Same here. My husband has had no problem keeping his specialists.
Yeah ā¦ I have no idea the why and wherefore of different advantage plans. I mentioned two friends but then remembered my brother-in-law in Colorado who wanted a particular doctor for cataract surgery. His advantage plan stopped him. He switched to standard medicare the next year and had his surgery done by his doctor of choice.
It shouldnāt be this confusing.
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Working in healthcare and watching the discharge planners pull their hair out trying to find rehab placement, home PT and OT for those on Advantage plans, especially those who lived in small towns where there was often only a single approved provider or facility in a county was enough to convince me. There were many roadblocks when care needs were highest. I also saw these roadblocks for my mom when she switched to an Advantage plan unknown to me and had many care needs. We switched her back to United Healthcare and access improved in that next year. That there is also a copay for hospital stays in some cases can become a big deal.
I remember a patient terrified in the middle of his cardiac hospitalization as he had a daily copay. Speaking with someone who knew, yep, he chose that plan.
Talking over the scenarios with a couple I know, the H went with an Advantage Plan, as he wanted the dental and a few other benefits and resented paying a larger fee for a part B supplement with fewer services. He is healthy and has the resources to self-pay if a crisis occurs. He is happy with the gamble he chose.
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The cap on annual out of pocket was one reason I chose MA.
I went to 4 financial counselors and they all, independently, suggested the same Medicare option for me, a BC/BS PPO MA. I dealt with my motherās insurance and care and absolutely everything was paid for, but her premiums were high.
Itās unusual for me to just rely on the advice of others (I like to research) but I dealt with the confusion by getting 4 opinions, at two hospital financial offices and two town SHINE counselors. The consensus was convincing and now I am wondering why they all suggested my plan! I described my health challenges and my finances and that a priority for me was being able to use doctors in different health care systems.
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If you get a secondary, which almost everyone does, thereās also a cap. The problem with the MA ācapā is that there are usually separate caps in and out of network.
I think we all have different situations. For me a $3k cap when all the health care/hospital systems that I want to use in network and a copay of $0-$79 seemed like a good choice. Weāll see! Itās been 7 years but no longer hospital stays as yet.
I do find there are times I donāt do all the health care I might if it were free (imaging, PT) unless absolutely necessary. Maybe thatās a good thing but probably not!
Most Advantage plans are HMOs, and licensed by the States, as long as they meet the minimum federal standards. People select them for lower costs (and perhaps a few more benefits, such as vision & dental). To save money, your BIL chose a limited network. Itās not that he could not get a cataract surgery from his Advantage plan, but he wanted to see a non-network doc. That was his personal choice.
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And again some are not HMOās but PPOās, at least in our state.
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Some people pick Kaiser, and if you do, then just like with āregularā Kaiser, thatās the system you are in. There is a little cross over, like when the Kaiser hospitals are full you get sent to a non-Kaiser hospital (or taken there by ambulance). My friendās husband has Kaiser, my friend has Humana. They donāt see the same docs.
My daughter was born in a hospital that was 1/2 Kaiser and 1/2 āotherā. My daughter had a āregularā doctor during the day when there were several docs on duty, but sometimes had a Kaiser doc overnight or when there was an emergency. They worked it out for billing. Kaiser specialists came in for their patients and other specialists for the other kids (surgeons, ophthalmologist) when it wasnāt an emergency. I didnāt get to pick which specialist cared for my daughter.
All insurance is state by state, even medicare. Some things are covered in some states and not others. I remember reading about a woman getting some kind of cancer treatment that wasnāt covered in Colorado but when she got a treatment in California while on vacation, it was covered. She then started flying to California for the treatment every month because it was cheaper to pay for the flight than the treatment (and she got a trip to California out of it).
Thatās the keyā¦the ones you want to use. We travel, a lot. Thereās risk if I wreck my bike, have a heart problem, etc. while away from home that I could unknowingly see an out of network doc. This happened to Phil Gaimon, a professional cyclist who was double covered. He wrecked in a race and ended up with a $200K bill! I think MA, like any other PPO, works greatā¦until it doesnāt. With standard Medicare, that risk is off the table.
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@eyemgh you have raised a few concerns for meā¦the out of network anesthesiologist and now travel. I can actually enroll at any time in the year due to a state program. If I contemplate travel I am going to look into this.
ps this case was complicated:
But in an Oct. 19, 2019, letter, Health Net denied Gaimonās appeal because he āself-referredā himself to a surgeon in New York. It also described the surgery as āoutpatientā even though he spent the night at the hospital. The letter went on to say the Hospital for Special Surgery had categorized the surgery as elective
.
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I think the risks are low, but real 
That story is horrifying. That they are all not budging, even after the NPR publicity, is scary.
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indeed, I think the word āmostā in my post covered it. (PPOās were only added to Medicare Advantage in 2011.)
the cyclist travels a lot and purposely purchased a lower cost regional policy with few travel benefits. Before/instead of self-referring to a Manhattan surgeon, 100 miles away, he could have called his health insurer (HealthNet in CA) and asked what he should do about his broken scapula. When he checked into the NYC Surgery center, did they not tell him that he had no coverage? (Never known a surgery place to not contact insurance first.)
Not surprisingly, NPR is missing a few things.
btw: not sure the new federal law would help the surgery in NYC, since it was deemed not an emergency.
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THIS! My DH and I have both had surgery while on Medicare. In all cases, the surgical center would NOT see us until they got the amount we had to pay put of pocket to them. And that needed to be paid FIRSTā¦before any surgery.
We have a MA PPO. Our OOP costs in both cases were $30. Total.
But we absolutely knew this up front!!
His surgery was marked as elective unbeknownst to him.
Itās easy to armchair quarterback his decisions without all the facts, but even if he did make that decision, which he didnāt, itās a crime that a clavicle should cost $150,000.
I was with a rider in Italy who suffered the same injury. The doctor asked if she was wearing a helmet. She was, so her costs were 100% covered, even though she was a US citizen without travel insurance.
We canāt keep running our healthcare system the way we do without it collapsing, or having an uprising.
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Sure, he may have been told by the local hospital that traveling to NYC for surgery would be covered, but itās hard to believe that the Manhattan Surgery Center would confirm without first checking with HelathNet for payment approval.
āWe canāt keep running our healthcare system the way we do without it collapsingā¦ā
Agreed.
Seems like the moral of the story is that navigating medical care and medical insurance in the US is complicated, and it is very easy to make expensive mistakes, especially when one is under duress due to a medical condition or injury requiring unplanned medical care.
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Correct, but a national class athlete, for whom access to top Orthopods is important, and who travels a lot, should know to ask about travel coverage. This is no different than those snowbirds from the NE who head to Florida for the winter. You can believe they inquire about coverage in multiple states.
Asking about multi-state coverage when purchasing a policy is not all that complicated IMO.