In my opinion, when shopping for Medicare health plans, one should consider plans that have higher Medicare Stars ratings (Stars ratings are CMS quality measures).
Sorry for being contrary, but by definition, this canāt be true. A PPO is a preferred provider network. It is just thatā¦a closed network of providers that the insurance prefers. Essentially, they work at a negotiated discount. It can be a giant network, like the blues for example, but there will be doctors out of network. A classic example was Zuckerberg Hospital in SF. They were out of network for ALL commercial insurances. It has subsequently changed, but if an ambulance took you there and you had commercial insurance, the bill could be very high. There was a feature on NPR where a woman was charged $25,000 for an uncomplicated broken arm. All hospitals take Medicare. Traveling is never an issue.
2 Likes
Actually, Medicareās ānetworkā is very large, but not 100% of providers in the US.
2 Likes
Itās true that PPOs do have some non-participating providers and when you happen to have care provided by one (even without your knowledge), it can ge an expensive surprise. We have had an out of network anesthesiologist when my S had a procedure out of state. The medical center was in network and everyone but the pediatric anesthesiologist was in network. We were never told the anesthesiologist was out if network and we learned there were NO in network pediatric anesthesiologists in that state. After some back and forth, the bcbs agreed to pay more andiologist agreed to accept whatever the increased amount bcbs paid (which was closer to billed amount.)
Fortunately PPOs allow a lot more choice than HMOs, most of the time.
1 Like
Thanks @eyemgh. I will check my policy and be careful on this. So far, with all the major hospital systems in my area, I have been able to āsee anyone I wantā so I guess that was merely anecdotal. I do have coverage for out of network but you are right, it may be more costly, and I need to find my benefit booklet and be sure of coverage where I go.
For me the annual cap was a big factor.
When those three financial counselors at three different hospitals recommended this BC/BS Advantage Plan, it seemed like the best way to go for me. I am also going to check whether underwriting would be required if I switched and got a Medigap plan. Not that I want to switch.
2 Likes
We have MA through a Blue. It is a PPO, the network is very extensive. There is no authorization required to see any medical provider. (Certain procedures do require authorization which has always been approved.) It includes a drug plan and a dental and vision plan. There is no deductible and the copayments are reasonable. (Zero for PCP visit, $30 for a specialist etc.) We also pay a zero premium per month.
Very satisfied.
1 Like
The out of network anesthesiologist that you have no ability to choose among different anesthesiologists or get told is out of network is the classic āsurprise billā scenario.
5 Likes
IIRC there was legislation passed that prohibited this practice.
We have an advantage PPO plan. In our case, there is no āinā and āoutā of network for Medicare providers. Any doctor taking Medicare must take this plan. Same with hospitals (there are very few hospitals that can afford NOT to take Medicare patients).
So @eyemgh i guess our PPO is Medicare providers plus anyone else who happens to decide to take this coverage.
As I said in my other post, mine is a huge group of subscribers. Huge.
So far neither my husband nor I have had any difficulty with providers.
I will add, we have Cigna dental as a benefit as well. Now THAT is an issue because the dentists come and go from that network of providers. We have been lucky that our dentists have remained in network, but I know other folks who have had to either payā¦or seek other dentists.
ETAā¦.Iām not telling folks here that they should get an advantage plan or regular Medicare plus medigap. That is a decision each person needs to make. Iām sayingā¦all Medicare Advantage Plans are not created equally.
@ChoatieMom id be interested in hearing about your āMedicare family planā. We also used a broker and weāre clearly told that Medicare and medigap, and advantage were for each personā¦not family plans.
1 Like
My husband has dental coverage through his Advantage plan. Itās saved us a lot of money.
H and I have discounted rates because we have the same Medigap company. I think the discount is 5%.
I havenāt run into any problems seeing providers in many different hospital systems, but appreciate the caution on anesthesiologists. I donāt need referrals but get authorizations for specialty meds and imaging. Dental savings are considerable. There is a free version but I chose the $79 one, donāt even remember why.
When the rubber hits the road, the biggest difference is the fundamental purpose of the plans. Medicare is a social program designed to absorb risk. Medicare Advantage plans are managed by business entities designed to avoid risk. As I tell my patients, their job is to not pay.
10 Likes
Again, it varies for different people. Weāve had nothing but a great experience with my husbandās Advantage plan even with some major medical issues. I will be signing up for it in 5 years. I would advise people ask around to see what people in their area recommend. Thatās what we did.
1 Like
I agree there are good Medicare Advantage plansā¦but it is helpful that people understand that many of these plans are offered by companies whose primary objective is to make returns for their shareholders (unlike Original Medicare).
Avoiding risk, as eyemgh said, is one way to maintain/increase profitability. Further, continued revenue and/or profit growth is paramount to publicly traded companies, which many Medicare Advantage plan sponsors/custodians are.
Here is a list by state of the Medicare Advantage market share leader: The largest Medicare Advantage payer in every state
Hereās some general Medicare Advantage industry and trend data, United Healthcare and Humana (both public companies) have a combined Medicare Advantage of nearly 50%.
1 Like
Wasnāt this the case for employee sponsored health insurance? At least with Medicare advantage, you have some choicesā¦and the choice to choose regular Medicare and medigap. With an employee planā¦many had no choiceā¦at all. We didnāt.
And for some of those employee plansā¦the first answer was āno, we donāt cover thatā. And Iām talking about things like an emergency room visit where someone was admitted to the hospitalā¦.a Lifestar ride where the patient was not given the option of driving themselves, a ED doc who was out of network (like anyone has the choiceā¦or would even ask the doc if they were in networkā¦ohā¦and the doc likely doesnāt know). In all cases for us, these things were covered, but it took a song a dance to get it done.
And add to thatā¦if your employer self insured, that added a whole different level of angst. And usually you didnāt really understand that until a claim was denied!
No song, no dance with Medicare. It just gets paid. Thatās one of the reasons Iāll be opting into Medicare with a secondary. Iām sick of the opaque system designed to not pay. For anyone else who has been satisfied with their advantage plan, by all means, keep it. 
3 Likes
My husband and I are new Medicare members as of Friday! Currently we have been covered by my work provided insurance and have been on a high deductible plan. I spent hours (and I mean hours daily) over 3 weekends researching and comparing. My husband made the comment, āWe are smart people, how do the uneducated navigate this?ā Luckily, we are both medical and have friends and family in the insurance business, so spent time picking their brains.
We decided on traditional Medicare with a Plan G; we will go with the same Plan G to get the family discount. Our premiums will be high this first year due to IRMAA, but should go down in 2024. Our OOP cost will be the same as with work insurance, and might be less. I have some known procedures and scans that have been costly in the past; with Medicare, they will be covered after my $233 deductible. Not seeing that $4200 hospital/radiology bill in February will be nice!
We are going for a cheap Part D as we currently are on medication that is inexpensive with GoodRx, so donāt need the plan to cover those. But, if one of us were to need a specialty medication, we would have the coverage needed.
At this time, I did not feel an Advantage plan was a good option for us. If things change in the future, I might consider it, but I doubt it.
6 Likes
Ditto. Never any issues whatsoever.
As I posted elsewhere, since I had Covid diagnosed on Motherās Day, I have had pneumonia twice and bronchitis three times. Diagnosed with Covid and first pneumonia at urgent care, cost to me zero. First pneumonia led to visit to ER (urged by my pcp after she listened to my lungs, copay zero). ER stay overnight, cost $75. Second pneumonia, admitted to hospital on Halloween as soon as they had a bed for me from the ER, five nights in hospital, and I just got the bill: $1400. Office visit with pulmonologist after release from ER, copay $40. All of my doctors are affiliated with the NYU Langone network and the ER/hospital I went to is NYU Langoneās Brooklyn hospital with comprehensive services, 450 beds. This coverage is via Humana.
In 2017 I had three hospitalizations and two major surgeries (open gallbladder surgery, knee replacement, additional hospitalization for pancreatitis after diagnostic endoscopy). I had a different Medicare Advantage plan (Empire Blue Cross), different PCP, etc. My total cost that year was the maximum in the plan, I think $6000. Everything else was completely covered.
In 2020, just before the pandemic, I broke my arm. ER visit $75 and specialist joined the Humana network so visits were $40.
Absolutely no complaints here.
1 Like
Itās not a āfamily plan.ā DH and I have separate policies, but there was a discount for having both of us with the same company.
5 Likes