get my tier 1 drugs for free by mail order. I also get a $50 quarterly credit for OTC items. I do know that these plans differ by state/region, so I would recommend moving to mid-coast Maine!
5
I turn 65 soon, and as a health care professional of 40 years, who has seen patients with all types of insurance, I will not touch any Medicare Advantage plan "with a ten foot pole." If you are considering an Advantage plan please talk to someone you know in health care (a nurse, or most ideally a social worker). What you will find is that the "we cover everything Medicare covers plus...." which sounds too good to be true, is too good to be true. Or at least is a big lie of omission. Services are covered but there are usually severe limits on those services under Medicare Advantage plans (which of course are run by insurance companies who want to make money for their shareholders). One example is the home health company I used to work with got a fair reimbursement from regular Medicare for visits, but lost money on each Medicare Advantage visit and so severely limited the number of visits. I will pay a little extra (and do without Silver Sneakers and other gimmicks), have regular Medicare, with a supplemental policy and a drug plan. I will pay for dental and glasses out of pocket.
84
@4Katydid I agree, but most people reading your comment do not realize that a supplemental policy is a completely different animal from Medicare Advantage. Medicare Supplement and Medigap are synonyms, Medicare Advantage is not.
21
I have traditional Medicare A and B plus a supplement through my former employer (I am a retired school district employee). Yes, my plan, plus a separate drug plan, is expensive, but it’s a pleasure to not have to obtain referrals for specialist visits and I can go anywhere for lab work and PT. I have peace of mind knowing that I can get care from almost any physician. Copays are reasonable. My plan covers Silver Sneakers, which is wonderful. I belong to two well equipped gyms at no cost and have access to all classes and facilities, not just the classes geared for seniors. With a chronic condition for which exercise is the most effective treatment, not having to pay for all this is a blessing.
2
@4Katydid I have traditional Medicare and a supplement with AARP United. My supplement covers silver sneakers and has paid every single claim in full over the last seven years (fortunately very few). I am thankful every day that I have this coverage and that it is free of brain damage. When one doc was "too busy' to deal with my problem, I just picked up the phone and called another, got in right away and problem solved. I get my dental care and glasses in Mexico and save even more. Just saying.
It will be revealing to see what provisions are made for the disabled who receive Medicare ( and Medicaid), but are under the age of 65. Many of the services and needs that these people require go unmet. Many states allocate too little money under the Medicaid waiver program. Hence, many people wind up in institutions where costs are astoundingly higher, the care less appropriate ( such as for the developmentally disabled) and least desirable setting for the person and their expended families ( if they have one.) Medicare for all is truly the very best solution for a single payer health care delivery system in very respect.
13
@Mark
Medicare does not cover custodial care (nursing homes) or home health aides. They are covered for the poor by Medicaid. The states are obligated to pay for nursing homes, with the federal government covering 50% of the bills.
Medicare for all would not cover home health aides or nursing homes. that is only for poor people.
1
Looking forward to more specifics on eligibility for additional benefits offered by these plans. The article suggests that some may well be restricted to Special Needs Plans, which limit enrollees to those with specific diagnoses and conditions. In addition, under current rules, if a beneficiary enrolls in an Advantage Plan when he/she 1st enrolls in Medicare, he can return to original Medicare after one year and enroll in a Medigap plan regardless of his health status. After the 12 month “free look” tho, any Medigap policy will be subject to underwriting and acceptance NOT guaranteed. New Medicare beneficiaries and current Medigap enrollees need to review their options very carefully before jumping the original Medicare ship. Advantage Plans are reportedly, and not accidentally, very profitable for private insurance carriers. Consult with a SHIP (State Health Insurance Assistance Program) for free, unbiased advice and READ THE SMALL PRINT!
23
Locally, the dominant hospital chain here offered an Advantage plan that was quite generous, if one could accept their captive network. The plan went out of business earlier this year due to losses and I had to scramble to find a replacement by April 1. It is quite daunting to compare the plans and select the best.
There is some self-selection for Advantage plans. For healthy people, at least locally, the larger copays should add up to much less than the monthly Medicare supplement premium for comparable medical care. The network offered locally is more than adequate. Plus the extras are not available with traditional Medicare.
The downside is that we could be subjected to underwriting restrictions or rejections for supplement plans if we later either decide traditional Medicare plus supplement fits our needs better or are forced to leave Advantage because of a move to a rural or underserved area with insubstantial networks.
5
@Bruce Michel
Medigap plans are not subject to underwriting: they have to accept all comers. But they are age priced, so the older you get the more expensive they get. They are also priced by location, so if you move somewhere medical costs are high, like a rural area, the premiums are going to be higher.
When i read, "thanks to Congress, the list of benefits could expand even further," I thought something was wrong. What? This Congress helping citizens get a healthcare benefit? That's impossible. Republicans don't want people having access to healthcare. They're sabotaging the ACA and are plotting on cutting Medicare and Medicaid as we speak. Sure enough, the article is about Medicare Advantage -- a program that gives public money to private insurance companies which then figure out a way to profit from the scheme.
67
@Tim Agree that this is fishy... in my experience of 40 years as a physical therapist, Medicare Advantage plans have always been deceptive to 100s of my patients. Of course my goal is getting needed care for my patients, not making a profit for an insurance company. Whenever a friend or family member who is approaching 65 asks about coverage, I start my "sermon" by saying that the claim " We cover Everything regular Medicare plus...." is a great example of the saying " if it sounds too good to be true...." Consult your state's SHIP office.
12
Yay, Ron Wyden. As a former Oregonian, please note how often this man sponsors citizen-friendly legislation"
1
I believe, if you check, that Medigap plans are not allowed for beneficiaries of Advantage plans.
6
Great, another reason for the insurance company to raise our rates. They should be looking for ways to lower costs not add frills that few will use but we will all pay for.
3
For 2018, my Part C plan doubled the deductible -- now $8500 -- the copays for doctor visits, labs and meds and ER fees. Part B costs rise every year: $108, $117, $124, $134. Social Security COLAs don't keep up.
I'm 70 years old, in good health if you don't count asthma and a coronary stent five years ago. I eat well and exercise daily and have no complaints.
This year, my medical costs will exceed $3000 -- my third biggest outlay after the mortgage and property taxes.
I think it's a lot to spend for such a routine medical profile.
12
@Occupy Government
I'm not quite old enuf for Medicare, but as a self employed Ohio resident, I pay close to $700/mo in premiums with a $6400 deductible and I can only see doctors or use facilities connected to a Toledo, Ohio provider (Promedica). Get sick someplace that's not Toledo? Nada. Want to see anyone a specialist at Cleveland Clinic or U of M? No way. I cannot wait until the time when my annual health care spending tops out at $3000. Oh my gosh. That sounds like heaven.
6
Medicare advantage is great if you are healthy. Everyone I know buys traditional Medicare with medigap.
50
Pardon my skepticism, but given the current credibility index (low) of the current administration and Congress, I worry that many unsuspecting seniors could get caught in a bait and repeal scam.
39
Your worry is valid. Those seniors signing up save money and generally are pleased
UNTIL they have a catastrophic medical event.
14
sounds good..BUT remember the managed care plans (for that matter companies which offer supplements too) need a strong/consistent " bottom line" to survive..., although the expansion sounds good on paper , consumer need to be wary for the long term
10
@jackpine2: you can choose a new Medicare Plan every year in the enrollment period (Oct-Dec). In fact, Medicare Advantage offers you an "opt out" after 3 months if you hate it, and you can return to regular Medicare without a penalty.
3
@Concerned Citizen: So you can "opt out" after 3 months?
That means you're still STUCK for 3 months if you need a hip replacement or a knee replacement, or other major procedures, and don't like any of the docs in their network!
3 months is a long time to wait to get to the right doctor.
My husband and I have been with Kaiser forever. It totally made sense for us to continue with their Medicare Advantage Plan when we reached Medicare age. Coverage with ANY HMO is seamless. What YOU have to do is learn how to manage the managers! Speaking -medicine- helps. It is definitely a second language and not for all.
12
You can speak the language all you like but you have little right to appeal a hospital discharge, rehab or skilled nursing facility denial under the plan once you get sick. The third party insurance case manager and medical director are not concerned about your well being - bottom line is saving money.
8
Also, remember, the Medicare Advantage plans are case managed and your health care needs will need to be authorized based on your medical condition. A beneficiary can be denied services if one doesn't meet the insurance company's criteria. I am a hospital case manager. I know when my time comes, I want government issued Medicare A&B and I will be happy to purchase both supplemental plan and part D for prescriptions. It is called Comprehensive Coverage that most of us will require as we age.
109
@Louise
The no out of pocket maximum for traditional Medicare motivates some to use Medicare Advantage.
Keep in mind, also, that although Medigap has to take all comers regardless of health, the premiums are rated for age, and get progressively more expensive for older participants.
MA plans charge the same price for all participants.
@Louise: the standards for both regular Medicare and Advantage are pretty much the same -- the only difference is Advantage uses preferred providers, who have negotiated with them for lower charges. You do need to read over the contract (each year; it changes) and if it does not suit your needs...you can CHANGE PLANS every year in the enrollment period. Back to regular Medicare, or Medigap, or a DIFFERENT Advantage plan (they are not all the same).
Most people don't "get" the benefit of Advantage -- it's the NO PREMIUMS. If you are reasonably healthy, you could have low or even no charges for the year and STILL BE COVERED for all your benefits.
In your early Medicare years -- 65-72 or so -- if your needs are minimal, you can save THOUSANDS OF DOLLARS and put it towards care in your later years.
With regular Medicare, you pay monthly Medigap fees REGARDLESS of whether you need care or not. If you are sickly, and need to see the doctor every couple of weeks...Medigap is superior (no copays). If you rarely see the doctor, then Advantage is superior because there are NO PREMIUMS. The typical Medigap premium is roughly $350 and about $4200 a year. Advantage has a CAP of $4200 a year. So if you use that much care...its a wash. If you use LESS care...Advantage comes out ahead.
What Medicare Advantage plans give, they can take away or obfuscate. Grab bars and $22 per hour aide coverage is nice but Part C insurance providers will present you with a plan that determines where you can get your health care (and it is not anywhere they accept Medicare), what your premiums are (if any), co-pays and deductibles and it may provide some sort of Part D coverage.
What I want is the right to go wherever my diseases or chronic conditions are best treated and no keeping track of co-pays and deductibles which is original Medicare.
Original Medicare plus a Part F supplemental insurance plan (which covers everything Medicare payments don't but that are allowed by Medicare) is what gives most everyone the comprehensive medical care they may need (drugs not withstanding) without being wiped out financially. Of course, Medicare does not provide long term care which is Medicaid's job if you run out resources. But rest assured, "New Perks" from Part C coverage still require that profits are made.
54
@Emergence
True...Medicare Advantage is basically privatization of Medicare, which the Republicans love. I want to hold on to my original Medicare as long as I can. However, I am also paying high premiums for long term care insurance; my policy does cover some home health care and adult medical daycare but am not sure how long I can deal with those premium increases. If I have to drop it, where does that leave me? At the point at which I will have to look at an Advantage plan unless original Medicare beneficiaries are afforded the services newly available in Advantage plans.
6
@human being: Medigap and Advantage are NOT privatization -- they are SUPPLEMENTS to your original Medicare. Medicare has NO CAP -- and you pay 20% of costs -- meaning you could theoretically owe hundreds of thousands of dollars for a very prolonged, serious medical problem -- cancer, heart transplant, etc.
Long term care insurance is tricky, as the costs are obscene and most people cannot afford it. And the insurers are FLEEING the market and canceling policies -- OR they pay out far less than the true cost of a nursing home -- OR they renege entirely on the contract, because the costs of nursing care in some parts of the US now top $18,000 PER MONTH (do the math!). There is no insurance that can ensure you against those expenses, which could run for 10 years or more.
@Emergence: people really need to be doing stuff like grab bars themselves. That is not the place for HEALTH INSURANCE at all!
Health aides are very costly and if widely adapted this ALONE could sick Medicare -- so be careful what you wish for. The cost of a health aide 24/7 is $180,000 a year!
8
Having lived on both sides of the 49th parallel I'm struck by both the complexity of American health insurance and the prescience it demands of its consumers.
86
@James Gaston - Original Medicare plus comprehensive Medigap insurance is incredibly straightforward with no deductibles, no co-pays and no provider restrictions. Original Medicare is the model care for everyone but everyone must pay into it one way or another. If we could only get drug costs under control.
40
@James Gaston
And I'm struck by what a quality/financial mess that national health services truly are --
https://www.wsj.com/articles/u-k-s-national-health-service-struggles-wit...
Your taxes are going up, because the truth is emerging. Good luck, sir.
2
@James Gaston: it's actually pretty simple and there are "facilitators" to help enrollees all over in November each year -- at supermarkets and malls and online or the phone.
Medicare is actually single payer, very similar to Canadian single payer. I believe you guys ALSO are permitted to buy "add-on" policies to give you extra services, prescription drugs, dental and vision -- this is similar.
3
One of the concerns about the Medicare Advantage plans is that they are "for-profit" plans; in fact the companies selling them are given extra dollars than traditional Medicare is allowed. The plans are generally explained to potential enrollees by "representatives" who are paid for signing up participants who met the companies' requirements and --one assumes--will not cost the Advantage plans excessive money.
In my mind, it is like the private school version of education where the costly students who need special services are left for the public system while the private system tries to keep enrollees with great statistics.
The changes discussed in Paula Span's column seem like common sense improvements, however, with a "for-profit" system one always has to ask "Who is benefiting from the money being spent?" Will the cheaper non-medical improvements become the first choice rather than a supplement?"
43
@Lynda: there are just a form of Medigap coverage, but more comprehensive. You give up being able to choose "any doctor or hospital" for their network, which is JUST LIKE most people's existing PPOs or HMOs.
ALL Medigap policies plus Advantage are able to sign people up in the ENROLLMENT period -- every year! -- and you can change plans EVERY SINGLE YEAR if you wish. All Medigap/Avantage plans have to take ANY senior on Medicare who signs up -- they cannot cherry pick customers!!!
You are quite wrong about Advantage. I handled Medicare for my senior relatives -- put them into Advantage -- they were very happy with every service, and for some, was a significant cost savings.
4
@Concerned Citizen: " You give up being able to choose "any doctor or hospital" for their network, which is JUST LIKE most people's existing PPOs or HMOs."
That's exactly the issue: You give up choice, and you are at the mercy of whoever is busy denying or delaying care that day (remember the Aetna exec who admitted he never even read the cases he was asked to "review" for appeal?)).
I *hated* dealing with PPOs and HMOs for the past 40 years (for coverage through my employers) - I spent so many hours on the phone (on hold!) and had to put in quite a few appeals and complaints to get the care I needed. They did not have MY best interest at heart, that's for sure! My doctors were also inconvenienced by having to "prove" to the insurer why I needed a procedure, etc.
So why on earth would I want to continue that miserable experience as a retiree, now that I finally have a choice?
1
@Concerned Citizen
Medigap coverage is not the same thing as Medicare Advantage.
Medigap sits on top of traditional Medicare.
Medicare Advantage replaces traditional Medicare.
Paula,
What a great article. These kind of changes are things that the aging field has been seeking to promote for quite a while. In addition, I really enjoyed the way you ended the article. I work with older adults and they often share their troubles navigating and understanding all the different Medicare plans (both advantage and non-advantage). Each plan has different benefits, networks, and co-pays (which is particularly important for older adults whose sole income is their social security check).
One of the things I worry about the amount of energy and time it takes for older adults to purchase the correct Medicare plan for them. In addition, as companies increase their supplemental benefits, will Medicare become more difficult to navigate. I am worried that in the future that people will select a plan based on their "name-brand" recognition, rather than a plan that would provide the best health-outcomes for themselves.
28
@Andrew
If you choose an independent insurance broker that represents many plans they will navigate the differences and help you make an informed decision each year if necessary.
Advantage plans are great when your healthy but have maximum out of pocket costs ranging from 3400 to 6700.
Copays like 20% of a bill for radiation treatment...395 a day for inpatient hospital care etc.
And, many institutions are not accepting advantage plans.
A medigap supplement yearly is much less with no copays and you can go to any dr. Or hospital that accepts Medicare.
As we age we won’t get healthier and things can change on a dime.
This isn’t car insurance folks, it’s your health coverage!
23
@Sue
Traditional Medicare has 20% co-pays after the deductibles [parts A, B,D] and no out-of-pocket maximums. OOP caps of $3400-6700 after deductible and 20% co-pays sounds much better than unlimited OOP.
A disadvantage of Medicare Advantage plans is that they are geographically limited, so not appropriate for people who travel or snowbird. Anytime you are away from home, you are out-of-network.
An advantage is that anyone who signs up for a particular MA plan pays the same premium, regardless of age.
Particularly with people who travel or have more than one home, traditional Medicare, plus part D plus a medigap policy, although it is more costly on a per month premiums basis will be acceptable to any physician who accepts Medicare patients, so there is not network problem. You trade off higher premiums for lower co-pays and a cap on out-of-pocket maximums.
A disadvantage of medigap plans is that although insures have to take all comers regardless of health or pre-existing conditions, the premiums for older participants are higher than for younger participants. A 65 year old new participant would be charged a substantially lower premium than her 90 something parents, for the same plan from the same insurer.
It is worthwhile to be familiar with your personal health conditions and lifestyle preferences and to review your situation annually with a licensed insurance broker.
I would never use Medicare Advantage for the exact reason stated, namely: You're stuck with in-network doctors, and the network shifts "by the minute," as the article states.
I'm not interested in playing a 3-card monte game with my health coverage. Over many years I've found myself some very good doctors - many of them are specialists - and I'd have to be insane to risk those relationships & the level of care I get.
Medicare Advantage could tell me any given doctor is "in-network" today, but when I need an appointment with that doctor next month, I might find out that now she or he is "out-of-network." NO THANKS!
164
@L And that's fine for you. However, I am in good health, have a GP who is in my network and have rare use of specialists other than once a year visits. Rather than pay thousands of $$ per year for Medicare and a supplemental plan, I have no monthly payment, get dental coverage, gym membership, no copay for my GP or for eyecare and small copay for specialists who do not need any referral. Yes, I am limited to in-network but if you don't have extraordinary needs, you might find it more advantageous, and remember you can change every year.
9
@skeptic -- one's health care needs can change in an instant.
36
@skeptic
Yes, your health can change. When it does,
your right to buy a Medicare supplement plan
(Medigap plan) varies with the State where you live. In some States, your only guaranteed right to buy a Medigap plan is the Federal right to purchase within the 8 months of your original eligibility for Medicare. You could later be subject to medical underwriting by the insurance company----where the company charges you a higher premium based on your pre-existing conditions and your age. Insurance companies can even refuse to sell you a policy! Other States are
guaranteed issue for Medigap policies, regardless of health status or age.
3
I am an internist specializing in geriatrics. I chose Medicare Advantage for myself. Traditional Medicare supplements are way over priced--by about $200/ month. You could self insure and after about 3 months be better off (statistically) self insuring.
I work with one large medicare advantage program and my patients and I are very satisfied with it. It's good for them and I get paid with little paper work.
Are 1/3 of Medicare recipients stupid? No. They are cost conscious responsible adults who have chosen what works for them.
Traditional Medicare is fine, too. It should be the national system. offered to every American.
Yes, every American would be able to purchase Medicare, either Traditional or Advantage. Man, that would create true competition and would lower health care expenditures down to European levels.But our venal politicians won't allow it. They are all in the thrall of the health care lobby.
243
@Michael Plunkett MD Anyone applying for Medicare should keep in mind that Medicare Advantage plans restrict where you can go for your health care but not original Medicare. For the serious diseases many of us will get as we age like cancer, cardiovascular and autoimmune disorders, complex or cutting edge treatments are not equally as effective or available anywhere you go. Outcomes and availability vary quite a bit.
32
Good for you. My husband and I were forced into an Advantage plan in order to maintain employer coverage. We were also not told about the issue of precertification. We learned the hard way. My husband required massive open heart surgery to be followed by doctor prescribed acute rehabilitation not approved by the insurance company. After appeals denied, my husband’s recovery was severely compromised and we are paying big time in quality of life. Traditional Medicare would have covered the acute rehab no questions asked. We are now on traditional Medicare and supplemental all at our own expense, but the damage is done, and we’re protecting ourselves for the future. Oh, and BTW, Advantage insurance is refusing to pay some providers many thousands of $$ which had been approved. Throughout the health care industry it’s called Medicare Disadvantage. Buyers beware.
16
The piece you need to lower American costs to European levels is an all-payer fee schedule. Original Medicare gives you this -- if it were made universally available, including the fee schedule -- that would go a long way towards cost control
1
I have a Medicare Advantage plan through United Healthcare and I love it (switched this year from Humana, which was a nightmare). My premium is deducted from my SS, and I pay no extra premium above that. All the docs around here accept it. I have a $5 co-pay for my primary, with a $35 co-pay for specialists. If a specialist is out of network the co-pay is $50 because my plan is a PPO. My Tier 1 drugs are totally free and sent by mail. I get a $50 credit every quarter for OTC items, which covers my CoE Q10 (very expensive in regular drug stores). ER is covered all over the world. I could go on and on about the benefits--I recommend checking it out.
17
@kanecamp Good to know. I just looked at the Arizona state health insurance website (followed the link in the article) and didn't see any advantage program that offered nationwide coverage. As we are still traveling a lot, e nationwide coverage is essential.
3
@kanecamp: If you need a hip or knee replacement, do you get to choose the BEST doctor in your opinion, or are you stuck with maybe some 2nd-best that participates in your network?
My own orthopedist, who is nationally top-ranked (and a very fine person as well), is NOT in any Advantage plan's network. As a person with orthopedic issues, that's a deal-breaker for me.
12
@L--As I mentioned above, out of network docs receive a slightly higher co-pay from the patient ($50 as opposed to $35). This is because it's a PPO, not an HMO (where out of network docs are not paid). If they take regular Medicare they also take this insurance.
2
I am a Utilization Review nurse so I deal with all manners of insurances for the hospital I work for. I understand how appealing an advantage plan can be to many seniors, but do keep in mind it acts like a traditional commercial insurance. You must get pre-approvals and referrals that standard medicare does not require. I have had many senior patients and physicians express frustration to me about a certain medication or piece of medical equipment being denied because it has been determined 'not necessary' or out of network.
There are behind the scenes issues like admissions being being denied as not medically necessary despite meeting our government mandated outlines for medical necessity. Often this leads to the hospital being compensated very little or nothing at all for the patient's hospital stay.
Humana and UHC are some of the worst offenders in my experience. I'm not trying to vilify anyone. I know of many people who have these plans are quite happy, but behind the scenes can be a whole different story. My parents are in their mid 70's and have straight medicare A and B with a supplement and are very happy with their coverage. I just recommend to anyone looking to sign up for an advantage plan to do their research very carefully.
161
To me, it comes down to this: If you're looking for coverage by a for-profit insurer, who will require pre-approvals, pre-certifications, and limit you to using providers in their network, etc. - then you want an Advantage plan. They are going to make their profit by limiting providers & making you jump through certain hoops for the care you may need - so your premium may be cheaper, but you may find that you're paying in time & aggravation.
But if you'd like coverage that is NOT trying to make money off you, and to which the greatest number of providers in the country belong (& which doesn't require pre-approvals or pre-certifications), then you want good old MEDICARE.
I lived with enough stress & denial-of-coverage from the for-profit insurers I had to deal with when I was working full-time; I will not deliberately yoke myself to the for-profit system again now that I have retired.
158
I worked in this field for many years. Advantage plans are popular but there is a major problem for satisfied enrollees. Many Advatage plans are offered through large insurance companies and the insurance companies do not have to stay in the market. A satisfied enrollee can suddenly find the plan they like will not be available the next year and there is no alternative other than traditional Medicare. The Advantage plans that work best are those offered by local plans who have an investment in the community.
18
This year my husband had 22 radiation treatments (out of what would have been a total of 30) for brain cancer. He became too ill to continue and passed away at the end of June. He had regular Medicare and a supplemental policy with AARP (United Healthcare). The projected cost for the 30 treatments was $89,000.
Since his radiation oncologist accepted Medicare assignment and UHC paid the 20% Medicare didn't cover, we ultimately paid $0. Somehow, I don't see Medicare Advantage working that way, since those insurers are for-profit. It scares me to think what I might have been liable for if we had gone that route.
115
@TexasBee
I am so sorry to read of your husband's passing.
You are so correct to point out the big difference between original Medicare and an 'Advantage' plan.
I posted below ... different situation, but my husband had a lengthy & unusual medical incident, and we, too, fortunately, had essentially $0 out-of-pocket, and access to any and all providers and testing -- necessary access across multiple disciplines to track down and treat a 'zebra' diagnosis.
I don't believe for a moment an Advantage plan would have been nearly so comprehensive or inclusive.
Your posting will help people think more broadly and critically about their choices. Thank you for sharing your difficult personal experience. Best to you.
39
@jazz one
A comparison: Under a standard PPO from BCBS at $134 a month I had to pay $4154 copay for my 44 radiation treatments for prostate cancer. I also had two $269 copays for my chemo shots.
I will look at other plans this year.
1
I am an 83 y/o retired orthopedic surgeon.
1. advantage plans have gate keepers and their practice is monitored by the Insurance company so they are reluctant to refer patients.
2. The insurance has a preferred provider group so you do not get to pick your doctor.
3. The frills are offered by insurance companies to entice enrollment.
4. What is most important is good medical care when you need it not frills.
5. Means tested high deductibles should be instituted to keep costs down. Skin in the game is necessary.
6. Congress is on the take to the insurance companies and supports advantage plans at our expense.
7. Keep your standard Medicare and pay for a supplemental plan.
8. Tell your Congressman to do away with advantage plans or vote them out of office.
167
This contradicts my experience with my MA plan. I was able to keep my Primary doc, and the bills for dental, eye, and medical have been less. Especially for my total hip replacement.
5
@ring0 Medicare would have done the same. You had to select a doctor that was on their list. These are not always the most proficient. Choice in health care is more important than getting eyeglasses or dental cleaning.
2
@Vincent M Tedone MD FAAOS thanks for a great summary. In my practice as court-appointed conservator, I learned to avoid advantage-type plans for seniors. Worst recollection: hospitalist informing me that senior had to be discharged from hospital AMA because she was costing the insurer too much $.
18
I was shifted to a MAP through employer supplied retiree insurance. I was on Medicare for 7 years and first 7 years had choices between different plans. Then, the company stopped all choices except an Advantage plan.
I can compare plans with home made spread sheets and experience in billing (retired physician).
I thought I would give it a try. Notable differences between Original Medicare + Supplement + part D and MAP is that the MAP has co-pays, co-insurances, limited network, and I didn't have coverage for travel out of country. Covered medications and co-pays changed and needed pre-authorization for commonly taken medication. When I received information for second year - Surprise - premium had gone up substantially!
Looked closely at Original Medicare+Supplement+D and found this allowed full choice of doctors, no referrals, travel coverage through supplement and no co-payments, co-insurances, networks. Bills are covered quickly and I haven't had any bills and I had two surgeries and many procedures, labs and doctor visits on Original Medicare. Premiums also lower than on MAP.
Look carefully at all the plans you consider. Do the MAPS or supplements exclude you for pre-existing conditions, require medical clearance to join, or charge higher premiums?
I am glad I am now on Original Medicare. I think the new benefits which will be given by MAPs should be available to all Medicare patients.
Universal Health Care Coverage for all - support these bills in Congress.
168
@joyce AARP and its "preferred" insurer, United Healthcare, refuse to offer it, but High Deductible Plan F is a good deal for many people. Even in an expensive insurance state like NY, it costs well under $100 a month. I think I pay about $70 a month. Don't know if it figured in your calculations, but for many people like you, who want to get out of corprotate retirees' advantage plans, it could be an appealing option.
3
While you have to applaud the kind of stitch in time common sense approach to care for the elderly, you have to shake your head at the clear development of a two tiered system. And once again, those who have money will be literally “advantaged.” A two tier system of care for the elderly because Congress won't spend more money to expand the regular Medicare to include common sense care. Golly, why is this not a surprise?
59