Isn’t Joe Namath a pitchman for Medicare Advantage. Of course he knows nothing about healthcare or medical insurance.
The advantage in Medicare Advantage is profit. Profit that goes to bureaucrats and computer record jockeys whose job is to spend less on health care, and increase salaries for the private insurer (Medicare Advantage is just a private insurance plan paid by the government, and privileged by the government to lie to you and rip you off). Profit is the malignant cancer that has killed decent affordable healthcare in the U.S. I am a physician, I see the scam at work. Skip the for-profit hospice on the way out, they are a rip off too.
7
I had Medicare for a couple years, then joined a Medicare Advantage since they would save me money but Advantage plans are equated with Medicaid by doctors. They pay even less than Medicare! I found it very hard to find a good GP. The insurance company gave me a few names, but it was just as this article says--either they weren't accepting patients or didn't participate in that plan. I had to make a lot of calls to find a GP of any sort. I was also concerned about being stuck in an HMO again, but it all worked out, even with a surprise major illness. I'm fortunate to live in a city with many top hospitals that accept these poor paying plans. However, hospitals with large numbers of Medicaid and uncovered patients eventually go bankrupt.
4
The health insurance provider (Fidelis) I chose through New York State’s healthcare marketplace provides a large directory of participating physicians. Impressively full of options. I’ve had the insurance for two years and now know that trying to find a doctor who accepts the insurance requires phoning office after office in the list in search of a doctor whose information is up to date, and who actually accepts the insurance. The compnay’s online physician list is no more accurate. The insurance company customer service when contacted for assistance (after a fruitless search for a specialist) said that it is up to each doctor to inform them of they no longer accept the insurance, otherwise their name remains on the list. Like a dating site that boasts an astronomical number of ‘members’, including accounts long dormant, with only a subset actually current, finding a doctor through this type of plan is the old needle in a haystack search.
7
Not surprising, I had to enter my doctor three different ways for my ACA coverage to show my doctor, his name, the practice’s name and the address.
1
Jeebus. Let's skip all this complicated "planning" and all get a single payer system.
9
Medicare Advantage plans were set up to save the government and patients money, certainly not to improve care. They typically choose providers and hospitals willing to accept lower reimbursement rates. Although this doesn't necessarily mean that they aren't as 'qualified', it does mean that the network hospital may not be the best choice for complex medical care. It also means that there will be medication and physician network restrictions.
This alternative exists because the United States hasn't been able to figure out how to provide good, accessible care at an affordable price. Instead the medical and pharmaceutical industries are allowed to push prices to what the market will bare. When patients have little skin in the game and insurance companies are still able to make a profit, little will be done to cap prices because we are driven by dollars, not by the value of humanity in US.
That being said, the VA works because its physicians are salaried. There are no incentives to do unnecessary testing and they have a centralized patient database so there is less redundant testing and more patient continuity, leading to lower costs.
Groups of government salaried physicians in the private sector agreeing to provide evidence-based care competing with the private industry could provide real market competition.
Additionally, a national, free online medical education program for patients could potentially reduce dependency on the medical apparatus
7
I have always belonged to a Medicare Advantage Plan since I turned 65. They provide great benefits and here their network is OK. Big problem is everything changes every year. Two years going the company I was with pulled out of NY, another time the plan I had was just canceled. Too bad they cant provide some sort of security.
5
I'm a solo practice internal medicine physician, and Medicare Advantage plans are an endless headache for my practice. First, a number of local plans didn't allow me to join because I'm affiliated with a local teaching hospital, which isn't the cheapest hospital in the region. Second, the plans change each year. When I signed up, I was given a list of the plans that I was allowed to participate in and the plans that I was not allowed to participate it. A few years later, most of the plans have been replaced by new plans with different names. I try my best to keep up with these changes, but this often means spending over an hour on hold with the insurance company only to speak with a clerk who knows nothing about the new plans or my contract status. Sometimes I don't know if I'm in-network until I try to submit a claim. It's a terrible system for everyone involved.
17
@Roger
i worked in a doctor's office for many years before my retirement. there are many stories to tell about tricks that insurance companies used to deny/ shortchange payments to doctors. 10 years after my employer pulled out from an HMO, we received call from a potential patient. we told her that we were no longer participating in her plan. she was furious because she signed up with that particular insurance company mainly because our doctor was listed in the insurance directory. i suspect the insurance companies purposely not updating their directories to attract new enrollees.
12
As I approached Medicare age, I did extensive research into the plans that were available to me. Even after visiting a specialist in Medicare plans and enrollment, I was left feeling like I would never understand all the nuances of this convoluted retirement health insurance(?)
I was right. It's impossible to comprehend and just when you think you've got it all figured out, something changes and you're left wondering if it will affect your coverage, or worse, if you'll have any coverage at all.
I decided to join a Medicare Advantage plan and I certainly lucked out. I guess all that research paid off. I found a wonderful primary care physician, who actually cares about her patients and who saved my life last summer.
I've had 3 surgeries in 14 months. I've had superb care from all my doctors and the hospital that treated me with the utmost care and professionalism. I'm lucky, humbled and satisfied beyond measure with my Medicare Advantage plan.
4
In fact, the "you can keep your doctor" claim has never been the case, even before Obamacare. Health plans tend to negotiate annually with network providers, so changes are possible at least annually. Also, health plans are notorious for not having real time or even nearly real time accurate directories of their network providers. There are some states that are enacting legislation to require health plans to maintain accurate provider directories, but the plans only do it if the law requires them to. Every health plan in the country should be mandated to post current and accurate provider directories online.
12
Years ago, doctors were fleeing fee for service traditional Medicare because the reimbursements were bad. Who knew that a couple of decades on we’d be more excited about FFS Medicare than commercial plans. The irony!
5
Lost in the “Bernie wants to end private insurance” panic is that this is exactly why you bar private insurance from duplicating coverage of services covered by the government. If Medicare For All is the only coverage, there is no incentive for providers not to accept that coverage. Which means EVERY doctor is in network, so even if a person might lose their personal coverage, they won’t have to change doctors unless their doctor moves or retires.
12
@Benjamin Hinkley
//If Medicare For All is the only coverage, there is no incentive for providers not to accept that coverage. //
Not quite. If Medicare for All is the only coverage, and doctors aren't happy with the payment schedule set up by the government, they are free to not provide that service at all. They move to another specialty or leave for other countries - like a lot of Canadian graduates do.
Access in rural areas is a huge problem in Canada. It's not just that it's not financially feasible to set up a practice in the middle of nowhere. Supporting services like blood labs, ultrasound labs, etc. aren't there to support the general practitioners.
2
@Viv - You fail to provide ANY numbers & NO references. Here is some with references:
"Except for Austria & Germany, fewer doctors were satisfied practicing medicine in the United States in 2009 than in any other surveyed country. That includes Canada."
"The Canadian Institute for Health Information has been tracking doctors' destinations only since 1992. Since then, between 60 & 70 percent of physicians who emigrate have headed south of the border. In the mid-1990s, the number leaving for the U.S. spiked at about 400 to 500 a year. However, in recent years, this number has declined, with only 169 physicians leaving for the States in 2003; 138 in 2004; & 122 in each of 2005 and 2006. These numbers represent less than half a percent of all doctors working in Canada."
https://www.washingtonpost.com/blogs/wonkblog/post/meme-busting-doctors-are-all-leaving-canada-to-practice-in-the-us/2011/06/03/AGVdAuHH_blog.html?utm_term=.aca286cc7cc8
This myth is similar to the myth that many Canadians come to the Us for treatment.
"As noted above, 0.5 percent of respondents indicated that they had received health care in the United States in the prior year, but only 0.11 percent (20 of 18,000 respondents) said that they had gone there for the purpose of obtaining any type of health care, whether or not covered by the public plans."
https://www.healthaffairs.org/doi/full/10.1377/hlthaff.21.3.19?HITS=10&hits=10&andorexactfulltext=and&searchid=1&RESULTFORMAT=&maxtoshow=&fulltext=snow&
4
@Benjamin Hinkley Ah but they can also not accept any insurance at all and just accept out-of-pocket payment, an increasingly common practice in the NY metropolitan area.
1
Once you join a Medicare Advantage plan you can go back to traditional Medicare but you may not be able to get the necessary supplemental Part B without medical underwriting. Those applying for Part B after the initial Medicare eligibility period are subject to scrutiny of their medical history and rates may be raised above the community rates.
Also, many MA plans choose physicians from exclusive IPAs, Independent Practice Associations, which can form narrow networks without notice or warning. I was a member of an IPA that had 37 ophthalmologists that suddenly threw out 36 and kept one. Narrow networks allow the IPA to exert economic pressure on the remaining physicians, in other words to lower rates. Once a physician's practice is made up of exclusively IPA patients, the IPA essentially controls the physician.
Another pitfall is the ACO, the Accountable Care Organization, which essentially places the traditonal Medicare patient in an HMO without his/her knowledge. Physicians form an ACO, usually through a hospital, and agree to refer patients within and not outside the ACO. The ACO is given a bonus if it limits expenditures and a penalty if expenses exceed the average. I don't know whether patients ever know their primary physician is in the ACO. Fortunately Trump is limiting this program as it isn't saving money.
6
@Jon
Key point, I'm glad to see it addressed by you.
Husband had been 'switched' via 'senior insurance agent' to a Medicare Advantage plan years ago. We(he) made the switch back to normal Medicare + were able to carry the same supplement ... but this was almost a decade ago.
Have learned since that there is only one - 1 -- 'switch' opportunity per lifetime, and after that you're stuck with a Medicare Advantage Plan forever.
We will never go that route unless forced to by bigger changes within the system.
Also have learned that we are essentially stuck with the supplemental carrier we chose a decade ago ... as yes, any new application would require 'approval' -- and could exclude things.
Which is rich -- as the supplement covers less and less, following Medicare cuts.
An exhausting shell game that continues until death.
6
@Jon Thank you for taking the time to share such valuable information!
1
I'm a veteran over 65 with VA health coverage and a Medicare Advantage plan. For me, it's the best of both worlds. I have Rheumatoid Arthritis, which requires me to take an Enbrel injection weekly, (very expensive copays under Medicare Part D), so I see a VA Rheumatologist. I get most of my drugs from the VA with $11.00 a month copays.
I just had a colonoscopy done under my Medicare Advantage plan at a local doctor's office, ($0 under Medicare), instead of driving 125 miles to the VA Hospital in Houston. I have access to the local VA Clinic if I need it, and my PC Physician with my MA plan also.
BTW, my wife has traditional Medicare with a part B supplement and part D coverage that works well for her. As long as we can afford it, she will keep that plan. What started as a $89 a month part B plan is now up to over $300 a month. She has severe RA, so the part D deductibles are high, as are the 33% copays for the Enbrel that she takes.
The real problem is the runaway cost of prescription drugs. When she first started taking Enbrel 12 years ago, the retail cost per month was $1200. It is now over $6000 a month retail. Have their manufacturing costs gone up that much in 12 years? You would think the cost should have gone down. Until we address drug costs, everything else is just hot air.
My point is do your homework, and figure out what is best for you. I'm lucky to have more options than most.
10
I wanted to find a different physician, after my plan approved one started requiring me to make appointments for every 3 months supply of medications I've taken without issue for 10 years, ad each time they'd require that I fill out a complete medical history on paper. I'm a healthy, active 66 year old.
Of the 240 choices I was presented as internists, all were specialists like wound care only, chemical dependency only, and cancer only care/ I failed to find an appropriate physician. I had to make over 30 calls to find this out, even after calling the plan's 800 number twice.
In frustration,and needing a prescription renewal, I went to a doctor I'd previously used in a city 200 miles away. Her office accepted a direct payment for a well visit that was considerably less than a premium payment. She spent more time with me reviewing my health than my previous doctor had, and I was very satisfied with my care.
Her office had all my records, including that of recent tests and office visits that my previous physician had ordered, as well as all of my previous medical history as part of a computerized system in which her physicians group participates.
I'll be cancelling my medicare advantage plan next enrollment period.
4
As a newly-enrolled Medicare consumer this year, I can share that my month’s-long research and decision-making exposed—thank goodness—the bad deal the Medicare Advantage (“MA”) choice represents.
These plans, now marketed far too successfully as the modern or better choice for anyone, are anything but. They are simply the choice of the lazy or the brand-loving, if you are so inclined to think choosing the MA plan from your favored hospital system is a no-brainer—without learning just how unlikely it will be to know your covered providers or subsequent penalties if you guess wrong.
But more critically, understand these plans, sold on the basis of low, or even no monthly fee, cover nothing until you pay steep deductibles, often with limit coverages. It’s exactly the problem now with insurance through the ACA that allows insurers to put actual protection and health care out of reach financially for so many people.
So do yourself a favor: Choose the “original” Medicare option, designed the way group health care “originally” intended. Pay the modest $135 Part B premium, pay the modest $157 premium for a “supplemental” policy that covers deductibles, out of pocket expenses, and even providers’ (aptly named) occasional “excess” charges. Then get a cheap Part D prescription plan. It’s the only real health insurance deal left, America.
33
@JP
So well stated. I agree fully, this is the best / safest way to go.
And even if one finds themselves in a higher 'tier' (based on income) that pushes Medicare premiums to a more expensive monthly ... it's still a deal compared to all the other junk out there.
3
@JP Your information is inaccurate. None of the MA (no drug coverage only available to people who can get their drugs from the VA or MAPD (Medicare Advantage with Prescription Drugs) HMO Medicare Advantage Plans available to me in 8 or ten North Texas counties have deductibles. No deductibles - not even the Annual Part B deductible. I pay the monthly $135.50 Part B premium from my SS account. Medicare sends that payment to Humana for my care. They also send Humana an annual flat fee to cover my 80% coverage instead of waiting to pay 80% of my claims. My MAPD HMO plan has a $0 monthly fee. I get my care with no deductible but there is a Maximum Out of Pocket (MOOP) for co-pays during the year. My MOOP is $3,400. To date on July 13, 2019 I have paid $0 towards my MOOP. I see my Primary Care Physician (PCP) and get all my preventative services with a $0 co-pay from my PCP. No co-pays for lab work. I have Kidney Disease and will see my Kidney Specialist on Monday for a $20 specialist co-pay. My plan includes dental care, vision care and hearing coverage at no additional premium, 25 acupuncture sessions at a $0 co-pay a Silver Sneakers membership for fitness, and $50/quarter to purchase over-the counter products. The Original Medicare Option option you promote does not cover drugs, dental, vision, hearing or acupuncture. A cheap Part D plan may not cover any of the drugs you need.
1
@JP
What? For-profit insurance companies provide inferior service as compared to Medicare, the government not-for-profit plan? Say it ain't so.
Gosh, maybe we should ALL be part of Medicare.
Just a thought.
4
Many clinics don't even know if you are covered when you mention your plan; they direct you to your plan to find the doctors they'll reimburse.
How about we try free market insurance? You know, the kind that wouldn't be limited by states, as if our health is only an issue when we stay home. No doubt it would cover percentages of fees rather than have approved/disapproved doctors who are in plan or out of network.
Government messes up the systems by regulation, then wonders how it got so bad that some think they should just run it all now that they've broken it for all.
1
It doesn't make sense to encourage people to join these advantage plans. The government pays them a fee whether or not a patient uses their service. If a patient does not go to the doctor, the plan gets paid anyway. The government spends more money on these plans than conventional medicare. It is wasting medicare money. Why is the government funneling money to these companies when it is not cost effective? This is another scam by a bunch of insurance lobbyists perpetrated on the American taxpayer.
17
@S.L.
the government is trying to wash its hands off Medicare. didn't you hear the "plans" some of our congresspeople continue to push: giving Medicare beneficiaries a set amount of money to buy insurance coverage of their "choice" ?! when most of the people get lured to "cheaper", " no premium"....plans of Medicare Advantage plan, government will discontinue traditional Medicare !
1
Some day the American people may wake up to the fact that the only thing that makes sense is a single payer system.
No more networks to figure out. No seeking out doctors who are willing to take Medicare or Medicaid as everyone would have the same insurance.
The insurance companies and their lackeys in Congress are betting on the stupidity of the American people to continue to believe that a single payer system will destroy the American healthcare system.
Every other industrialized country in the world has managed to figure this out but somehow the country which is celebrating the 50th anniversary of managing to put a man on the moon can't find the brains to do it here.
13
@Steve Insurance that has no basis in risk or usage isn't insurance.
Limited by networks and states is created by government rules that preclude fair market solutions, right up to big businesses getting to write off insurance as non-wages, while self-employed pay higher rates often on after-tax wages.
@Steve A single-payer system is a myth. If you look at the EU it is a two-tiered system. Those who can afford it (most working adults) buy secondary insurance so that they can get the type of access to the elective healthcare they want that isn't available through the public options. Providers create secondary networks that are only available through the extended insurance network. It is as complicated as our current system. In essence, what happens is higher taxes for all to cover the whole population with no better efficiency. Granted, more people get coverage. What we need are legal constraints that require all healthcare insurance Payers to be non-profit. Payers and Providers need to be independent of each other (no collusion) and all costs need to be transparent so that a market that drives competition and quality can form driven by consumers.
1
@NS
This is quite true. The UK now has a two tiered system likely stemming from overutilization of a system where the patient has little financial skin in the game. The only way you can get to the front of the line is basically by offering a 'bribe' in the form of private insurance.
But there is a very important primary reason that our systems have become inefficient. We have a healthcare system that is based on the premise that the patriarchal dispenser of care, the medical professional, is always necessary to dispense 'care'. Granted when AI finally gets incorporated into healthcare, prices will go down, but in the meantime, we need to start changing the structure of dispensing care and focus on educating the patient from childhood onward.
There should be a single national patient health information website that will educate patients on prevention, recommendations, and the basics about medical conditions and the expected standards of care. Right now, even the most educated of patients is still clueless in basic assumptions about medical issues. Registration and authentification could be required in order to provide 'incentives' for learning like reductions in premiums or coupons for healthy foods.
Additionally, giving patients tools that monitor vital signs that can be transmitted to telemedicine/offices could reduce 'maintenance' care costs. We need to start thinking outside of the box rather than focusing on the 'payer' of care.
None of these problems would exist with single-payer Medicare for All. People choose any doctor or hospital. In addition, out-of-pocket expenses would be eliminated removing a substantial barrier to care.
I do have an issue with one claim in this article, "[F]or instance, covering only doctors who meet quality standards and tend to provide more efficient and valuable care." Where is the evidence for that?
I have seen evidence that "quality standards" equates to costs for insurance companies. I have seen evidence that nobody can figure out good quality standards, which is why they keep changing. I have seen evidence that quality standards are useless (https://www.clereviewofbooks.com/home/qualityindustrialcomplex), but nowhere have I seen evidence that support the author's claim.
3
@Joseph Sparks Does your "for all" mean that you get unlimited services at the same price as someone who uses none? If so, you don't have insurance, you have an "all you can eat" system. Personally, all you can eat is great for pigs, bad for healthy eaters, and the food is never as good.
1
@David you miss the point.
People don’t want insurance, they want health care.
3
In our case, we were pretty much forced into using Medicare Disadvantage because our state retirement program only offered it this year to people in our community. Next year we will look around for a totally different plan. It's not growing because people prefer it; it's growing because the cartel of insurers and hospitals love it.
6
For the commenters who have wonderful things to save about their advantage plans, I just wonder if they think that all those TV ads and mailings extolling the benefits provided by those plans are being done because those insurance companies are truly placing the interests of the people they cover first.
Anybody who has had to struggle with insurance companies paying bills for supposedly covered services would get a good laugh out of that.
14
I think the size and structure of the HMO makes a difference. Kaiser Permanente's physicians are all KP employees. In the San Francisco Bay Area, one can choose and switch primary physicians from a fairly large base.
Specialists tend to work as an internal group, but once you have one, you can stick with that specialist if you like them. I think the plan involves a provision that if it can't provide a necessary service, it has to pay for it elsewhere. But I don't think there's much they can't provide in California, at least.
My previous experience with the UCSF connected HMO was similar. The trick, I think, is finding a sympatico primary m.d. But that's always the case, HMO or not.
2
@Dennis KP may have a good "lower cost" (but definitely not low cost) plans, but you are stuck in their network. Insurance shouldn't care about who provides the service, just that they would pay only a fixed amount. Insurance isn't even the right term for what government regulations have created in health care.
I have Humana Medicare Advantage and couldn’t be more satisfied since I pay $0 premium and get a $52.00/m rebate. It includes Medicare Parts A,B and D. It includes vision and dental benefits. If you are a healthy senior who takes responsibility for your health (diet exercise preventive healthcare)it is a cost effective. It includes deductibles, co-pays and out-of-pocket limits but having been involved in a employer HSA which was basically being self-insured. The out-of pocket limits was $13,500! Traditional Medicare has its place absolutely but its far from perfect.
2
@KB I also am a member of a Humana Medicare Advantage Plan in North Texas. My plan includes Part A, Part B and Part D. I pay a $0/monthly premium. Medicare sends my month Part B premium of $135.50 to Humana to help cover my potential costs. In addition, Medicare sends an additional amount to Humana to take care of my 80% costs. My Humana HMO network includes thousands of PCPs and specialists including many of the best doctor in North Texas from Baylor and UT Southwestern. My current plan includes 25 no-copay acupuncture visits. To date, I have paid $0 in co-pays that count toward my annual $3,400 maximum of out pocket costs. All services provided at my PCP's premises have a $0 co-pay. I am seeing a specialist next week and I will a $20 co-pay. I get a gym membership, dental, vision and hearing coverage. Many North Texas doctors no longer accept Original Medicare because they get paid more and faster than if they accept Original Medicare. I am very happy with my plan.
@KB
Good for you and I am glad you are happy.
However ... even if one is a 'healthy senior who takes responsibility for your health' ... bad things happen. As they did to my husband, out of the blue, a decade ago. And was I ever glad & grateful then that he had 'traditional Medicare' + a supplement. I can't imagine the additional headaches, stress and struggle I'd have had to navigate had his totally unexpected, Unpreventable and difficult to diagnose health crisis occurred. As it was, he got great care, recovered completely -- and I had no bills. Grateful with a capital G.
4
"People could easily stumble into a narrow network plan without knowing it. As with many things in health care, it’s hard to make an informed decision."
Some countries have national health care. We have "Ha ha, GOTCHA!" care.
18
@Frank F How is it that 50 states have all decided against building public hospitals that charge no fees beyond taxes for services provided? That's government health care. Having the government pay for private health care is scam, a theft from the masses to fund the least healthy and the rich medical/pharma system.
1
Always visit your Shine Rep at you local Council On Aging.They will clear up many issues. Shine reps are trained to present all the facts.
When presenting an Advantage Plan, the Shine Rep advised to check with all medical providers that you use. The providers will advise their acceptance of rejection of Medical Plans.
If you can afford the max out of pocket, Advantage Plans can be very good.
Please let us not corrupt this process with politics.
1
This problem is true for all insurance companies for all doctors. Complete incompetence is acceptable because it helps promote profits over people.
6
Most of us on medicare are best served by adding a traditional medicare supplement rather than a medicare advantage plan. The traditional supplement does not have a network. The medicare supplement may cost a few dollars more a month than an advantage plan but is worth the expense.
12
The author and his editors completely ignore the reality that real patient outcomes are not available for Medicare Advantage plans. Coverage and network adequacy are important. But more important are the actual clinical outcomes for conditions like acute MI, atrial fibrillation, stroke, pneumonia and heart failure stratified by risk. Congress,HHS, and CMS allow these HMOs to operate without effective oversight.
As for the readers who think they get all the care they need, they need to think about care they need but are never referred for and are never told about.
Right now, the HHS Inspector General should investigate how many people with significant aortic stenosis in Medicare Advantage plans are not getting needed referrals to cardiologists and cardiac surgeons for valve replacement surgery that would extend their lives.
HHS and administrations of both major parties have been pushing such HMO plans for the past 30 years because the economists who run US health policy like the idea of defined contributions. It makes budgeting easier and covers up rationing care to some of our sickest citizens.
18
I recently saw an insurance salesman sitting in the lobby of the hospital where I’d gone for a check-up. In a subsequent meeting, he pushed an “Advantage” plan so hard that it smelled fishy. Sure enough, it was- upon inspection. Fellow seniors- don’t fall for it. Medicare, with a medigap policy, is the real deal....no loopholes, ripoffs, or excess profit to the health insurance industry.
17
could someone (anyone) please simplify this stuff...jeez...
3
I belong to a very large Medicare Advantage plan, a state-sponsored for state retirees. We see any physicians we choose, and there is no distinction between "in network" and "out-of-network" benefits. I admit that I do not understand the economics of medical insurance, but I suspect (but do not know as fact) that the low premiums and generous benefits of the plan are a result not only of subsidies but also of the cost spreading and bargaining power derived from the huge number of participants. My point is really that there is no one Medicare Advantage plan - my plan isn't expensive or restrictive at all, and in that I am so very fortunate. I will also say that I fervently wish that every citizen of our country had the same access to medical care and affordability of health insurance that I have. We are moving there, too slowly but I hope surely.
4
@LB Here's the dirty truth. If every citizen had the same access to your plan or similar ones, your access would diminish and the cost of insurance would increase.
3
Medicare Advantage was conceived of as a form of privatizing Medicare by limiting access.
Mission accomplished.
30
Private Health Insurance is a corrupt system of gerrymandered health plans, drug formularies and risk pools designed to discourage utilization and maximize profits . Private health insurance can only be reformed by restricting ALL insurers to selling just one national standard health plan to ALL Americans anywhere in America. We must merge our employed and individual market health risk pools onto the ACA exchanges, and this can only be done via tax policy reform that grants ALL a full health premium tax deduction on IRS Form 1040, Schedule 1, Line 29.
8
Until I recently retired, my work allowed me to see that many of the Medicare Advantage plans sold themselves on the basis of low monthly premium. That is all most customers think to look at. But they frequently paid the physicians a little less than regular Medicare and wrung and reduced their payments through payment denials that don’t happen in regular Medicare. Should anyone be surprised that the physician networks of Medicare Advantage are narrower than for regular Medicare? Most physicians are busy enough and don’t need Medicare Advantage to keep their practices full.
Keeping insurance company directories updated is something that can only be fixed when they send doctors a questionnaire annually and hold payments for those who don’t respond by deadline. This is not a high tech or expensive fix; insurance companies do this annually to enrollees to find out if they have another source of insurance coverage.
8
"Psychiatrists are least likely to be included in plan networks; a typical plan covered fewer than one-quarter of them."
That's true but not only for Medicare Advantage. A number of mental health specialists in my neck of the woods do not accept any insurance coverage at all. Their plan is "pay up front and it's your fight with the carrier... good luck!" Double whammy: that puts them "out of network" which means it either it's a separate deductible "pot of money" the consumer has to spend or it's not going to affect your deductible, period. Hello, 100 percent co-pay.
8
This is true but it helps to know why. The supply of psychiatrists is in severe shortage nationwide. Among physicians, psychiatrists have been stigmatized by other doctors for many decades and few physicians choose the specialty. Specialized behavioral managed care networks often paid them less per unit of time than any other specialty. Now the shortage is so severe that private psychiatrists tend to stay out of some commercial insurance networks and almost all forms of Medicare and Medicaid. They have full practices with waiting lists without seeing patients with government insurance.
14
@Marcia Myers
Yes, absolutely... supply and demand at work. Few providers open to new patients and long wait times if they are. (Which sends people to the ER...)
Around here, this isn't just for psychiatrists here though, it's for other types of mental health services. I suspect the same is true elsewhere as well.
1
@Marcia Myers
The reason for the shortage of psychiatrists is because it is one of the lowest paying specialties and therefore few American med school grads are entering. If it wasn't for foreign med school grads, most of whom have no interest in psychiatry and many of whom have difficulty speaking and understanding English, something of vital importance where much of diagnosis depends upon what patients tell you, there would be very few psychiatrists in training in this country.
When someone finally decides that saving the life of one with major depression or schizophrenia is just as valuable as operating on someone so they can once again play tennis or golf, maybe things will change.
Many psychiatrists don't participate in insurance plans because the level of reimbursement for many of them is so low it wouldn't even cover office expenses.
4
Medicare Advantage is such hot garbage nobody in their right mind should ever choose. Traditional Medicare is single payer choose your own doctor and hospital. After you add the supplemental on top of traditional, you get no copays other than prescriptions. Premiums are higher with traditional plus supplement, but you don't have to ration your care due to copays. Folks get tricked by the lower premiums, low PCP copays, and low value benefits like gym memberships. All that comes back and much more when you find out about the expensive MRI/CTScan copays over $200, $250+ per night in the hospital and skilled nursing, denied benefits where you end up paying 100% out-of-pocket and reduced access to doctors and hospitals in the tiny and ever-changing HMO network as mentioned in the article.
Why in the world would you give up the only single payer option in the US with full doctor and hospital access for a "free" gym membership and $50/month savings? You pay for it dearly the first time you get seriously sick on Medicare disAdvantage.
50
@FrankM Sorry, but I completely disagree. My Medicare Advantage plan includes both major hospitals in my market and all the physician groups. I've never been turned away for an appointment with any doctor, or waited an unreasonable length of time.
I do have some co-pays and deductibles, with an annual out-of-pocket cap, but I factored in my ability to absorb those, if needed, when I signed up. Just today, I ordered a generic Epipen via the included drug plan, at zero out-of-pocket. And yes, thank you, I do take advantage of that "free" gym membership -- several times every week. I figure that it helps to keep me healthier.
1
@FrankM
When my husband required a rehab stay the better quality local facilities refused to take his United Health Care Medicare Advantage Plan' They would have taken traditional Medicare.
At that point, he was stuck in a second-rate place.
17
@Joel My gym membership at the very nice Las Vegas Athletic Clubs chain costs under $9/month in CASH. People who trade their national standard government Original Medicare for Private Medicare Advantage are trading their Island of Manhattan for cheap costume jewelry.
13
Because I'm disabled, I have to get off the Affordable Care Act and onto Medicare in October years before others. This article and the comments could not have come at a better time.
11
Just turned 65 and started on Medicare. I get A of course and B. I also pay for Part D (drugs), but could not afford a supplemental plan. It appears I only have 6 months to find the money to start a supplemental plan without having to answer health questions and have them be applicable to getting coverage. This sounds like pre-existing conditions are considered and quacks like it too. Pentalties for getting B or D late ... not sure about the supplamentals. It's a jungle out there.
14
@deborah wilson Medical underwriting still exists for Medicare supplement. Obamacare did not get rid of medical underwriting completely. Yes, you will get denied for pre-existing conditions once your initial Medicare 6 month period expires.
14
@FrankM Thanks so much for taking the time to verify her comment
Medicare Advantage is simply moving toward privatizing Medicare that is why the Trump administration is pushing it. Republicans want to privatize Medicare and if done, seniors across the country would go bankrupt trying to pay medical bills.
34
The other problem with Medicare Advantage is since it is run by private insurance companies they are now denying medical claims to make more money.
Many doctors and hospitals do not accept Medicare Advantage so what happens if you are sent to a hospital ER and treated and then find out they didn't accept Medicare Advantage.
24
I just had this kind of thing with the insurer databases of who is in-network being inaccurate, and causing me to need to spend 50 hours of time on a change to a new insurance policy. And it would have been 200 hours if I weren't lucky.
This was not Medicare, but rather ACA, but the problem is the same.
I was switched to an expanded-Medicaid policy in MA from an on-exchange plan owing to the MA agencies updating Federal Poverty Level (FPL) cutpoints midyear.
In trying to pick one of 9 expanded-Medicaid subplans, each from a different insurer, and have a local primary care provider, and have a hospital near me in-network, I first tried calling providers, and double checking via online- and on-the-phone- insurer databases.
However, the insurer databases of in-network providers were wildly inaccurate and incomplete, and I had to find a different method.
The insurers then told me the only reliable way to determine in-network was to call, during business hours, each provider's business office, and get all possible 10 digit National Provider Identifiers (NPIs) that could be submitted with a bill, and to have each insurer run those NPIs, by phone, through their NPI database, to see if the provider was in-network.
(Even this failed once, with a provider insisting they were in-network, all 4 locations, while the insurer, with the NPI, insisted only 2 of 4 were in-network. They had to resolve between them, which took a few days.)
Thus, there went 50 hours.
Crazy system.
20
@Norm Spier
I read the comment, and it makes no sense that anyone has to go through this effort. Computer A knows the provider NPIs, computer B knows the accepted NPIs... connect the dots. The provider directory should be resolved daily if not immediately on database update (with audit history). If a provider's system can't connect, that provider can't participate. It is bad enough that the American system is opaque, overpriced, inefficient, and derelict without worsening the situation through idiocy like this.
4
@MH
You sound you are a skilled, analytical, capable computer pro.
Like the kind of computer people I wish they had running things at the two MA agencies handling the ACA. (MA Medicaid=MAHealth and the MA Health Connector.)
I'm getting ACA insurance, and my income runs around the cutpoint between the two halves of the ACA: Expanded Medicaid (to 138% of the FPL) and on-exchange plans, (above 138%).
I've had terrible problems, about 5 in the last year, of disruption of insurance coverage, owing to the poorly thought out systems at the two agencies, and as well, miserable coordination between them.
Just today an issue: the Connector agency told me I can switch halves now if I want to to theirs (no-subsidy on-exchange), but they have no idea if the other agency will cut my old insurance before the new one starts, and they would have no way to stop it. And I can't find out from any reliable source at the new agency.
The two agencies just don't coordinate adequately, and even the elite ombudsman staff at each agency tells me there is no one who can resolve a problem that involves the two agencies in a coordinated fashion.
The MA agencies are in well above their capabilities in administering the ACA. The computer system didn't work at all the first year of the ACA, and they had to give everyone free Medicaid. It's noticeable better now, but they probably still have a 5 or 10% failure rate.
4
There's a meme that Medicare Advantage plans are good for healthy people. That may be true, but I can say from personal experience that you can go from being a healthy person who walks three miles each day to needing extensive medical care in the blink of an eye. Original Medicare and a good supplemental plan ensured that when I was suddenly hit with emergency surgery and six months of follow-up chemotherapy, I was able to concentrate on my health and not worry about networks, bills, co-payments, etc. I never saw a medical bill during my illness.
44
@gesneri
1000% correct on all points.
I wish you a full recovery.
Clearly, the chief purpose of selective contracting (health plans only contracting with selected health care providers) is to give health plans leverage in negotiating prices. If health plans have to cover services from "any willing provider," they cannot threaten to exclude providers from their network if the providers refuse to accept lower prices.
6
I would warn people to research thoroughly before signing up for Medicare Advantage -( how were they allowed to use THAT name?).
My husband had a bad experience with " out of network " charges even though the tests had been approved by the hospital and the doctors office.
You are basically signing away your traditional Medicare ,yes it is less expensive but it has networks. I would advise this , Medicare Primary ( keep your Medicare ) and get Supplemental , my husband has Plan F
24
@L. Finn-Smith That's the choice everyone gets. Most people who have a choice do not think that choice is worth $25,000 more over the first 10 years on Medicare. But you have the choice
1
@Dennis Byron
not sure what you mean. Plan F costs $150 every 3 months -$600 a year ( Little Rock )
8
Please remind people that if they take an Advantage Plan, it can be difficult if not impossible to get real Medicare when they change their mind.
The Advantage Plans are the Republican attempt to destroy Medicare. Don’t fall for it.
58
@Cecelia Agreed. Once you are in Advantage, you cannot ever return without passing medical underwriting. Don't believe for a second that Obamacare got rid of medical underwriting completely. There are loopholes like choosing a limited location HMO, then moving to a location not served by the HMO, and then switching to traditional. But you don't want to end up having to choose tricks like this to get back to traditional.
15
@FrankM I read somewhere that people who choose government Original Medicare at age 65 can later switch back and forth between the government and private medicare systems with no medical underwriting, but those who choose Medicare Advantage FIRST lose their protections for pre-existing-conditions if they leave then try to come back. Funny how government Original Medicare does not care about pre-existing-conditions but private Medicare Advantage insurers do.
8
@xzr56
Our experience was that husband started on traditional Medicare, casually said 'ok' to an Advantage plan (sold by an agent, of course) within a year or two ... then we took our one -- 1 -- opportunity to switch back to traditional Medicare during the next enrollment period -- and don't ever intend to look back. MA was a confusing nightmare; sure didn't feel like an 'advantage.'
That was within the last 8 years or so ... rules could have changed again.
One has to ask a LOT of questions. Don't be fooled.
2
It is not just the provider directors in Medicare Advantage plans. It is the provider directories in private insurance HMOs, PPOs and EPOs and Medicaid managed care plans.
The problem is more complicated that the writers discuss. Physicians contract with the plan for payment using a particular name. (For example, "XYZ sleep disorder clinic"). That is the name that appears in the provider directory. However, the physician's office staff uses a different name and tax id number to bill the insurer (such as "ABC Clinic"). The insurer's physician payment has multiple tax id numbers. A patient whom has seen provider who is on a provider directory may get notified by both the physician's billing office and by the insurer that the bill was denied by the insurer and the patient now has to pay the full "retail" price for the service.
This has happened to me and other members of my family more than once. There is no synchronization between provider directories, physician billing systems and insurer payment systems.
This does not happen anywhere in the private health insurance systems in the Netherlands, Germany, Belgium, Austria or Israel.
Regardless of "Medicare for All" or "Public Option", this has to be fixed.
20
I am currently dealing with this with regular insurance. The billing company screwed up the claim and put the practice name with the doctor's tax ID rather than the doctor's name. Instead of being in-network, it is out-of-network. I have spent three months trying to get it resolved already. Part of me wonders if they are doing it on purpose to get the out-of-network price which is three times what they get for in-network.
14
Why is the provider list not considered part of the insurer's contract?
16
@CLF
Well, I think we can guess why. But perhaps this is a question that each and every one of us should be asking our Representatives and Senators!
4
Rather than call the plan, which can result in incorrect information, talk to your current primary care physician. Find out which plans s/he participates in and go from there.
In my experience, I had nothing but frustration trying to talk to the "plan."
9
@mary That's fine until you break a leg and need an orthopedic surgeon, or get diagnosed with cancer and need an oncologist, or have a stroke, or develop diabetes, or your spouse shows signs of dementia -- or any of 1000 other health issues that require specialist treatment. It is NOT POSSIBLE to do the research to evaluate the adequacy of the plans network to treat all possible health conditions.
18
Enrollees of Medicare Advantage Plans should call the plan whenever they are seeing a new physician to see if that physician is in the network. They should not rely on directories, which like telephone books these days, contain numerous errors. I am surprised that a research outfit as sophisticated as Kaiser would use directories to substantiate a network when everything is online these days or at least on phone. As far as networks go, it should come as no surprise that plans seek to reduce costs--and presumably enrollee premiums--by narrowing the network. The economics simply don't work out when enrollees pay low premiums yet have access to all the specialists and services they desire. What should cause concern are the efficiency standards being applied to physicians. Efficiency and quality often do not go hand in hand. A doctor limited to a 10-minute visit, who does not have time to review the chart, may be efficient but not serve the patient's best interest.
13
How about a law holding patients harmless for insuror errors in network affiliation? You can beet that would get them to make their directories accurate.
28
I had a United Health Care plan and found it very hard to locate labs, doctors, specialists. I went to one lab for a simple blood test (the nearest other lab was 30 min - each way) in the just received 'Provider Directory' and found a deserted storefront. I asked the store owner next door if they were open other days or or if there was another address. 'Nope' he replied and then said 'They've been gone at least 3 years'.
I called United and said they should remove the entry so other people don't waste their time. United's response? 'Only the provider can make that request so you should have them notify us'.
You can't make this stuff up...
75
@A2er Seems like anyone (providers and patients both) who has had to deal with a United policy of any kind for any length of time realizes that in the last year or so they appear to have made a decision to compete for the world nightmare bureaucracy title. It's like night and day, the change from what was once a halfways decent company.
All of this confusion, along with unaffordable prescription drug prices, job lock, and out of control healthcare prices, could be solved with Medicare for All. All providers included, no copays, no medical bankruptcies, and on and on. Who wouldn't want to give up his/her limited employer-provided policy for a seamless, less expensive Medicare for All?
29
@Chef George
"Medicare for All" will not solve this problem. There has to be uniform Federal regulation of how provider directories are linked to the provider billing and insurer payment systems.
@Brad
Chef George is correct. With Medicare for All, all providers are included under one system, no provider directories needed.
23
I switched from Medicare Advantage back to original Medicare with a supplement years ago. It probably costs me slightly more money, but not worrying about whether a bill will be paid, whether I went to the "right" hospital and doctors who don't actually work for the hospital and aren't in network is well worth the cost. All I need to think about is whether I need to see a doctor, how urgently and which one. Almost all the doctors in my area where retirees have become common take Medicare.
38
@Barbara
I joined Medicare last month and got a comprehensive Supplement plan from the start to avoid this mess and balance billing surprises.
Universal coverage, whether through "Medicare For All" or otherwise, is the only way to go.
And if we don't have universal coverage, we can end government-funded medical research and let the "free markets" work their magic...not.
23
I am a retired rheumatologist in the south. 'sign up guys=SUP', as I called them, pushed hard for my patients to switch to a medicare advantage plan. The SUPs pretended to find out about their clients medical problems and assured all that signed up that their care would be cheaper, broader and everyone would get a pony. Unfortunately many of my patients required one of those enormously expensive drugs (TNF blockers such as Remicade or Humira.) for their rheumatoid or psoriasis. Traditional Medicare with a supplement (F or G) covered almost all of the cost if it was an infusion but Advantage plans usually had that 20% copay after the deductible. This invariably led to a year of inadequate treatment due to the multi thousand dollar copays. There was no recourse by the time I was asked. The SUPs were clueless except about their commissions and bonuses and really checked nothing. The only uniform fact was the hard sell.
This comment of course does not address the cost of these meds. More extensive use of biosimilars and changes in the pharmaceutical market may of course obviate some of this issue but only somewhat.
52
medicare advasntage= HMO in another itteration.
14
@Rhsmd1 Medicare Advantage plans are just limited local network Obamacare plans traded to the healthy age 65+ market in exchange for their national standard government Original Medicare benefit.
4
@xzr56. It's inaccurate to blame Obamacare for Medicare Advantage plans, which came into existence due to a 2003 law (GWBush administration): "The Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA) made the biggest changes to the Medicare in the program in 38 years. Under the MMA, private health plans approved by Medicare became known as Medicare Advantage Plans. " (from the Centers for Medicare Services website).
1
I have a family member eligible for both Medicare and Medicaid. Coordinating those benefits is overly complicated for the average consumer, including my family member. She is in a Medicare Advantage Special Needs Plan designed for people who have dual eligibility. The plan is definitely more limited in terms of providers (it is Kaiser so you have to go to Kaiser), but it is so much easier to understand and use the benefits than it would be with original Medicare and fee-for-service Medicaid.
1
Medicare Advantage Part C is overly complex and therefore inferior to Traditional Medicare plus a supplemental or MediGap plan. These plans range from less coverage of expenses not covered by Parts A and B, to covering everything except of course dental, vision and hearing. MediGap plans are priced according to coverage.
It's so much easier to stay healthy with the less complicated and no more expensive original Medicare. You can be seen and treated anywhere Medicare is accepted which is every major medical center in the U.S.
Medicare Advantage is complicated and incomprehensible enough to make you sick.
33
@A Goldstein - Regarding Traditional Medicare, I want to emphasize the importance of being able to access without pre-authorization medical centers of excellence anywhere in the country for major procedures involving serious diseases. You are also likely to get a team approach for optimal care during diagnosis and treatment. This is either not possible or assured with Medicare Advantage.
24
Good to know.
I hope my Plan F continues...
What I don't understand is how any hospital or practitioner survives on the tiny approved Medicare payouts.
One for all and all for one.
Aren't our politicians guaranteed full medical for life after one term?
No wonder they don't care about the little people.
32
@Why worry
At least Medicare pays bills. When hospitals close, it's usually because too many patients are not insured at all. Witness all the rural hospitals closing in states that rejected Medicaid expansion under the ACA.
25
@Why worry Even Medicare Supplement plans that are closed to new enrollment are available to you as long as you maintain continuous coverage.
2
@Garak Residents in states without Expanded Medicaid can still get ACA subsidies all the way down to the poverty income level. I experimented on the Tennessee exchange and learned i could choose a Blue Cross silver plan with CSRs in Knoxville for 32 cents per month premium for someone my age. The FREE, UNTRACKED federal subsidy was about $950/month, all while avoiding the LOAN of Expanded Medicaid Estate Recovery tracking & draining the value of my home and savings.
3
Here is the dirty little secret of Medicare Advantage plans --- the COPAYS
I did a comparison using the actual bills with just Medicare B and its 20% copays vs the Advantage plans in this state
(1) Upfront deductible for Part B services - Advantage $250 vs Medicare B of $185
(2) Physical therapy -- Advantage $45 -50 PER visit vs Medicare B 20% of $18.70 -21 PER visit
(3) GP office visit - Advantage $20-25 vs Part B 20% of $15-20
(4) Outpatient procedure at the pain clinic with specialist - Advantage $225 -250 every time vs Medicare B 20% of $142.37
(5) Specialist office visit - Advantage $50 vs Medicare B 20% of $35
Advantage plans nickel 'n dime you to death on the copays & charge copays that are up to 238% MORE than the Medicare B 20%
A Medicare Medigap plan to cover the 20% copays makes much more sense.
A Medigap Plan A is $92 a month in my county & it picks up the unlimited copays of Part B & the copays for hospitalization -- you pay the $185 for Part B services & the $1364 deductible if hospitalized -$1289 for the year
A Medigap Plan D is $98 a month & it picks up all copays of Part A & Part B AND pays the $1364 hospitalization deductible. Annual cost to the patient $1361 (Plan premiums plus the $185 Medicare B deductible)
Other Medigap plans will pay both deductibles -- the $185 & $1364
With the lowest premium Advantage plan with 1 GP visit and the regular 4 out patient procedures with the specialist, I would be paying $1355 - do the math
28
@AnnS this is so useful. I am a retired provider, and even I have a hard time with this.
Humana’s PPO Advantage plan cannot even TELL me which doctors (specialists) are covered.
I live on Kaua’i just over 100 miles from Honolulu, the center of advanced health care for Hawai’i.
The on line accessibility manual will only search on an algorithm up to 100 miles from my home. (Which still leaves me a $180 airfare away! Add to copay ). So I have to randomly Google specialists and call to see if they take Humana.
I pity those who are more elderly, infirm, cognitively disabled, or not computer literate.
It is a nightmare...even for me.
29
@AnnS
It is important to do the math for coverage IN YOUR AREA. For example, the premium for Medigap Plan A is $220 here on top of which I would pay separately for prescription, vision, and dental insurances plus copays for services provided by the latter, not to forget the $135/month for Part B. In other words, it is extremely difficult for the individual consumer in the United States to win the health care game--especially when options can vary BY COUNTY!
19
@Stephanie You are right and be sure to check BY COUNTY whether Medicare Advantage plans are accepted. In my county, the doctors accept the plan and the hospital will not.
13
Before reaching conclusions about Advantage (and insurance companies), read what standard Medicare says about its network of participating providers:
"All physicians and other clinicians included on Physician Compare are enrolled in Medicare, meaning they treat people with Medicare. However, some clinicians may not accept Medicare-approved payment amounts , or may not be accepting new Medicare patients."
https://www.medicare.gov/physiciancompare/#resources/faqs
11
Medicare plans also vary state to state, so if one moves to another state they more than likely will not have the same coverage. There can be quite dramatic differences and this can be extremely difficult for someone who has ongoing medical needs. This is one of the main reasons we need a national health care system with consistent coverage no matter where one lives or moves to. I also agree that insurance companies have learned to make things as complicated as possible for the consumer. Our entire health care system is so complex and set up to benefit the for-profit system rather than care for the patients. Hospitalized for 2 weeks a year and a half ago, I had to advocate and actually argue to get the care I needed. The "hospitalist" who was assigned to me tried to block me from getting what I needed every step of the way. My problem was a neurological one in my spine, so I wasn't sick, I'm intelligent and know how to advocate for myself. All I could think about was what to do for those who ARE sick, not feeling well, for any variety of reasons are unable to advocate for themselves and have no family to provide support. That doctor would have sent me home in a dangerous condition. I live alone. Our health care system is a disgrace.
52
@Kathleen Brown Private health insurers have GERRYMANDERED the health insurance and care system to affect a maximum profit for them no matter the damage it causes us..
5
Medicare Advantage is a rip of both tax payers and the unsuspecting recipients
As an ER physician, I deal with limitations of the these plans every time on shift. few examples
1-the local group of urologists are on not the plan, I have send patients 60 miles away, they will need a referral from the primary care, compare to patients on traditional medicare, they wont need a referral, and they can see the local urologists group
2-You cannot send patients to nursing home from the ER, patients must be admitted to the hospital for three nights, get off the medicare advantage back to traditional medicare before they can be sent to nursing home. How is that saving money?
3- the primary care group that "manages" the medicare advantage take aggressive stands against admissions from the ER, and length of stay in the hospital. that is how they make their money, fights admission, less days in the hospital. How is that okay?
As far as I am concerned medicare advantage plans are added risk factor for patients. in the ER, we jokingly say, the patient has diabetes, hypertension, medicare advantage.
67
In 2014, the first year I qualified for Medicare, I signed up for an Aetna Medicare Advantage plan in my area because their on-line directory listed doctors I might need. However, after I had the plan I found that the directory was incorrect and my preferred doctors were not part of the plan. I contacted Aetna and the person I spoke to insisted the doctors were in the plan because they were listed in the directory. I checked again with the doctor and his office said he was not in the plan. Again, the Aetna representative insisted the directory was correct. This happened with more than one doctor.
At the next open enrollment I switched to standard Medicare with a supplementary medigap policy. I've kept that arrangement for the last few years I have had no problem finding good doctors who accept Medicare/medigap. (Medigap is not the same as Medicare Advantage -- there's a nice explanation in Wikipedia.)
To attract customers, the insurance companies exaggerate the number of physicians who accept their Medicare Advantage plans.
66
I chose an Aetna Advantage plan with no monthly premium. So far I am very happy. I get some limited dental, my drug co-pays are almost all $0.00, I get some vision and some dental and I get a free gym membership. I also get $25.00 per month in over the counter products. Before I chose the plan I called my doctor and all my specialists to find out if they are in the plan. They all are. And all of them are highly rated doctors. This plan is way better and way cheaper than what I had from an employee plan.
9
@Paul Ruszczyk
No monthly premium? Is that a typo? Or maybe you pay an annual fee? Please explain. Thanks!
3
@Sylvia
There are some Medicare Advantage plans with no monthly or annual fee and they may be right for some people who are in relatively good health and not likely to need more than a check up or a quick primary care visit or two during the year. Check medicare. gov for plans in your area. I don't endorse these. I'm simply giving you information.
4
@Barbara
Compare the plans - definitely. But I disagree that the Advantage Plans are only good for healthy people.
3
Any time an insurance company starts pushing a product really hard it means there’s more profit in that product for the insurance company. I was inundated with Medicare Advantage offers when I retired. But I had had experience with traditional Medicare and a supplement when I cared for my mother as she declined with dementia. I also knew from personal experience how difficult an HMO, which is essentially what Medicare Advantage plans are, can make it to get specialty care. I never paid a bill for my mother other than the cost of the supplement since Medicare and the supplement paid for her doctors, hospitals, medications, tests, etc. No specialist care was ever denied by Medicare, and I never had to fight for a referral for my mother to see a specialist. I travel out of state frequently and I wanted the convenience of not having to stay in network or having to get referrals to see a specialist. But the biggest disincentive to utilize a Medicare Advantage plan is that while you can always switch to regular Medicare if you don’t like Medicare Advantage, you will be subject to underwriting for a supplement plan, and you may not qualify for it health wise. Why would anyone take the risk of being without a supplement if they can afford one? Not me...
43
Yes, is essence an HMO; managed care.
This isn't just a problem with Medicare Advantage. It's a problem with all insurance companies and plans. I'm a mental health professional, who, in a previous role, often helped clients find therapists and psychiatrists who were covered by their insurance. The lists provided by insurance companies were little help, as they were very inaccurate. It seems like the insurance company could afford to hire someone whose job it is to call or email providers regularly and keep their lists updated. I saw an article recently about some states passing legislation that would require insurance companies to keep these lists more up to date. I'm in full support of this.
29
Selecting a Medicare Advantage plan is predicated on the ability to anticipate future medical needs. In my thirty years of practice I never met a patient who said they would have cancer or a heart attack diagnosed nine months hence.
Who would choose to buy auto insurance if it only covered the damage from an accident that had already happened.
37
Seems we are lucky in Boston. My BCBS Advantage plan is excellent, and I assume the reason is that we have so many great hopsitals and doctors in Massachusetts. It is easy to compare plans through SHINE, (Serving the Health Insurance Needs of Everyone) the Mass. state health insurance assistance program that provides seniors free health insurance information counseling and assistance to Massachusetts residents with Medicare and their caregivers. The SHINE Program is administered by the Massachusetts Executive Office of Elder Affairs in partnership with elder service agencies, social service and community based agencies and Councils on Aging. The program is funded by the Administration for Community Living.
10
The same lack of accuracy is legion in Obamacare plans, and any plan available to the public, with addresses years of date, doctors who once participated but no longer do, doctors who never participated, etc. And errors pointed out to the insurance company go uncorrected, year after year.
Best of all, nothing stops you from signing up for a PCP with an imaginary office and an imaginary practice. Or making an appointment with a doctor who isn't in the network, and finding out afterwards, when the bill is due.
All this is called "added value".
12
@jrd. The lack of accuracy resides with the insurers only - it has nothing to do with Obamacare or the specific plan you have. The insurers are not held accountable for the accuracy of the item that is of most value to subscribers - its list of covered providers. Until we get rid of the GOP control of government, which eschews regulation in favor of protecting big business, this will be the way things work.
1
When I turned 65, I was suddenly inundated with come-ons from "Medicare Advantage" plans. It seemed to me that there is a gold rush of insurers to fool Medicare recipients into giving up their Medicare benefits for plans that have all the disadvantages private insurance. Unfortunately, many seniors are caught up in this.
44
@Stephen - Exactly. When Medicare Advantage plans were first introduced, they were set up so that they were paid 15% MORE than traditional Medicare paid for the same services. The ACA did away with that slush fund. But our insurance guy told us agents get paid a $700 bonus for every client they sign up for Medicare Advantage. It really is an attempt to privatize Medicare and move it away from being a government program.
We specifically chose traditional Medicare so we could see any doctor we wanted and use any hospital, and could see a specialist without prior approval from a GP. It's a shame so many people fall for the hype and lock themselves into the same disadvantages private insurance has.
74
In general Medicare Advantage plans chanel patients into the least qualified physicians. That’s why the plans are cheaper.
13
Medicare Advantage requires you to see a PCP for authorization for most specialists. You end up spending hours waiting for them. You have to argue if you choose to refuse a test. They bargain. “Ok, no mammogram. But what about a bone density test?”
If you read Gilbert Welch on Overdiagnosed, or watch his videos on YouTube, you’ll begin questioning the tests. I’m on the Ezekiel Emanuel plan myself.
I had such bad experience with Advantage. Never again.
16
Well put! Telling details.
I'm a retired Texas public school teacher who was very happy with traditional Medicare plus a prescription drug plan through our Teacher Retirement System. Then, a shortfall in funding , the Texas legislature forced retired teachers on Medicare to switch to one specific Medicare Advantage plan or leave the system without the possibility of return. Premiums have increased, and 36,000 teachers have left the system for cheaper plans. Luckily, my doctors are all on this plan- so far. Advantage plans tout the extras they include, but things like free gym passes are useless if the only participating gym is an hour away. Meh.
19
@Edie Clark--How can a legislature do this--do they supplement your plan financially? Aren't you American citizens who can pay your own premiums?
@Edie Clark
"..the Texas legislature forced retired teachers on Medicare to switch to one specific Medicare Advantage plan or leave the system without the possibility of return"
Sounds like some money changed hands there. Time for your local papers to do some investigative reporting!
2
I have used Medicare Advantage plans over traditional Medicare for more than 10 years, and have changed plans 3 times with no problems. First, it is cheaper and more comprehensive (eye & dental) than regular Medicare. I live in a large city and cannot fathom why anyone in populous area would opt for anything else.
5
@acd
Can't fathom why? I'll give you one great reason:
no need to deal with an insurance companies and no networks -- pick your own doctors.
This is priceless.
Funny, how the Trump administration went full bore, trying to sell these plans -- dozens of emails. Ever wonder why, since they cost the taxpayer more?
15
@jrd Most medicare advantage co-pays are greater than medicare co-pyas, why would anyone sign up?
12
Like the phone companies a few decades ago, medical insurers have fully absorbed the lesson that the best way to handle consumers is excess complexity. Make it complicated in detail, then blare rosy-sounding appeals that are at least formally, true, and you can get people to sign up for a plan. And because such sign-ups are sticky -- people don't easily change, particularly when they get sick and need the insurance -- you can exercise every clause and title buried deep in the fine print to extract rents far above what the plan -- Medicare, Medicare Advantage, ACA care, etc. -- is supposed to impose on health care consumers.
Having dealt with a traditional Medicare for a family member, I can attest to the utter incomprehensibility of the paperwork, and the repeated efforts by providers to bill my family member for things that were in fact covered. "Balance billing" is illegal for Medicare, but a large respected hospital chain tried it anyway. Other firms billed quickly for items that were covered by Medigap, with no information at all that such coverage was likely... a less vigilant consumer might have paid the bill.
And Medicare is the _easy_ plan... others (with the honorable exception of Kaiser Permanente) are much _more_ complicated, and impose many more hidden restrictions.
So just remember: health insurance in the US is absurdly complicated because the insurance companies, hospitals and doctors WANT it to be, because they profit directly from consumer confusion.
82
@Pquincy14
So true. We are also paying for the added layers of bureaucracy needed to support the pay to play system we have: CEO salaries, accountants and lawyers so they can keep more of your premiums, advertising, and not too many people to answer the phone so you get frustrated and give up.
Medicare for all seems like a good solution.
25
@Pquincy14
I have turned in providers to CPFB for confused billing eg
" pay this amount , by this date " , even though the Insurer has not even been BILLED yet !. Its crazy and should be illegal
11
@Pquincy14, As a physician who just expanded our billing department from 2 full-time people to 3 full-time people for the same volume of patients, I can tell you that doctors despise that complexity. It is the insurers way of shoplifting. It you had somebody prepare taxes, paint your house or provide legal services, then the credit card company, as a matter of policy, fought payment for those services, that would not be tolerated. Rather, it would be considered a criminal conspiracy. Yet, that is business as usual for us.
3
This article provides yet another reason to opt for the comparatively simple structures of genuine "medicare for all" single payer insurance plans available in countries like Canada, France and the UK, in which there are no limits on which doctors are "covered" by the plans. In my home Canada, I can go to any doctor who is accepting patients at the time and engage her as my family doctor.
When I was contemplating a relocation back to the US, trying to figure out the various aspects of Medicare in the US was a nightmare, with all its "Parts" and copays and deductibles and limits on hospitals stays and the need for [the ill-named] "Advantage" component.
To be sure, it was a minor miracle that Lyndon Johnson managed to get any version of medicare for all passed. However, the one the US now has turned out to be a pale version of the genuine article one finds in many other countries.
47
@David Zimmerman,
I think your statement that “ trying to figure out the various aspects of Medicare in the US was a nightmare” hit the nail on the head! And the previous reader comment by msf provided numerous detailed examples.
I am now coming to believe that obfuscation is the goal, so that patients ultimately paying far more than they should or need to for medical services.
22
There are so many different types of errors and they are so hard to deal with.
Addresses - providers may have multiple places of business while the insurer covers only some of them. Sometimes all the locations the insurer lists are fictitious. Then going to the provider at any real one has a risk; that might be one of the locations not covered.
Type of provider - when is a PCP not a PCP? When listed incorrectly or not at all. We were billed a specialist copay for our PCP because the doctor didn't appear in the directory. We were told that somehow she was still covered because she works through Medicare. That made no sense and it took months to straighten out.
Multiple databases - though the doctor didn't appear in the public directory (hard copy or online), we found out that the insurer had a private database that did include the provider.
Verbal assurances - a currently covered provider mysteriously vanished from an upcoming year's directory. We asked about this at the insurer's sales presentation. After multiple calls on our behalf by a sales rep, we were assured that the provider would still be participating. How does one rely on that?
The worst part may be that even when a doctor and an insurer agree that the doctor is in network, it seems impossible to get the directory corrected. Calls are made, information exchanged, but ultimately nothing changes and each faults the other.
20
At 68, this is my fourth year as a Medicare beneficiary. My first year I selected an Advantage plan that had the lowest possible MOOP (Maximum Out of Pocket) expense. I had no problem locating wonderful nearby PCPs (Primary Care Physician). I loved my first PCP but she left the network to start her own practice.
My second PCP is wonderful and I have recommended her to dozens of other Medicare beneficiaries. She is still my PCP.
During my first year on Medicare I needed to see a Kidney specialist. It was quite a drive to see her but she has such a wonderful way of helping me understand my condition and treatment, that she is still my Kidney doctor and I do not care how far I have to drive to her office.
In 2017, I became a Texas Licensed Health Insurance Agent specializing in Medicare. I became my first client switching to a different Advantage Plan. This year I changed to my third Advantage plan. Each time I changed my plan, I verified that my PCP and Kidney doctor were in network.
I am certified to represent Advantage plans from three insurance companies in Texas. Two of the companies have good online resources to identify network doctors and if they are accepting new patients. Because the third company's resources are so poor, I automatically call the doctor's office to verify network and new patient status for every client and potential client.
Many doctors change their status and never notify the insurance company to change their updated information.
19
@Linda Can you share what the commissions are for the plans you are representing?
9
@Linda I'm getting a whiff of Medicare "Advantage" damage control here.
5
@Linda To no real medical or financial advantage, one has to become a snoop or deal with a (hopefully honest) agent/advisor to join an Advantage plan. Furthermore, one has to be constantly aware of change or games the plan may play. Why not simplify one's life without having to worry whether all the members of your medical team are on your plan's approved list -- a particular problem in an emergency or when traveling.
1
Why, over the last couple of years, does the Medicare Trustee's report only list the number of "non-institutional" physicians participating in Medicare?
4