Routine question about Medicare (for old timers)

Parents Forum Parent Cafe
21

A lot of my friends in my area have Medicare Advantage plans via Kaiser and are very happy with them – but generally, they were already on Kaiser, so for them, it was just a way to continue with a plan they were happy with.

Other than that, it’s not so much whether a provider takes Medicare Advantage, but rather which plan they take. Because it’s the same basic network problem that is part of all the ACA plans – the companies save costs by negotiating directly with the providers and then limiting patient choice to those providers.

22

Definitely impacted by where you live and what mix of patients docs see. Here in SW Florida which is already senior heavy, we’re seeing that many docs won’t accept new Medicare patients. Talking to my doc friends, the Medicare reimbursement rates are just too low to have more than a certain % of their practice be on Medicare. I suspect if you live in an area with fewer seniors and at least a middle class average income, you’d have a wider choice of doctors since docs wouldn’t have to limit their number of Medicare/Medicaid patients.

23

Medicare Advantage Plans vary wildly in their coverage. The one I have is a group plan Premium PPO. It covers anywhere.

24

Physician here. I have been disappointed over the years, before and after having Medicare, with routine physical/wellness exams done by various physicians.

Be sure the physician has any covered labs correctly code. I was frustrated trying to get checks for labs covering disorders covered when my physician did not- several attempts denied. Part of my problem was getting the initial exam and labs in summer then a repeat of labs around six months later when needed to renew prescriptions. Tried at least twice but legit clainm denied. Proper coding needed- routine versus for a disease.

btw- there is also supplemental coverage, different than the Advantage plans. Currently don’t have either but just a drug plan as those costs so far outweigh costs for needed services. Next month you need to figure which type of added coverage is best for you. For me, any HMO style coverage was not good because I prefer the physician I use, not one in any local plans.

The great thing about Medicare is cost control. Places are limited in their charges. The costs without any insurance are astronomical.

25

I am on Medicare + supplement. I had my first Wellness Check in Dec. of last year. My doctor ordered blood work, mammogram and bone scan. Medicare + supplement covered the costs. I also had an eye exam and again Medicare + my supplement covered the cost. I’m surprised by posts that say that Medicare places limits on the annual wellness visit since I didn’t have that experience.

26

My husband’s advantage plan is going to cover dental, eye glasses, and contact lenses in 2020! Still no premium.

27

“Medically necessary” can be a judgement call. But different physicians may make different judgement calls for the same patient, so the system as a whole can have both overtesting/overtreatment and undertesting/undertreatment.

28

You may wish to have your doctor get a treatment that “may” be covered pre-authorized to see if it is probably covered or not covered.

My MDs have gotten me pre-authorized for several Rx and procedures so we don’t have coverage surprises. I’m not Medicare for another 3 years.

29

Yes, the admins knew to get pre-auth on several scans I needed.

OP/calmom is asking about the annual physical, not the “wellness visit.”

30

@ignatius – I’ve realized after reading various concepts that the issue is the difference between what Medicare pays & what the supplement pays.

I went to see an ophthalmologist for a particular medical problem last month. Medicare authorized the services, but the Medicare claim indicates that I “may” owe about $200 – because there is my $185 Medicare part B deductible plus copays on the services provided.

But I have an F supplement, which is supposed to cover those costs – so Medicare should send the claim info to the supplement carrier, and then the carrier should pay the doctor. (I don’t know how long that takes – I’m about to learn).

But now I see the problem. Medicare part B doesn’t cover a routine physical (NOT a “wellness visit”) or the types of labs that doctors typically order for those types of visits. But no questions asked if I feel like going to the doctor for an office visit for whatever reason I feel appropriate – and the doctor can then order whatever tests she feels are appropriate. But it won’t be free – there will be that deductible plus copay. But it won’t matter to me, because I’ve got the F supplement. However, it would matter a lot to someone who doesn’t have a supplement that pays the deductible, and maybe doesn’t feel like paying $185 for a routine checkup. But after reading the post from @wis75 I figured out that the main thing is that the billing department does NOT code anything as being preventive (as opposed to being follow up for a diagnosable condition. So the exact opposite of what I had to worry about with my high-deductible ACA plan, where preventive care was the ONLY thing I could get without charge.

@Himom – under standard Medicare (part B) – there isn’t really a pre-authorization process except in limited circumstances. This is different than private insurance or Medicare Advantage (which is a form of private insurance). (Long thread on that here: http://talk.qa.collegeconfidential.com/parent-cafe/2112461-contacting-medicare-for-pre-authorization-p1.html )

Best advice I’ve gotten on this thread was from @esobay

My primary physician is part of a very large group practice, so fairly good bet that the billing department has someone who gets it and will tell me what to do.

On another note, I had to jump through a bunch of unexpected hoops this week just to get a flu shot. But it turned out that Riteaid offers a free scoop of ice cream along with the flu shot… so all ended up OK.

31

OK, @calmom. I didn’t know. Sorry. There was a pre-auth for when we were getting a medication for my Medicare-covered dad, but maybe that’s one of the exceptions? I think it’s a Medicare B Rx. I think H has had to get prior auths for his PT sessions as well.

32

Does anyone here have a Medicare REPLACEMENT policy (not supplement) from BCBS or Aetna (or another, but those are the ones I am curious about). Thoughts? experience?

33

I have an Anthem Blue Cross Blue Shield Premium PPO Advantage Plan @jym626 . It happens to be a group plan purchased through my state teacher’s retirement board (I pay my Medicare premium plus an additional cost to the retirement board).

I like this plan a lot. It has coverage in every state. Any doctor who takes Medicare patients is on this plan.

34

Mine’s an advantage HMO via AARP UHC. No issues because my practice is well-run and has an underlying priority for patient care. It essentially functions like a PPO.

But I’m not in CA, where things vary so much, by region. I’d prefer BCBS (very well run, ime, when I previously had them.) But the overall costs were higher.

35

From my understanding, the replacement plans are run/managed by the insurance company (like BCBS) So if there is an issue one deals with BCBS, not Medicare. Is there a need for (or is there even) a supplemental?

36

It boils down to one or the other. Original Medicare with (or without) a supplement, or an Advantage plan. For me, it’s just an administrative distinction.

You kind of lay out what you need now, could need, only “might” need, etc, and figure which offers you the best overall. I also looked at what if I do need skilled care, cost of ER, etc.

Sorry, that’s probably self-evident. And sorry, but if one is concerned with costs, you do need to project numbers. My mother had a fab Plan F supp, but costs were too high for me and the break even wasn’t worth the higher monthly.

37

@jym626 — I don’t know what you mean by “replacement” plan.

As far as I know the choices are either original Medicare with an add-on drug plan
Medicare Part A: government-administered, covers hospital care
Medicare Part B: government-administered, covers out-patient care
Medicare Part D (drug plan): private insurance company, covers prescription drugs

  • (optional) supplement (Private insurance company, but it functions like an umbrella policy -- highly standardized and the company does not have discretion -- it just functions as a way of covering the deductible & copays/coinsurance that Medicare doesn't pay).

OR

Medicare Part A: government-administered, covers hospital care
Medicare Part C (Medicare Advantage): private insurance company, replaces Medicare Parts B & D

You can NOT have a supplement with Medicare Advantage – it is one or the other. It is illegal for a company to sell a supplement to anyone who has MA coverage…

Also, unless you buy into a supplement at the outset, there is no guaranteed issue – all the stuff about pre-existing conditions comes into play for the supplement - so choosing the privately-administered Medicare Advantage plan at the outset can function as a waiver of the ability to ever switch.

It IS possible to have primary coverage through another source rather than Medicare part B or C – this typically would be through employer-provided insurance. That can be one’s primary insurance (instead of part B/C) or it can function as a secondary policy, covering stuff that Medicare won’t (such as the comprehensive annual physical mentioned at the outset).

Even though Part C is administered separately from Part B – it still requires payment of the Part B premium – but I think the way it works is that the government then sends the Part C plan the premium. But that’s what people are talking about when they say they have a -0- premium with Part C. It’s not that they are getting a break or free insurance – it’s that they don’t have to pay any extra beyond the Part B – which is collected by the government, not the insurance company.

@Himom – prescriptions are always covered via a private company – either Part D for those of us with parts A & B - or bundled in with the Part C - plan. Part B doesn’t generally cover prescriptions that you fill and pay for – though it can cover drugs directly provided by your doctor. There are some exceptions, like oral chemotherapy drugs – but for the most part, if your father needed authorization for a specific RX, it would have been outside the government-administered system. Generally it would be to allow purchase of drugs outside the company’s formulary – each company has a list of which drugs it will pay for, and if you want or the doctor prescribes a brand-name drug outside the formulary, there is a process to get it approved for payment.

As to physical therapy – Medicare pays for that but there is an annual cap on the total $ amount it will pay, so if someone needs PT beyond the cap, then they have to go through a specific process to apply for an increase in the total allowance.

38

calm:

I believe that Medicare Advantage are a ‘bundled plans’. If one signs up for Kaiser in NorCal, one only receives one bill for hospital/MD/Rx. In other words, Medicare Part C combines A, B, & D (the latter in most plans).

https://www.medicare.gov/Pubs/pdf/12026-Understanding-Medicare-Advantage-Plans.pdf

“original medicare” will still cover hospice care, however.

39

@calmom- I think you described it - a Replacement plan is one in which the insurance company provides the coverage instead of medicare. So guess there would be the traditional copay with a replacement plan https://www.accuratemedbilling.com/what-is-a-medicare-replacement-plan/

We have a HSA and DH can continue to contribute to it (I already have Medicare A so I don’t think I can, though its all through DH’s employer anyway). At present we are thinking when its time, of getting traditional Medicare and the Plan G supplement (since F is going away) through USAA. And I think we can pay for the premiums of the supplement with HSA $.

40

On my plan (Advantage,) physical therapy was covered with a $30 copay, per visit. But several times, when we checked, it was confirmed that the coverage was “unlimited.” I don’t know if it was coded in some way to ensure that.

I offer that more as a hint that, if some elements of coverage are key to you, check them. Again, it can be state dependent. As I understand it, a state (or region, in the case of CA,) can shape some of the coverage(s) available.

There can be a difference between copays adding up vs 20% or whatever. Eg, ER at a fixed cost vs percentage.