We’ve talked about traditional Medicare supplements versus advantage plans. I found this report from The NY Times. And I 
gifted the link.
Thanks for @oldmom4896 for the idea of gifting links as I had no idea I could do this.
Don’t @me if you don’t agree with the article. I know some love their advantage plans and not all plans are created equal. I’m passing on information if you are looking at this decision.
I read the article and comments. Just to clarify one point: not all Advantage Plans are HMO’s with managed care. Mine is a PPO.
I think the quality of Advantage Plans must vary from company to company, and state to state. In Massachusetts, SHINE counselors tend to recommend BC/BS PPO Advantage plans in my experience (4 counselors). One comment cited a counselor telling people to stay away from Advantage Plans, not sure which state.
I think the “often” in the title is a bit misleading: “About 18 percent of payments were denied despite meeting Medicare coverage rules.” I believe these problems are occurring with a certain number of insurance companies.
We all need to research, meet with financial counselors and make smart choices!
Yes, my husband’s Advantage Plan is wonderful. He’s had it for three years and never had a problem with coverage. I know he paid very little for his trip to an ER, while I paid about $1,500 for mine and I’m covered by Anthem (not Medicaid). He’s also had reimbursements for dental and eye care that I don’t get. We just submitted a request for a $400 reimbursement for fitness equipment (that’s an annual benefit of the plan). I wish I were 65.
The problem with most advantage plans is when you really need them. Think cancer treatment. All of the sudden the gym membership, dental etc doesn’t look so great when they deny that drug you need or extended physical therapy.
What like all plans are doing is just what the article was saying. They are auditing doctors office NOT for patient care. They are looking to see if there is more money they can get out of each visit for their added profits. This is one thing the government is trying to recoup. They don’t want to pay the doctors their time getting the charts ready and sending it to them. This is NOT a Medicare audit. There is so much call it fraud going on and the government should get back money paid out. This will lead to increase fees to Medicare advantage plans. Not that their not making profits. But they want to make a certain profit margin.
There are tons of articles like these.
I helped my mom choose an Advantage plan 5 years ago, and it has worked out very well thus far, including multiple hospitalizations. It is a PPO plan, not an HMO. It has helped that the agent we purchased the plan from is always available to her to clarify and help out with benefits.
My family and I have excellent private insurance coverage through my husband’s employer and we still have to “haggle” with them at times to get things right. It seems to be the default of insurance companies to deny, and it can require diligence and persistence to get things “right” - along with the ability to correctly read and interpret your policy, which is often overwhelming and daunting for anyone.
All I can tell you is that the people I know in Maine who have this particular plan love it. My friend’s husband was hospitalized in Florida and had major surgery. They had no problem getting reimbursement for it. I have heard of zero problems with it. So I guess we’re lucky.
I think the point isn’t that Advantage plans don’t work in the vast majority of times. But that there are times you really need them to work and the advantage insurer slows down the timeframe. Or makes you go through hoops to get the coverage you need.
82% of the time, things work just as they are supposed to. But what if you are in the 18%? And need that MRI? Or CAT scan? Or PET scan? And it’s first denied? But you appeal and then it’s approved? But you have cancer and it’s progressed? Or your parent needs rehabilitation?
It’s not about how it works right now. Or how it’s worked in the past. But how it’s going to work in the future.
My mom fell and was admitted to a rehabilitation center. She has a Humana SUPPLEMENT. Twice in the 6 weeks she was there and released, we had issues because they thought she had an Advantage Plan. Twice we called, said it was a supplement and twice we were told, oh great, no problems, you are covered.
Maybe it’s plan specific. We see patients in our office highly confused. They mostly think they have Medicare buts it’s an hmo product which we don’t take. We only take ppos. We usually get “they will pay everything” and we tell them they won’t. Too many commercials and bad information trying to sell them on insurance packages and talk about just about anything but health care. We also see it from the office side with them.
But, if you or a loved one has a plan that’s been great then that is good. I think it’s really regional on how good /bad these plans actually are honestly.
US News rates our plan as 5 out of 5 stars.
Another article: https://healthpayerintelligence.com/news/bma-ma-member-satisfaction-is-high-prior-authorization-denials-low
" Medicare Advantage beneficiaries express high levels of member satisfaction, an eHealth survey found.
eHealth surveyed nearly 2,850 individuals online toward the end of May 2022.
Nearly two-thirds of Medicare Advantage beneficiaries were “very satisfied” with their coverage (63 percent) and a total of 88 percent of Medicare Advantage members stated that they were satisfied."
PPO’s may work better. I have had cancer while on my plan, lupus, osteoporosis a bunch of neuro things etc. My plan provides not only case management but links to a service with docs, PA’s. NP’s who come to my home to check on things every few months, whom I can call if I need to see someone at home, and who can do blood tests and mobile x-rays for free. They also provide behavioral health. I haven’t been charged for any of this.
My doc just ordered an MRI and a CT and I had no problems with authorizations.
Must depend on company, plan, and state. Not to repeat myself umpteen times, but I love mine.
And some Medicare Advantage Plans are PPO plans. Do you take those?
For now yes but reevaluating. My practice is actually very young over all. We don’t have a lot of seniors compared to others practices.
a good review of the differences between Medicare with a Medigap plan and Medicare Advantage is at Medigap vs Medicare Advantage / The Great Medicare Debate - YouTube
Medicare & Medigap is standardized. If your doctor or hospital accepts Medicare then if your Medigap plan covers the service at all then you’re covered by you Medigap policy.
Medicare Advantage is a managed care plan. Even if they call it a PPO instead of a HMO they still have in-network and out-of-network providers. If you’re a light user of medical care and die in your sleep in old age with little medical care needed prior to that time then Medicare Advantage is probably a big win. However if you get sick and need hospital care, need to see specialists, want to see someone at a teaching hospital, then with Medicare Advantage you may pay a lot in order to do so since there may be significant co-pays or they may be out-of-network.
Also worth keeping in mind is that choosing Medicare Advantage may be irreversible in most states. Everyone is guaranteed acceptance if they sign up for Medigap plans when first eligible at age 65. But Medigap plans can require medical underwriting after than, in which they can refuse to issue policies to those who they think need care. So if you get cancer and decide you don’t like the costs with your Medicare Advantage plan or the restricted network you may be unable to change back to ordinary Medicare since you won’t be able to get a Medigap plan.
My MA plan has no in and out of network. All physicians and hospitals who accept Medicare accept this plan. It’s a very very large group retiree plan…and any doctor who accepts Medicare accepts this plan. It’s part of the plan.
Like with anything else, the specific plan is what makes the difference.
And unfortunately we know more than a bunch of people who have had or are having cancer treatments, and some at one of the teaching hospitals in this state. They have no issues.
In addition, folks also have moved OOS and are able to use this plan with no issue…again, part of what was negotiated with the provider for this VERY large retiree group.
That’s how my husbands plan works. He has serious medical issues and regularly sees a doctor at a teaching hospital in Boston. There has never been an issue with coverage.
Also, in our state you can switch back to regular Medicare if you want during open enrollment. It seems like many of the things people are talking about here are state specific.
The bottom line is that people need to research before making a decision. In Maine, everyone I talked to loves their MA plan. And yes, some of them had serious medical issues.
This isn’t how it works in other states. Depending on the plan I could be in network or not. I wish it worked this way everywhere.
It’s how my MA Plan works in other states. YMMV…and as noted by others…these plans are not once size fits all. Folks need to understand their plans.
Yes, my friend confirmed their MA plan worked fine in Florida.