Is your plan open to everyone?
working on it
did that work?
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Yes.
The Medicare Advantage PPO from BC/BS of Massachusetts is available to everyone 65+. There are three different levels, one free one $79 and I forget the third, a little higher.
I do not feel limited to one narrow network (as that article says). I have physicians at least four different hospital systems.
In the article there was some union resistance to Medicare Advantage Plans. I think people are nervous about what they see as non-traditional.
I do have co-pays. $10 for PCP, $40 for specialists (free if telehealth) and imaging like CT or MRI seems to be $120. The plan covers drugs (with co-pay), dental (cleaings free twice/year), vision and hearing once/year each. $150 for gym membership or other fitnes organizations.
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Sounds similar to my husbandâs plan but itâs free in most counties in Maine and he gets $400/year towards anything fitness related. It can even be ski lift tickets. He pays a lot less for prescriptions than I do, too.
My MA plan has Renew Active which is sort of like Silver Sneakers. I can join any number of gyms or the Y using my Renew Active number which is at no additional cost to me. Itâs a great benefit. I previously had Silver Sneakers, and my gym says Renew Active is actually easier for them to use!
I did not mean to revive the old arguments. I just found the use of AI by this one Medicare Advantage program (UHC) kind of horrifying. Traditional Medicare is so highly regulated that the private supplement plans wouldnât have the space to deny coverage this way. It would have to be the government making those kinds of decisions. And totally NOT ALL ADVANTAGE PROGRAMS DO. I donât know if insurers in the non-Medicare space are using these kinds of algorithms or not. I can imagine it though.
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Would be interesting to know how the levels of satisfaction or dissatisfaction with Medicare Advantage plans correlate to the CMSâs star ratings for Medicare Advantage plans. (1 to 5 stars, with 5 stars being the best â more description at https://www.cms.gov/newsroom/fact-sheets/2023-medicare-advantage-and-part-d-star-ratings )
If you shop for Medicare Advantage plans at Find a Medicare plan , you can see the star ratings for the plans shown.
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We donât pay anything for the MA plans, and have 3 choices (United, Aetna, Humana). Each has a little different coverage, but all the hospitals accept all of them (except of course the one I use, and it only takes Aetna - I have to decide if I want to stick with it or change).
There are all kinds of extras that go with them, like Silver Sneakers, $75/quarter in OTC health care items, no referrals, different hospital charges but they are all pretty close at about $1000 OOP per year, etc. Different drugs are in different categories, so my broker said to look up the drugs Iâm on and see which plan is best.
My mother had United and paid $44/mo. She had a $3000 max for her deductible, but her oncologist had some benefactors who paid it for her for two years so mostly her costs were low.
Only real problem was the prescription donut hole.
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To clarify, my MA plan in Massachusetts, BC/BS PPO, also has a free plan. Not sure why I chose the $79 plan but little difference between the $79 and higher cost one that I could see.
The Rx donut hole is a problem for a lot of us. I was in a state program, Prescription Advantage, to help with that but may not qualify this year. I needed a brand name drug for cancer and reached the donut hole quickly, but got out of it quickly too.
The article on AI imposing limitations on care coverage by Medicare Advantage plans is in the Boston Globe and Stat and no doubt other papers.
I donât get it. Almost half of Americans are on these plans. If the media keeps this up, I am starting to feel afraid that enrollment will go down to the point that I and others will no longer be able to have our plans.
The article features an elderly person being forced out of rehab too early. Guess what? That happened to my mother too on traditional Medicare with an expensive supplement.
Why is the media after MA plans? Can they at least target specific ones and admit that some are really good?
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I believe to qualify to remain in rehab a patient has to be able to demonstrate a certain level of continued improvement. Even if the patient could definitely benefit from continued care in a facility, if for a variety of reasons they arenât demonstrating continued improvement (and in some cases the patient isnât always willing or able to cooperate with the rehab services) they will likely get discharged.
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I have traditional Medicare and a high deductible G supplement. I pay the regular part B premium and $37/ month for the G-HD.( 68 yrs old). I pay Medicare part B deductible first. Then Medicare part B pays 80% second. Lastly ($2700 -$226) deductible applies to the rest of 20%. Once that it met, plan G-HD pays the rest.
Example 2022
Medicare covered in full the covid booster, yearly mamo, dr visit and blood work . In 2022 I also had a diagnostic mamo of both breast, unilateral extra view, and ultrasound one breast . Additional 2 primary Dr visits, one with EKG, I had an hospital outpatient echocardiogram and additional blood work . One cardiologist visit.
I paid $394 total for this.
@jym626 believe me I am aware!
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My understand from the insurance broker I just met with (turning 65 this year) is that everyone has to have A and B ($165 per month). If you donât get another plan, A and B always pay 80% and you pay 20%, and there is no stop loss. You could pay forever.
She recommended MA plan for most people.
My friend, also turning 65 (with a different agent) went with the traditional plan because she has expensive asthma medications and wanted the âGâ coverage. Sheâs still buying her inhalers in Mexico, so I donât get why she if paying more for coverage here.
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In 2011 my mother was discharged from a brief stay in the skilled nursing rehab unit, back to her Continuing Care Retirement Community apartment, because she was ânot improvingâ in her walking or transfers.
The reason she was ânot improvingâ was that she was not allowed to weight-bear yet on her fractured right hip (she had a screw and plate, not a hip replacement) and was not strong enough to hop on one foot with a walker, or do transfers on one foot.
We had to hire a live-in, 24/7 caregiver, at very significant expense, for months until she was allowed to weight bear. After that she resumed walking!
A few years later, Medicare clarified this policy. Improvement does not need to be demonstrated to remain in skilled nursing.
Quoting from AgingCare.com:
Senior Rehab: Medicare Coverage of Skilled Nursing Facility Stays - AgingCare.com
"## Debunking Medicareâs âImprovement Standardâ
"For many years, senior rehab facilities told their patients that Medicare would cease paying for skilled nursing care if their health stopped improving or had âplateauedâ within their covered benefit period. However, Jimmo v. Sebelius, a 2013 federal court settlement, prompted the Centers for Medicare and Medicaid Services (CMS) to make an admissionabout this policy:
ââ âMedicare has never supported the imposition of this âImprovement Standardâ rule-of-thumb in determining whether skilled care is required to prevent or slow deterioration in a patientâs condition. Thus, such coverage depends not on the beneficiaryâs restoration potential, but on whether skilled care is required, along with the underlying reasonableness and necessity of the services themselves.â
The current Medicare Benefit Policy Manual has reflected these clarifications since 2014, but some senior rehab facilities havenât adapted to help chronic patients get access to the coverage they are eligible for. Furthermore, many business offices rely on software programs to manage their billing, and it is possible that some of those programs havenât caught up."
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With original Medicare and a supplement, if your wanting prescription coverage, a Part D plan is needed.
Thank you for that information. The necessity of demonstrating improvement within a limited period of time is something thatâs concerned me as I age and seem to take longer to heal. Iâm glad to learn that current Medicare policy is not what I thought it was, but I wonder how often patients have to spend hours trying to get the coverage to which theyâre entitled.
For various reasons, over the last two decades both I and one of my kids have experienced delays in recuperating from some surgical procedure or healing from injuries that prompted calls from our health insurance provider. Usually the call was from an individual who insisted that weâd fare better if we permitted her to communicate directly with our doctors about our care and who questioned the need for everything from Rx meds to durable medical equipment.
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