Medicare Advantage Plans Disadvantage Many Elderly and Disabled People

[justaprogressive]

Last edited Tue Dec 5, 2023, 07:46 PM - Edit history (1)

When retired veterinarian Richard Timmins went on a Medicare Advantage plan in 2016, he admits that he knew very little about Traditional Medicare (also called Original Medicare) or the more than 3,800 Medicare Advantage plans that are marketed to seniors and the disabled.

“I went to a so-called Medicare Information Session and took the recommendation of the speaker and ran with it,” Timmins told Truthout. “I did not know that he was paid a commission for every person he signed up for a plan. The issue for me was cost.”

Like other Medicare beneficiaries, Timmins knew that the standard premium for Medicare coverage — $164 per month in 2023 — would be taken out of his monthly Social Security checks. He also understood that there would be a $226 annual deductible for Part B, which covers doctor’s visits, but after that deductible was met, Traditional Medicare would pick up 80 percent of the cost of his care. What’s more, he knew that dental, optical and audiology were not covered by the plan and that he would be responsible for paying the remainder of his health care costs — 20 percent of the total — out of pocket unless he purchased a separate, costly Medigap insurance plan.

Not surprisingly, when Medicare Advantage promised broader coverage for less money — the same deduction would be taken from his Social Security check, but he would not need a supplemental Medigap plan since Medicare Advantage (sometimes referred to as Plan C) would provide coverage for most of the services that Traditional Medicare did not offer — Timmins quickly signed up. That’s when his nightmare began.

After his primary care physician noticed a lump in his ear, Timmins was told that he needed to see a dermatologist. “I have a family history of skin cancer, so I tried to make an appointment right away but was told that I needed prior approval from my insurer to see the specialist,” he said. “It took seven months to get this approval and, in that time, the growth tripled in size and became painful. I finally had surgery to remove it in 2022. Had I been on Traditional Medicare, I would have quickly seen the dermatologist and the oncologist since prior approval is not required. I would have had the lump removed when it was smaller, before it extended into the tissue.”

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[Lonestarblue]

1. Advantage plans are great for the healthy but often not so great for the seriously ill.

I know people who have been denied further treatment for cancer even though the doctors knew the cancer was not gone. One nearly died waiting for the doctors to convince the insurer that their patient would die without treatment.

Advantage requires you to first go to your personal doctor, which can often take weeks or months to get an appointment, and then get a referral to a specialist (who must be in the insurance company network) which may also take weeks or months to get an appointment. The solution people in dire need of treatment often have to follow is the emergency room, which the Advantage plan may or may not pay for. Medical debt is one of the biggest categories of debt in this country.

I have original Medicare, and I can see any specialist without a referral. If I have a suspicious skin lesion, I can go to a dermatologist without waiting. And, yes, I have to pay for my own eyeglasses and dental cleanings, but those are small prices to pay for knowing that if I need serious medical care, I will not have to fight an insurance company more concerned about their profits than my need for treatment.

[dalton99a]

10. +1. Eyeglasses, dental cleanings and gym memberships are peanuts in the world of medical bills.

Using them as shining objects was a stroke of genius on the part of MA companies

[former9thward]

2. I have a MA plan and never had any issues as descibed in this article.

The article is very deceptive taking one story out of tens of millions and blaming the whole system for it. Why did he wait seven months? If I were in my late 60s with a lump and family history of cancer I would have gone to the dermatologist and paid cash and worry about who was going to pay for it later. Someone is going to wait seven months just because of paperwork? That does not sound rational to me.

Also, in the article they talk about issues of things like "upcoding" as if that only happens in MA plans. It happens all the time with regular Medicare. Why didn't the article mention that?

[ret5hd]

3. because original medicare is:

pay now, investigate later.

you never wait for a referral/approval…if the doctor says you need it, you get it. if there are issues with coding etc it is handled later.

[former9thward]

4. I have never had to wait for a referral/approval.

All the stories seem to come from people who have never been on a MA plan but tell us all the horror stories about it.

[Kingofalldems]

8. So this guy is lying?

[Ms. Toad]

9. All of us have been on traditional insurance plans, after which MA is modeled,

I certainly have ample experience with traditional insurance plans, delays while waiting for approval, and being forced to choose between paying out of pocket and risking the condition worsening (in one instance an aggressive cancer which doubled in size during the two weeks the insurance company imposes for a pre-surgical MRI), and fighting for more than a year in one case to get coverage for care by an out-of-pocket network provider paid - even though the insurance company had actually approved it.

Traditional insurance is a bad model for anyone who needs immediate access to medical care - and who is not independently wealthy. And all the data (i.e validated research) supports what we are saying.

So do you really believe your n=1 anecdotal data is more reliable than all the large studies which have documented the significant problems with MA plans?

[former9thward]

11. n equals1 in the OP.

Last edited Tue Dec 5, 2023, 08:14 PM - Edit history (1)

One story. No problems with regular Medicare? Nice to know. I and tens of millions of others will stick with MA.

[justaprogressive]

25. Unless you are being

compensated for these views, regrettably it will be to your sorrow, and you will be seeing
someone like me, a nurse in LTC or like my wife a nurse in Hospice sooner than you think.

More's the pity.

*Please understand I post these articles to save people's lives.

[former9thward]

26. Thank you for the good wishes!

Always happy to see informed discussion!

[Scottie Mom]

42. So answer me this, OK?

The person is making profit off of MAR the insurance companies and the insurance company sales persons. Nobody makes profit off of original Medicare.

There is no reason for somebody to lie about the disadvantages of MA.

[former9thward]

43. Insurance companies administer Medicare.

Don't believe that? Well let's hear from the government on the official Medicare website:

A Medicare Administrative Contractor (MAC) is a private health care insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B (A/B) medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries. CMS relies on a network of MACs to serve as the primary operational contact between the Medicare FFS program and the health care providers enrolled in the program. MACs are multi-state, regional contractors responsible for administering both Medicare Part A and Medicare Part B claims.

https://www.cms.gov/medicare/coding-billing/medicare-administrative-contractors-macs/whats-mac#:~:text=CMS%20relies%20on%20a%20network,and%20Medicare%20Part%20B%20claims.

So, yes, insurance companies make a profit off of regular Medicare. They also make a profit off of the Medigap policies which many, if not most, regular Medicare enrollees buy.

So I guess they are telling the truth when they make a profit off of regular Medicare buy lying their asses off when they are handling MA plans? Yeah, ok...

[Scottie Mom]

45. The ins cos are EMPLOYEES of Original Medicare.

They are not in charge of making denials re treatment. They cannot deny treatment for a patient with Original Medicare.

There is a huge difference between being paid a salary to administer a program over which you have no control how the program functions and what benefits the members of the program receive and being in charge of the program where you can deny benefits and increase your profits.

You know exactly what I’m talking about. It’s the profits they get not the salary they receive as an administrator.

[former9thward]

47. You don't believe the government website?

They ARE NOT EMPLOYEES.

From my previous post and the U.S. government Medicare website:

MACs are multi-state, regional contractors responsible for administering both Medicare Part A and Medicare Part B claims.

https://www.cms.gov/medicare/coding-billing/medicare-administrative-contractors-macs/whats-mac#:~:text=CMS%20relies%20on%20a%20network,and%20Medicare%20Part%20B%20claims.

These are not employees. They are CONTRACTORS just like the MA plans. They DO NOT get a salary. You know exactly what I’m talking about.

[Scottie Mom]

62. Pls, only relevant replies, OK? EOM

[RobinA]

51. This Is

flat out bull. I've got a denial for an echocardiogram, from traditional Medicare, for my mother sitting right here on my desk. Not only did they deny the one they questioned, they denied all of them that she had after her recent cardiac episode BECAUSE they denied the one. Their words. I'm sure the hospital will work it out with them, otherwise she'll be on the hook for a few echos, and NOT at the low ball rate they bill Medicare. Medicare knows every trick of the trade they all use to not pay money to claimants.

[Ms. Toad]

5. Not everyone can pay thousands of dollars to worry about it later.

(just like under traditional insurance, if you go to a doctor without pre-auhorization, none of the care by that doctor is covered - so it won't be just the initial visit that is not covered, but likely all of the care provided by them that together handed to later or with about later.) And it happens so frequently that it is exemplary, not cherry picking.

You've seen the data before, and choose to ignore it because you haven't (yet) experienced it. Under traditional Medicare, you don't have that dilemma - you just go and it is paid for.

As for upcoding, the problem is significantly worse in MA plans. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8649706/

The study generally limits all Medicare together, but separate them in figure 3, and the discussion indicates

In 2018, the National Bureau of Economic Research reported that specific diagnoses were considered more profitable, and hospitals responded by suggesting types of admission and treatment plans that have increased these diagnoses. In 2014, Geruso and Layton examined that upcoding had cost Medicare $10.5 billion, or $640 per Medicare Advantage enrollee; but since the deflator was applied uniformly, upcoders retained a large share of their charge.

[former9thward]

6. It does not cost thousands of dollars to see a dermatologist.

And get some basic info about the lump. It doesn't. The person in the OP was a retired vet. A well-paid occupation. I think he could afford to go the dermatologist. But he waited to save a couple bucks even though he has a family history.

[Hassin Bin Sober]

12. Huh?

My last dermatologist appointment was over $700 for a skin check and freeze a couple spots.

That didn’t include any surgery or biopsies. Removing a lump and doing pathology would easily run in the thousands.

[former9thward]

15. The initial appointment to find out if the lump was cancer or not would not cost thousands.

That is what I said. Afterwards he would be armed with info to decide what the next course of action would be.

[Ms. Toad]

19. And likely still stuck with the denial of care

That flowed from the initial denial.

Thr point is that doesn't happen with traditional Medicare.

[former9thward]

20. There was never a denial.

He says he waited 7 months for an approval to see the dermatologist. He got the approval and then the operation.

[Hassin Bin Sober]

21. You are proposing a "kick the tires" appointment?

A doctor isn’t going to eyeball a lump and tell you it’s fine. Especially when cancer is suspected. They are going to tell you it needs to be biopsied.

Great spend a couple hundred on an appointment and get told “it might be it might not be. I need to biopsy”

[Demobrat]

34. Except you won't spend a couple hundred on an appointment

because you won’t get an appointment without pre-approval.
The whole argument about who is going to pay is moot. Nobody is. Because there is not going to be any care.

[Hassin Bin Sober]

39. Yeah, blow a couple hundred to be told you need a biopsy.

[Ms. Toad]

18. Read the first paragraph.

An initial denial generally serves as a denial of all care that flows from the denied care. I have personally experienced this - even though in my instance the denial was simply a miscoding of approval. Coverage of the surgery, physical therapy, and all subsequent care was denied. Repeatedly - for more than a year. Ultimately, when - after a break in care - I needed more care I insisted on starting from scratch through a separate approval process, since the additional care linked to the same miscoded approval would also have been denied.

[brooklynite]

36. "My last dermatologist appointment was over $700 for a skin check and freeze a couple spots."

I had the same done last week, paid through the for-profit insurance program provided by my former employer ( which becomes my secondary insurer when I go on Medicare). $25 co-pay.

[Hassin Bin Sober]

40. Yeah I have insurance. I'm saying what the charges were. As in what they would be without insurance.

Or what the charges would be paying up front out of pocket

[SharonAnn]

57. But what did your insurance company get charged? That's what he would've had to pay.

[Ms. Toad]

13. You apparently missed the first paragraph in the body of the text.

A denial of authorization for care by a specialist generally means not just a denial for an initial visit - but all care provided by that specialist. I have personally experienced this in a traditional insurance plan after which MA plans are modeled. It took more than a year to sort out - and the surgical costs which were denied were well into the 10s of thousands, if not hundreds of thousands. (The irony is that they had actually approved the care, but had miscoded it - and the initial miscoding resulted (just as an actual denial does) in all subsequent charges being denied.)

That aside, the cost of a visit to a dermatologist and initial evaluation (which typically includes a biopsy, lab fees, and the time of a pathologist) is around a thousand. But my reference to thousands of dollars was to the care that would have been needed - and, in my experience denied because it flowed from the initial denial.

It likely would have been ultimately covered, but the last time I was in that situation with an actual denial (not the miscoding of the approval mentioned above) my choice was to wait through the appeal process, or pay cash up front for the estimated cost and hope the denial was reversed. Fortunately, that particular care was not urgent enough for my daughters health to incur any significant detriment by waiting.

And, again, even if this person could have afforded it, many retirees can't.

[Hope22]

56. Fifteen years ago I had a biopsy in the dermatologist office.

When they did it I explained clearly that it would need to be sent to my insurance carrier’s approved lab. Yes, yes they said! When all was said and done they sent it to the wrong lab. The bill was $1,200.00 back then. They ended up eating the whole thing. Never underestimate the craziness of medical expenses.

[RobinA]

54. I Have Employer Provided

health insurance and have for 42 years and I have never in my life gotten authorization to go to any doctor. Insurances are very different, so best not to jump to conclusions about an individual policy. There are crap Advantage plans just as there are crap Obamacare plans and crap employer plans. With luck, we're all in a position to afford something that works for us.

[Ms. Toad]

59. I'm hardly jumping to a conclusion.

In the specific incident being discussed authorization was required.

I have had several different insurance plans in my life. Some have required authorization for specialists, all required authorization for out-of-network to be covered at the same rate as in-network physicians, some have required authorization prior to going out-of-network (even if services were recovered at a reduced rate).

All plans I have had denied payment if prior authorization was required, but not obtained - and services which flowed from the unauthorized consult were also denied.

MA plans are modeled after standard insurance plans - that's the premise of MA plans.

[DemocraticPatriot]

61. Maybe they did not have as much money as you,

and were thus dependent on their insurance.....

Congratulations on your personal resources....

Did you not read all of the article submitted ??

"but was told that I needed prior approval from my insurer to see the specialist,” he said. “It took seven months to get this approval and, in that time, the growth tripled in size and became painful. I finally had surgery to remove it in 2022"


Doesn't seem to me as if they waited "seven months" because they had any other choice...

"If I were in my late 60s with a lump and family history of cancer ".....

It seems that you aren't, and probably still have a good income which is not a 'retirement income'...


"IF"

[former9thward]

64. The person said they were a retired veterinarian.

A well-paid occupation.

[dalton99a]

7. States should allow switching from MA to supplement without underwriting.

Countless people on MA did not have this critical information - or did not realize its importance - when they signed up

MA is great if you are healthy and not needing serious medical care or rehab

There is a reason most MA brokers would choose a supplement plan for themselves and their own family (but they tell you to choose MA because of the nice commission at sign-up and every year thereafter)

[llmart]

14. You can also be very healthy and fit as I am...

and one day you find a growth that needs surgery. Nothing major like a cancer, but a benign tumor that has to come out. My total costs for doctors' and hospital and tests and anesthesiologists was over $70,000 and all I paid was my deductible which was about $280. I have Medicare and a supplement plan. I had an Advantage plan when I first was eligible and something told me that I should switch for peace of mind as I aged. I am so glad I did. I could pick whichever doctor I wanted. I even got two second opinions - one for the radiologist's findings and one for the surgeon. No charge.

My point is, you can be healthy one day and not the next, especially when you are entering your senior years. I've had a lifetime of rarely having to see a doctor, but I'm not naive to think I'll be that one person who never needs anything major as an older person.

[Ms. Toad]

16. I know of one that does -

But you still had to make the right MA choice - the state (Illinois) mandates that at least one MA plan allow transition to a Medigap plan. I don't know if others allow transition - but not all are mandated to permit it.

But the challenge with that is that it would encourage healthy individuals to join MA plans, which would then become even cheaper - because once big bills hit all of the sick people would transition to traditional Medicare - making it the high risk plan, with the associated premium increase. The same reasoning that generally requires you to buy Medicare at age 65 or pay a surcharge applies to requiring you to buy a Medigap plan at the same time. In order to cost average expenses and come out to a reasonable premium, the plan has to include the full range of health statuses.

[Habibi]

63. New York does, thank goodness!

[Politicub]

30. So much this

This is not clearly explained when you sign up for Medicare.

[Emile]

17. After the next election when Democrats

win back control of Congress they need to do away with these republican disadvantage plans before they destroy Medicare.

[justaprogressive]

22. They're already halfway there

I'm just sorry that so many people, including ones above(!)
really think they got a good deal ,

...and only hope they can get out before they are
killed by health management organizations whose ONLY raison d'etre
is to make money for their CEOs & shareholders!

[misanthrope]

31. Who is going to outspend the insurance lobbyists?

That is the crux of how we got here.

[MichMan]

52. Yes, tell half of all Medicare enrollees that the Dems are going to take away their health care plans.

Then tell them unless they pay extra every month for a supplement plan, they will be responsible for paying 20% copay. Sounds lie a winning message that will really resonate with voters.

[Emile]

58. Here is the thing, something needs to be done.

If that's not to your liking, national healthcare is and the only answer.

Republican Advantage plans are making traditional Medicare too expensive.

[redqueen]

67. They want to end Medicare and their chosen method is working

"Republican Advantage plans are making traditional Medicare too expensive."

Shrink it till it's small enough that you can drown it in a bathtub - just keep chipping away.

[NowISeetheLight]

23. Why I Switched

I need an MRI on my knee. It's messed up and isn't just arthritis. UHC MA never approved it. Xray first. Nothing. PT. Make it worse. Steroid injections. Ouch. Never did get it done. The minute my regular Medicare gets activated I'll gladly pay the 20% of $340 Medicare allowable and get it done. Screw MA.

[justaprogressive]

24. So happy you have

been able to switch over...

Doctors and nurses KNOW this coverage sucks!

[XanaDUer2]

27. Just got my traditional Medicare

And part D today. I'm going to have to just pay. Two drs told me don't use MA. I have melanoma history.

[dflprincess]

28. Interesting how traditional Medicare covers 80% for less than $200/month

But the 20% covered by private insurers costs more than that. I'm sure there's a logical, actuarial reason for that & has nothing to do with the insurance companies trying to push people into Advantage plans.

[PoindexterOglethorpe]

37. I have an Advantage plan.

It costs me ZERO more than what I already pay for Medicare. Zero. No dollars whatsoever.

And so far it had cost a fuck of a lot more than 80% for things related to my heart attack several years ago, and a recent broken arm. As in I paid several $25.00 co-pays, and one recent additional $40.00 for a scan. Meanwhile, the heart attack bill was $73,775.30. My insurance (that awful Advantage plan) paid $72,890.38. I pad $885.00, which seems like significantly less than 20%. The broken arm cost me a $25.00 co-pay in the ER, and then a $25.00 co-pay for the one physical therapy session I went to.

I cannot figure out why people here are so desperate to convince us that Advantage plans are the work of the devil.

[Scottie Mom]

46. Read this thread. The facts are there. EOM

[PoindexterOglethorpe]

48. I read the thread.

And I still say I've never experienced denial of care, and I pay far less than 20% of my medical bills.

Every single day there are threads here trashing Advantage plans. I just don't understand it.

[Scottie Mom]

50. Read your post.

You state: You have not experienced a denial.

That DOES NOT = Will NEVER experience a denial.

Is the most important difference between Medicare advantage and original Medicare. With original Medicare, No denials for treatment.

[DemocraticPatriot]

60. Seems like you were lucky. Care to tell us which MA plan that you have?

Obviously there are many, and obviously they will not all perform at the same level....


The biggest evidence that there is a big problem with the whole scheme, is the number of complaints that are being made about it to congressional representatives, and that many hospitals and doctors are ceasing to accept patients with 'medicare advantage'....


So please tell us what plan you have! That is a sincere question!

[PoindexterOglethorpe]

66. Humana.

[RobinA]

49. The Logical, Actuarial Reason

is that they make more money the more it costs the insured.

[MichMan]

53. Maybe because people have been paying into Medicare for 40 plus years from every dollar they earn?

Most people have contributed tens of thousands of dollars for Medicare long before they turned 65. Otherwise the cost would be significantly higher.

[JenniferJuniper]

29. My sister is a hospital discharge nurse,

she says it's very hard to place people with Disadvantage in rehab facilities. They don't want to deal with the coverage delays and denials.

[brooklynite]

32. Can we assume the "I hate Medicare Advantage" threads will end with the ads on Thursday?

[JenniferJuniper]

35. No, the threads were here before and they'll be here after.

So many seniors have been mislead. "Advantage" is anything but. It's the right wing's plan to privatize Medicare so health insurance carriers can make even more money.

[misanthrope]

33. Pretty simple understanding

If insurance companies spend the obvious amounts of money they do on advertising and soliciting Medicare Advantage plans, there is a financial incentive for them to do so. That almost never works to the benefit of the consumer.

[dflprincess]

38. That should be everyone's first clue there is something not quite right with those plans

the insurance companies do not push them because they love us.

[dalton99a]

41. Bingo.

[lindysalsagal]

44. In PA we can switch back into regular medicare every november

But I'll still take a look and see. If it's slightly more expensive, I'll just go with regular medicare because it's less aggravating and there's less chance of denials in serious situations.

[Demobrat]

55. It's not switching back to regular Medicare that's the problem.

It’s finding a supplemental policy to cover the 20% Medicare doesn’t pay.

[dalton99a]

65. +1. For people with preexisting conditions, it is practically impossible outside the initial sign-up window

unless you live in one of the very few states that allow it

[redqueen]

68. We need Medicare for All. Failure to get that done is accepting that the right will eventually kill Medicare.

Disgusted by the greed.