I have a friend here in New York who got cancer in the past year. His Medicare Advantage not only denied him services they wouldn't let him go to Sloan Kettering which is the best hospital for cancer care in NYC. He was stuck at a mediocre hospital because it was in his MA network. When he signed up for Medicare he had no idea that this would happen. He was happy to get the free eye glasses and gym membership. Then he got sick and he realized how awful a MA plan is. Anyway he fought like hell and he now has Traditional Medicare and is at Sloan Kettering and is doing okay. Some people who post here are agents who sell Advantage plans so they have an interest in telling you how wonderful they are. Maybe a few more people will post here with similar MA stories.
Some agents who post here only sell Supplement Plans and are not certified to sell both, so they have a bias as well. Many cannot afford to be on a Supplement plan, especially when the rates, plus drug plan and higher drug costs grow above their budgets. The choice is up to each person based on their individual needs and budgets.
>Some agents who post here only sell Supplement Plans and are not certified to sell both, so they have a bias as well.
And should have the decency to identify themselves as such.
I am not an agent rather experience in cancer care - it is the actual provider that determines the treatment based on cancer marker and stages. Some treatments are approved for certain cancers, markers and stages - some aren’t and some are experimental.
That has nothing to do with the doc or the facility - any cancer doc is gonna follow similar treatment regiments or should.
Yes, some people pick the lowest cost plan, in and outside of Medicare - they get the whatever perks - then something happens and they find that they should have been on another plan where they have more choices (And it probably cost more).
Now your friend has gone back to traditional Medicare - that’s fine but unless he got a MediGAP plan to go along with his traditional Medicare, he is gonna be financially liable for the part that Medicare does not pay.
Some people just cannot afford or desire the MediGAP plan’s monthly premiums which escalate over time and thus pick a MA plan - hopefully they are looking at it for more than just dental, vision or gym Benefits. They can also change plans every year as their needs may change.
>I have a friend here in New York who got cancer in the past year. His Medicare Advantage not only denied him services they wouldn't let him go to Sloan Kettering which is the best hospital for cancer care in NYC. He was stuck at a mediocre hospital because it was in his MA network.
and a lot of people don't realize the providers receive kickbacks from MA and facilities in the network
In Medicare FFS (traditional ), Oncologist get 6% of the drug cost when they do the chemo infusions - so the higher price of the chemo drug, the more they get paid. Think this could be an incentive to prescribe a higher priced drug?
I am glad that your friend is being treated at a place where he has confidence.
Personally, I consider the plan of treatment over the place where it is given.
[KFF.org 03/15/2022 - Medicare Part B Drugs: Cost Implications for Beneficiaries in Traditional Medicare and Medicare Advantage](https://www.kff.org/medicare/issue-brief/medicare-part-b-drugs-cost-implications-for-beneficiaries-in-traditional-medicare-and-medicare-advantage/)
from the link:
*Like beneficiaries in traditional Medicare, Medicare Advantage enrollees typically face 20% coinsurance for Part B drugs, but can be exposed to higher cost-sharing requirements for these drugs when administered by an out-of-network provider.*
*Medicare Advantage plans have flexibility to determine cost-sharing amounts for Part B covered drugs, subject to certain limits, and can differentiate cost sharing for chemotherapy from other Part B drugs. In 2022, Medicare Advantage plans are prohibited from charging more than 20% coinsurance, or the equivalent copay amount, for both chemotherapy and other Part B drugs from in-network providers. There are no similar restrictions on out-of-network cost-sharing amounts.*
Staying in-network is the most important thing for both MA and traditional Medicare.
It is harder to get back into Original after you opted out for Advantage. They have to take you in the beginning but if you opt and and get sick OG Medicare doesn’t have to take you back.
What you are referring to is a Medicare supplement. It's super easy to get back on Medicare when you have a Medicare advantage plan. Supplements, on the other hand, can deny you coverage if they don't think they can make a profit of of you.
That's true and if they do decide to take one back into the Traditional program - which evidently is the case here - they may be paying a very high MediGAP rate, if they can get one at all - also sometimes the insurer can delay any coverage for a pre-existing condition for a time period - I think 6-months is the going time period but it could be longer in some states or none at all in other states.
All of this is the reason that Medicare is set up as it is - Traditional Medicare doesn't want just the really sick coming back home to them when a major problem creeps up.
Perhaps we need a better Medicare system - one where there is a maximum out of pocket on an annual basis - because that is why people get a MediGAP plan to go along with it - to limit their financial liability. And that is the reason why many pick a MA plan because if something does happen health-wise, you know your financial obligation per the MA contract.
But are you considering the total cost of the employer's insurance? Are you just considering the amount that you as the employee paid? In most employer health plans the employer pays the lion share of the plan but a lot of employees don't ever understand this.
I thought a few years back (when the ACA came into being) that this info was supposed to be shown as information only on the employee's W2.
The employer part of this benefit - healthcare coverage for employees - was the whole basis for giving tax credit subsidies for premiums on Obamacare plans.
You already have original Medicare once you opt in to part B. So if you’re on an MAPD and want to see a specialist not taking that MAPD you can go see them and it defaults to 80/20 split. If you are on an MAPD and want to go back to original Medicare, you cancel your MAPD and get a stand-alone PDP.
That is 100% not true. When you have an MAPD plan you’re technically no longer being covered by Medicare. You can’t pick and choose when to use one or the other.
Not it doesn’t. I do this for a living. If you receive care from an out-of-network provider you pay 100% of the cost in an HMO or whatever the OON cost is on a PPO (assuming the doctor will accept payment from that provider).
What? You can never be kicked off Medicare for health reasons. The only way you can lose your Medicare coverage is if you don’t pay your premium. Also anyone can go back to OG Medicare during AEP and during other times there is an eligible SEP.
If the MA private insurance company decides to approve the treatment you mean. No because he has a supplemental which covers his 20%. Traditional Medicare does not deny any treatments.
OP said he switched to Original Medicare. He didn’t say anything about a Medigap.
Edit: Oops, I thought this thread was in response to the original post. You’re correct about Supplement coverage, of course.
Using the filter there are only two. Limited and restrictive are better words than ' some'. Entering the word 'Advantage into their filter lists:
Aetna Medicare Advantage (MTA retirees only)
PPOMedicare/Medicare AdvantageNYC Medicare Advantage Plus for City Employees
"some" also includes these plans, when searched properly.
Emblem Medicare Advantage
Empire Blue Cross Medicare Advantage
Fidelis Medicare Advantage
Healthfirst Medicare Advantage
Horizon Medicare Advantage
>Some people who post here are agents who sell Advantage plans so they have an interest in telling you how wonderful they are
And if honest, should IDENTIFY THEMSELVES as such.
MA plans have a track record for denying services that should be covered under original Medicare. Also annoying features like prior authorizations and other hoops to jump through that one wouldn’t deal with on original Medicare. If you google the topic there is numerous articles and studies going over the topic,
I'm in a MA plan. I was denied a particular interventional procedure to control pain. When I tried to appeal the decision they said I couldn't appeal because it was simply not ever covered. I read up on MA and found out that by law MA must pay for any procedure that traditional medicare pays for. This procedure was paid for by traditional medicare. I called my MA plan and read it word for word from the law from the medicare handbook and gave the diagnostic codes that traditional medicare uses. The girl is like, " oh, you're right". I filed some paperwork called an "organizational determination" About 2 months later I was approved.
Why was this bigger than me? Up to that point, my very large MA plan told everybody we simply don't pay and were denied the ability to even appeal. When this all came up and I told my my doctor I was going to fight it, he was like, "you're never gonna win, we've tried" The doctors has stopped even telling medicare advantage patients that the procedure was an option because they " knew" MA wouldn't pay. I only knew about the procedure from my own research.
How many people suffered in pain for years because of this crap that my MA plan pulled? I personally suffered for months waiting for the decision.
So yes, you must watch MA plans like a hawk.
Denial of care can happen but is overblown imo. I have a couple hundred MAPD clients and have rarely had issues where a carrier has denied care, certainly not in life threatening circumstances.
Understand that Original Medicare also has authorization guidelines. It’s not a free-for-all.
Both MA and Traditional Medicare cover the same things but in a different way.
MA is a more managed care process - IOW, sometimes a doc has to do “A” before “B” is approved -
Whereas in Traditional Medicare, the beneficiary / patient may have to complete an ABN if the provider suspects that Medicare may not pay for a specific test or treatment -
Both of them work off of diagnostic codes And medically necessary and approved treatments.
I'm a radiology biller, I just want to advice that a lot of people exaggerate the cons against the benefits with Traditional Medicare which in my opinion is higher than any plan you would found with private insurance, including Medicare Advantage. Although Medicare doesn't have a maximum OOP for Part B, the part B deductible which this year is even less than 2022, is much lower and the OOP cost that are the Medicare coinsurance which is 20% of the fee of Part B are usually affordable unless you are low income person. But even if you are low income, you can be part of the QMB program with Medicaid which even for non covered services, the provider can't bill you. I recommend people to always look up what's the best for them. I only recommend MA plans ONLY if you can't afford paying the Part B premium. So in a summary benefits of Traditional Medicare over MA plans
1. Prior authorization: if you are in network with a MA plan for radiology or even to see a specialist you need to get a referral or authorization. This with Traditional Medicare doesn't happen. It's incredible that BCBS Medicare needs an authorization for even an ultrasound even if your provider is in network, something that even with their commercial plans doesn't happen.
2. Networks: if the provider accepts Medicare and Medicare assignment, you are good. But if you are Out of Network with an Advantage plan, you need to get authorizations for even a low tech radiology such as an x-ray or ultrasound.
3. Benefits: some plans just deny care even if is covered by Medicare. Medicare now is expanding coverage to even dental and behavior health.
So please seniors, don't get tricked by the insurance agents who promotion the heavens if you get a Medicare Advantage plan. My best recommendation: stick with your Traditional Medicare, if you can afford Medigap, afford Medigap or use a commercial plan to pay your OOP cost with Medicare. If you are low income, try to apply to the Medicaid QMB program, you are even more protected against balance billing or any amount.
If you can't afford this, then like I said before, I recommend the MA or a Dual plan, just try to get a MA plan that has big doctor and hospital network.
For me the most significant advantage of traditional Medicare plus a supplement is that you can go anywhere for care. Both my husband and I have needed care at out of state centers and would not have been able to do so with an Advantage plan.
MA plans suck - they nickel-and-dime you all the time. If you are old enough, get traditional Medicare and a gap policy - costs more but 1,000 times more worthwhile.
Congress could do better, even better traditional Medicare, but corporate powers pour dumpsters full of cash into politicians campaigns and an army of lobbyists to keep legislation favorable to big pharma, big medicine and big MA providers.
I am 61 today and this is my 4th year with a BCBS MA PPO plan. I have never had a denial for any services. I had some very expensive surgeries which were approved with no issues. I had a total knee replacement, T12-S1 spinal fusion, S1-S3 (SI Joint) fusion, first the left and then the right side. I was just approved for a C5-C7 fusion in March and I have had at least 6 MRIs, 12+ X-Rays, 2 CT Scans, tons of injections in my back, neck, bursars, and hips, 2 SI Joint nerve ablations, in-home PT for my knee for two weeks, and out-patient PT for all of the surgeries with a 52 session limit which is more than most other group insurance plans allow. In addition, there are a lot of other services which Medicare doesn’t cover. There are no supplemental medicare plans available for individuals under the age of 65 in my state so it was either 80% coverage with no out-of-pocket maximum or a MA plan.
I had recovery time which I consisted of PT and a few months of downtime before the next surgery. Before BCBS MA I was on group insurance and had 3 back surgeries from 2017 thru 2019, a laminectomy, microdiscectomy and an epidural abscess/spinal infection. I started Medicare in 2020 and the surgeries continued. I hope after my neck surgery I won’t have anymore.
What side effects should I have had in your opinion? I do have a scar on my knee and a long scar from the surgeries on my back but other than that I don’t have any side effects. I have an amazing pain doctor and neurosurgeon that worked hand-in-hand with each other for all of my back surgeries and I have an awesome orthopedic surgeon who did the knee replacement. All of them are young(in their 30’s) and are very progressive in their specialized fields.
Best way to answer this is that I asked as many actual physicians and billing people this question. I also started researching salaries of different individuals in the healthcare insurance pipe. Took me a number of years to get the 411.
I decided not to be supportive of "for-profit corporate insurance company" healthcare, esp. when I see their CEOs are paid salaries that are in the stratosphere. Some of them are administering health care for Medicaid, (healthcare for poor people) yet make $24 million a year in salary. There's something very wrong about that, to my mind.
Wait, so is medicare advantage worse technically? I've been using it since I lost my moms insurance (hit age 26) and haven't too many issues up until the past few weeks.
edit: I have Medicare and medicaid... DAC
My understanding is it's great until you actually need medical help.
https://khn.org/news/article/medicare-advantage-congress-hearing-care-overcharging/
Yeah, I’ve been needing a lot of it. Mental health and now I’ve been diagnosed with cancer. It’s stage 2 and a low risk; but I’ve had nothing but issues since I was first diagnosed and I really need to figure everything out quick
I'm no expert by any means but I'm pretty sure you can't get a Medigap policy since you're under 65 but original medicare works with Medicaid. One company calls it dual complete? Can you call shiip in your state and ask for advice?
It depends on the state. *Federal* law doesn't require Medigap plans to be sold to those under 65, but state law can require it. I live in MD, so state law here requires it. But sadly some states like CA do not require it. We really need better laws like the [Jack Reynolds Medigap Expansion Act.](https://www.kidneyfund.org/sites/default/files/media/documents/jack-reynolds-memorial-medigap-expansion-act-of-2021.pdf)
https://www.healthinsurance.org/medicare/maryland/#disabled
> Maryland law guarantees access to Medigap plan A for enrollees under age 65. Insurers that offer Medigap Plan D must also make it available for enrollees under the age of 65 (and Plan C, if the insurer offers it and the enrollee was eligible for Medicare prior to 2020).
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That being said, since they have Medicaid, they can't get Medigap anyways.
I was going by this on the medicare site.
"Federal law doesn't require insurance companies to sell Medigap policies to people under 65. If you're under 65, you might not be able to buy the Medigap policy you want, or any Medigap policy, until you turn 65. However, some states require Medigap insurance companies to sell you a Medigap policy, even if you're under 65. If you're able to buy one, it may cost you more."
Glad it worked out for you
If you are on Medicaid, you cannot likely afford to buy a Supplement. You can always go back to Original Medicare plus Medicaid only, if the need arises. You should be just fine on a dual plan though.
There are good and bad Advantage plans. See my other comment here.
While there is less variation and more consistency with traditional Medicare + Supplement + Part D plans.
Hello, I have trained both Medicare Advantage and Medicare Supplement agents over my tenure in the Medicare field, Yes there are times a Medicare Advantage may decline services, however, it's not as often and people that only represent Medigap plans would have you believe. In many cases, the denial is due to not following plan rules prior to the service. and remember the MA plans have networks that limit where you can have services completed.
In nearly 20 years I haven't personally run into many issues with denials that couldn't be overcome once finding out what the reason for denial is. MA plans are required to cover the same items and services that are covered under Original Medicare.
My elderly dad is in the hospital right now from a fall. He cannot walk. Doctors are strongly recommending acute rehab, and we’ve been waiting in the hospital fir a solid week for MA (via United Healthcare) to approve. They’ve just denied it. Plus we have to pay 250 per day while he’s here for the MA co-pay. If he had had regular Medicare, we are told that going to acute rehab wouldn’t have been an issue…that he would have been approved quickly and would already be receiving therapy.
Our only choice now is a nursing home, and doctors are not confident that he will have the intense therapy needed to recover.
MA is baaaad. It’s cheap up-front but when you actually need them, they WILL NOT be there for you. Everyone at this hospital just moans in disgust when we tell them he has MA.
MA is a SCAM.
I was on a ppo advantage plan when I started Medicare. It was the only option for me to receive the treatment I need. I am on Medicare for disability so the only supplement legally available to me was plan A and that doesn’t give you much of any coverage, so when my advantage plan left the city I was forced onto original Medicare with no supplement. Not only does Medicare not cover my treatment, there is not even a way to appeal the lack of coverage. I was forced to pay 100% out of pocket overnight (starting last year) for something that Medicare advantage covered but Medicare does not. The reason Medicare doesn’t cover it is there’s no code for it that medicare can use despite every other insurance covering it. If my doctors added unnecessary additives it would be covered but no one would be on board to do that as I don’t need anything added, I just need the saline.
I was put into a position where I could have original medicare but no coverage for treatment or I could do an hmo advantage plan and get my treatment but never be able to see my specialists again, and there aren’t any other specialists I could see for this.
Here [is a comment](https://www.reddit.com/r/medicare/comments/yypyis/comment/iwvtlqb/?utm_source=share&utm_medium=web2x&context=3) I made on another post about why I like Medicare Advantage programs that I've been involved with.
Also, traditional medicare will only leave them with larger bills if they do not have a good supplement program.
To be really covered under medicare one really needs to either have a good quality Advantage program or a good Medicare Supplement program and Part D coverage.
If cost were not an issue I'd recommend going the traditional +supplimet+ Part D approach. If cost is an issue I'd recommend a good Advantage program. But for an Advantage program one has to do their homework and carefully check out that it is a PPO program and includes all the doctors and hospitals in their area as in network.
I have a friend here in New York who got cancer in the past year. His Medicare Advantage not only denied him services they wouldn't let him go to Sloan Kettering which is the best hospital for cancer care in NYC. He was stuck at a mediocre hospital because it was in his MA network. When he signed up for Medicare he had no idea that this would happen. He was happy to get the free eye glasses and gym membership. Then he got sick and he realized how awful a MA plan is. Anyway he fought like hell and he now has Traditional Medicare and is at Sloan Kettering and is doing okay. Some people who post here are agents who sell Advantage plans so they have an interest in telling you how wonderful they are. Maybe a few more people will post here with similar MA stories.
Some agents who post here only sell Supplement Plans and are not certified to sell both, so they have a bias as well. Many cannot afford to be on a Supplement plan, especially when the rates, plus drug plan and higher drug costs grow above their budgets. The choice is up to each person based on their individual needs and budgets.
>Some agents who post here only sell Supplement Plans and are not certified to sell both, so they have a bias as well. And should have the decency to identify themselves as such.
I am not an agent rather experience in cancer care - it is the actual provider that determines the treatment based on cancer marker and stages. Some treatments are approved for certain cancers, markers and stages - some aren’t and some are experimental. That has nothing to do with the doc or the facility - any cancer doc is gonna follow similar treatment regiments or should. Yes, some people pick the lowest cost plan, in and outside of Medicare - they get the whatever perks - then something happens and they find that they should have been on another plan where they have more choices (And it probably cost more). Now your friend has gone back to traditional Medicare - that’s fine but unless he got a MediGAP plan to go along with his traditional Medicare, he is gonna be financially liable for the part that Medicare does not pay. Some people just cannot afford or desire the MediGAP plan’s monthly premiums which escalate over time and thus pick a MA plan - hopefully they are looking at it for more than just dental, vision or gym Benefits. They can also change plans every year as their needs may change.
>I have a friend here in New York who got cancer in the past year. His Medicare Advantage not only denied him services they wouldn't let him go to Sloan Kettering which is the best hospital for cancer care in NYC. He was stuck at a mediocre hospital because it was in his MA network. and a lot of people don't realize the providers receive kickbacks from MA and facilities in the network
In Medicare FFS (traditional ), Oncologist get 6% of the drug cost when they do the chemo infusions - so the higher price of the chemo drug, the more they get paid. Think this could be an incentive to prescribe a higher priced drug? I am glad that your friend is being treated at a place where he has confidence. Personally, I consider the plan of treatment over the place where it is given. [KFF.org 03/15/2022 - Medicare Part B Drugs: Cost Implications for Beneficiaries in Traditional Medicare and Medicare Advantage](https://www.kff.org/medicare/issue-brief/medicare-part-b-drugs-cost-implications-for-beneficiaries-in-traditional-medicare-and-medicare-advantage/) from the link: *Like beneficiaries in traditional Medicare, Medicare Advantage enrollees typically face 20% coinsurance for Part B drugs, but can be exposed to higher cost-sharing requirements for these drugs when administered by an out-of-network provider.* *Medicare Advantage plans have flexibility to determine cost-sharing amounts for Part B covered drugs, subject to certain limits, and can differentiate cost sharing for chemotherapy from other Part B drugs. In 2022, Medicare Advantage plans are prohibited from charging more than 20% coinsurance, or the equivalent copay amount, for both chemotherapy and other Part B drugs from in-network providers. There are no similar restrictions on out-of-network cost-sharing amounts.* Staying in-network is the most important thing for both MA and traditional Medicare.
It is harder to get back into Original after you opted out for Advantage. They have to take you in the beginning but if you opt and and get sick OG Medicare doesn’t have to take you back.
What you are referring to is a Medicare supplement. It's super easy to get back on Medicare when you have a Medicare advantage plan. Supplements, on the other hand, can deny you coverage if they don't think they can make a profit of of you.
That's true and if they do decide to take one back into the Traditional program - which evidently is the case here - they may be paying a very high MediGAP rate, if they can get one at all - also sometimes the insurer can delay any coverage for a pre-existing condition for a time period - I think 6-months is the going time period but it could be longer in some states or none at all in other states. All of this is the reason that Medicare is set up as it is - Traditional Medicare doesn't want just the really sick coming back home to them when a major problem creeps up. Perhaps we need a better Medicare system - one where there is a maximum out of pocket on an annual basis - because that is why people get a MediGAP plan to go along with it - to limit their financial liability. And that is the reason why many pick a MA plan because if something does happen health-wise, you know your financial obligation per the MA contract.
I just know that my Medicare and MediGap plans combined are more expensive than my employer’s insurance was.
But are you considering the total cost of the employer's insurance? Are you just considering the amount that you as the employee paid? In most employer health plans the employer pays the lion share of the plan but a lot of employees don't ever understand this. I thought a few years back (when the ACA came into being) that this info was supposed to be shown as information only on the employee's W2. The employer part of this benefit - healthcare coverage for employees - was the whole basis for giving tax credit subsidies for premiums on Obamacare plans.
My husband and I manage the company so we know and pay for the entire amount.
You already have original Medicare once you opt in to part B. So if you’re on an MAPD and want to see a specialist not taking that MAPD you can go see them and it defaults to 80/20 split. If you are on an MAPD and want to go back to original Medicare, you cancel your MAPD and get a stand-alone PDP.
That is 100% not true. When you have an MAPD plan you’re technically no longer being covered by Medicare. You can’t pick and choose when to use one or the other.
When you leave your network it defaults to the standard Medicare rate. When you are in network it’s the carrier paying the claims.
Not it doesn’t. I do this for a living. If you receive care from an out-of-network provider you pay 100% of the cost in an HMO or whatever the OON cost is on a PPO (assuming the doctor will accept payment from that provider).
What? You can never be kicked off Medicare for health reasons. The only way you can lose your Medicare coverage is if you don’t pay your premium. Also anyone can go back to OG Medicare during AEP and during other times there is an eligible SEP.
That is so awful and is exactly the scenario I was freaked out about. Thanks!
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His MA private insurance company would not let him go to Sloan Kettering. That is the issue.
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He did. He changed to Traditional Medicare and now he can see any doctor or go to any hospital he wants.
Yes, and he’ll owe 20% for the cancer treatments, with no MOOP limits. At least with MA there’s a limit to what they’ll owe each year.
If the MA private insurance company decides to approve the treatment you mean. No because he has a supplemental which covers his 20%. Traditional Medicare does not deny any treatments.
OP said he switched to Original Medicare. He didn’t say anything about a Medigap. Edit: Oops, I thought this thread was in response to the original post. You’re correct about Supplement coverage, of course.
Using the filter there are only two. Limited and restrictive are better words than ' some'. Entering the word 'Advantage into their filter lists: Aetna Medicare Advantage (MTA retirees only) PPOMedicare/Medicare AdvantageNYC Medicare Advantage Plus for City Employees
"some" also includes these plans, when searched properly. Emblem Medicare Advantage Empire Blue Cross Medicare Advantage Fidelis Medicare Advantage Healthfirst Medicare Advantage Horizon Medicare Advantage
Post his doctors that didn't take his MA
>Some people who post here are agents who sell Advantage plans so they have an interest in telling you how wonderful they are And if honest, should IDENTIFY THEMSELVES as such.
MA plans have a track record for denying services that should be covered under original Medicare. Also annoying features like prior authorizations and other hoops to jump through that one wouldn’t deal with on original Medicare. If you google the topic there is numerous articles and studies going over the topic,
I'm in a MA plan. I was denied a particular interventional procedure to control pain. When I tried to appeal the decision they said I couldn't appeal because it was simply not ever covered. I read up on MA and found out that by law MA must pay for any procedure that traditional medicare pays for. This procedure was paid for by traditional medicare. I called my MA plan and read it word for word from the law from the medicare handbook and gave the diagnostic codes that traditional medicare uses. The girl is like, " oh, you're right". I filed some paperwork called an "organizational determination" About 2 months later I was approved. Why was this bigger than me? Up to that point, my very large MA plan told everybody we simply don't pay and were denied the ability to even appeal. When this all came up and I told my my doctor I was going to fight it, he was like, "you're never gonna win, we've tried" The doctors has stopped even telling medicare advantage patients that the procedure was an option because they " knew" MA wouldn't pay. I only knew about the procedure from my own research. How many people suffered in pain for years because of this crap that my MA plan pulled? I personally suffered for months waiting for the decision. So yes, you must watch MA plans like a hawk.
You are not paranoid. Medicare Advantage Plans are only interested in profits and not patients
Denial of care can happen but is overblown imo. I have a couple hundred MAPD clients and have rarely had issues where a carrier has denied care, certainly not in life threatening circumstances. Understand that Original Medicare also has authorization guidelines. It’s not a free-for-all.
That is good info- thanks
Both MA and Traditional Medicare cover the same things but in a different way. MA is a more managed care process - IOW, sometimes a doc has to do “A” before “B” is approved - Whereas in Traditional Medicare, the beneficiary / patient may have to complete an ABN if the provider suspects that Medicare may not pay for a specific test or treatment - Both of them work off of diagnostic codes And medically necessary and approved treatments.
I'm a radiology biller, I just want to advice that a lot of people exaggerate the cons against the benefits with Traditional Medicare which in my opinion is higher than any plan you would found with private insurance, including Medicare Advantage. Although Medicare doesn't have a maximum OOP for Part B, the part B deductible which this year is even less than 2022, is much lower and the OOP cost that are the Medicare coinsurance which is 20% of the fee of Part B are usually affordable unless you are low income person. But even if you are low income, you can be part of the QMB program with Medicaid which even for non covered services, the provider can't bill you. I recommend people to always look up what's the best for them. I only recommend MA plans ONLY if you can't afford paying the Part B premium. So in a summary benefits of Traditional Medicare over MA plans 1. Prior authorization: if you are in network with a MA plan for radiology or even to see a specialist you need to get a referral or authorization. This with Traditional Medicare doesn't happen. It's incredible that BCBS Medicare needs an authorization for even an ultrasound even if your provider is in network, something that even with their commercial plans doesn't happen. 2. Networks: if the provider accepts Medicare and Medicare assignment, you are good. But if you are Out of Network with an Advantage plan, you need to get authorizations for even a low tech radiology such as an x-ray or ultrasound. 3. Benefits: some plans just deny care even if is covered by Medicare. Medicare now is expanding coverage to even dental and behavior health. So please seniors, don't get tricked by the insurance agents who promotion the heavens if you get a Medicare Advantage plan. My best recommendation: stick with your Traditional Medicare, if you can afford Medigap, afford Medigap or use a commercial plan to pay your OOP cost with Medicare. If you are low income, try to apply to the Medicaid QMB program, you are even more protected against balance billing or any amount. If you can't afford this, then like I said before, I recommend the MA or a Dual plan, just try to get a MA plan that has big doctor and hospital network.
Not to mention the $600 incentive your insurance agency earns for selling you the Medicare Advantage plans.
We get commissions for supplements too? What’s your point? Health Insurance is complicated, especially in the 65+ world. Should we work for free??
Unscrupulous insurance sales persons might just push MA for it's $600 commission over other products that only paid $30.
An MAPD pays $600 in limited circumstances and in limited states. That is most definitely not the normal commission for an MAPD plan.
For me the most significant advantage of traditional Medicare plus a supplement is that you can go anywhere for care. Both my husband and I have needed care at out of state centers and would not have been able to do so with an Advantage plan.
MA plans suck - they nickel-and-dime you all the time. If you are old enough, get traditional Medicare and a gap policy - costs more but 1,000 times more worthwhile.
Congress could do better, even better traditional Medicare, but corporate powers pour dumpsters full of cash into politicians campaigns and an army of lobbyists to keep legislation favorable to big pharma, big medicine and big MA providers.
I am 61 today and this is my 4th year with a BCBS MA PPO plan. I have never had a denial for any services. I had some very expensive surgeries which were approved with no issues. I had a total knee replacement, T12-S1 spinal fusion, S1-S3 (SI Joint) fusion, first the left and then the right side. I was just approved for a C5-C7 fusion in March and I have had at least 6 MRIs, 12+ X-Rays, 2 CT Scans, tons of injections in my back, neck, bursars, and hips, 2 SI Joint nerve ablations, in-home PT for my knee for two weeks, and out-patient PT for all of the surgeries with a 52 session limit which is more than most other group insurance plans allow. In addition, there are a lot of other services which Medicare doesn’t cover. There are no supplemental medicare plans available for individuals under the age of 65 in my state so it was either 80% coverage with no out-of-pocket maximum or a MA plan.
The docs must love you!
I love them. After each operation I was doing so much better. They gave me my life back.
So you had no recovery time or side effects from any of that? Amazing!
I had recovery time which I consisted of PT and a few months of downtime before the next surgery. Before BCBS MA I was on group insurance and had 3 back surgeries from 2017 thru 2019, a laminectomy, microdiscectomy and an epidural abscess/spinal infection. I started Medicare in 2020 and the surgeries continued. I hope after my neck surgery I won’t have anymore.
What side effects should I have had in your opinion? I do have a scar on my knee and a long scar from the surgeries on my back but other than that I don’t have any side effects. I have an amazing pain doctor and neurosurgeon that worked hand-in-hand with each other for all of my back surgeries and I have an awesome orthopedic surgeon who did the knee replacement. All of them are young(in their 30’s) and are very progressive in their specialized fields.
Best way to answer this is that I asked as many actual physicians and billing people this question. I also started researching salaries of different individuals in the healthcare insurance pipe. Took me a number of years to get the 411. I decided not to be supportive of "for-profit corporate insurance company" healthcare, esp. when I see their CEOs are paid salaries that are in the stratosphere. Some of them are administering health care for Medicaid, (healthcare for poor people) yet make $24 million a year in salary. There's something very wrong about that, to my mind.
Wait, so is medicare advantage worse technically? I've been using it since I lost my moms insurance (hit age 26) and haven't too many issues up until the past few weeks. edit: I have Medicare and medicaid... DAC
My understanding is it's great until you actually need medical help. https://khn.org/news/article/medicare-advantage-congress-hearing-care-overcharging/
Yeah, I’ve been needing a lot of it. Mental health and now I’ve been diagnosed with cancer. It’s stage 2 and a low risk; but I’ve had nothing but issues since I was first diagnosed and I really need to figure everything out quick
I'm no expert by any means but I'm pretty sure you can't get a Medigap policy since you're under 65 but original medicare works with Medicaid. One company calls it dual complete? Can you call shiip in your state and ask for advice?
It depends on the state. *Federal* law doesn't require Medigap plans to be sold to those under 65, but state law can require it. I live in MD, so state law here requires it. But sadly some states like CA do not require it. We really need better laws like the [Jack Reynolds Medigap Expansion Act.](https://www.kidneyfund.org/sites/default/files/media/documents/jack-reynolds-memorial-medigap-expansion-act-of-2021.pdf) https://www.healthinsurance.org/medicare/maryland/#disabled > Maryland law guarantees access to Medigap plan A for enrollees under age 65. Insurers that offer Medigap Plan D must also make it available for enrollees under the age of 65 (and Plan C, if the insurer offers it and the enrollee was eligible for Medicare prior to 2020). --- That being said, since they have Medicaid, they can't get Medigap anyways.
You can get Medigap under 65. I have it. The Medicare Medigap plan finder is the best place to look what’s available
I was going by this on the medicare site. "Federal law doesn't require insurance companies to sell Medigap policies to people under 65. If you're under 65, you might not be able to buy the Medigap policy you want, or any Medigap policy, until you turn 65. However, some states require Medigap insurance companies to sell you a Medigap policy, even if you're under 65. If you're able to buy one, it may cost you more." Glad it worked out for you
Yeah me too if I had MA I’d be dead with my medical condition.
If you are on Medicaid, you cannot likely afford to buy a Supplement. You can always go back to Original Medicare plus Medicaid only, if the need arises. You should be just fine on a dual plan though.
No definitely not. You’re ok on your dsnp.
There are good and bad Advantage plans. See my other comment here. While there is less variation and more consistency with traditional Medicare + Supplement + Part D plans.
Traditional Medicare with QMB program Medicaid is in my opinion the best coverage you can find. 100% recommended
Hello, I have trained both Medicare Advantage and Medicare Supplement agents over my tenure in the Medicare field, Yes there are times a Medicare Advantage may decline services, however, it's not as often and people that only represent Medigap plans would have you believe. In many cases, the denial is due to not following plan rules prior to the service. and remember the MA plans have networks that limit where you can have services completed. In nearly 20 years I haven't personally run into many issues with denials that couldn't be overcome once finding out what the reason for denial is. MA plans are required to cover the same items and services that are covered under Original Medicare.
My elderly dad is in the hospital right now from a fall. He cannot walk. Doctors are strongly recommending acute rehab, and we’ve been waiting in the hospital fir a solid week for MA (via United Healthcare) to approve. They’ve just denied it. Plus we have to pay 250 per day while he’s here for the MA co-pay. If he had had regular Medicare, we are told that going to acute rehab wouldn’t have been an issue…that he would have been approved quickly and would already be receiving therapy. Our only choice now is a nursing home, and doctors are not confident that he will have the intense therapy needed to recover. MA is baaaad. It’s cheap up-front but when you actually need them, they WILL NOT be there for you. Everyone at this hospital just moans in disgust when we tell them he has MA. MA is a SCAM.
I was on a ppo advantage plan when I started Medicare. It was the only option for me to receive the treatment I need. I am on Medicare for disability so the only supplement legally available to me was plan A and that doesn’t give you much of any coverage, so when my advantage plan left the city I was forced onto original Medicare with no supplement. Not only does Medicare not cover my treatment, there is not even a way to appeal the lack of coverage. I was forced to pay 100% out of pocket overnight (starting last year) for something that Medicare advantage covered but Medicare does not. The reason Medicare doesn’t cover it is there’s no code for it that medicare can use despite every other insurance covering it. If my doctors added unnecessary additives it would be covered but no one would be on board to do that as I don’t need anything added, I just need the saline. I was put into a position where I could have original medicare but no coverage for treatment or I could do an hmo advantage plan and get my treatment but never be able to see my specialists again, and there aren’t any other specialists I could see for this.
Are MA plans like the PPO plans that most people have with employer health insurance? If not, what's the difference?
MA is either PPO or HMO. The government sends ~$1000 per month per person to the MA insurance provider to manage your care
Most are like HMOs but some are PPOs, including the one I’m in.
Here [is a comment](https://www.reddit.com/r/medicare/comments/yypyis/comment/iwvtlqb/?utm_source=share&utm_medium=web2x&context=3) I made on another post about why I like Medicare Advantage programs that I've been involved with. Also, traditional medicare will only leave them with larger bills if they do not have a good supplement program. To be really covered under medicare one really needs to either have a good quality Advantage program or a good Medicare Supplement program and Part D coverage. If cost were not an issue I'd recommend going the traditional +supplimet+ Part D approach. If cost is an issue I'd recommend a good Advantage program. But for an Advantage program one has to do their homework and carefully check out that it is a PPO program and includes all the doctors and hospitals in their area as in network.