Medicare time!

Old Sep 3rd 2020, 1:59 pm
  #46  
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Default Re: Medicare time!

Come back to me when you have a large medical expense, I suspect you will feel differently.

You are correct that not all plans are created equal though, even across state lines.
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Old Sep 3rd 2020, 2:07 pm
  #47  
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Default Re: Medicare time!

Originally Posted by Nutmegger
Nine months into the Aetna plan that I wrote about earlier in this thread I have had no problems with it, despite, unusually for me, having to actually use it a few times this year. It has also paid for dental work and contact lenses that I have never been reimbursed for in the past. Perhaps not all plans are created equal?
That's good to hear Nutmegger - not that you needed to use your insurance, but that you've found that it works for you
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Old Sep 3rd 2020, 2:08 pm
  #48  
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Default Re: Medicare time!

Originally Posted by civilservant
Come back to me when you have a large medical expense, I suspect you will feel differently.

You are correct that not all plans are created equal though, even across state lines.

I hope I will never have to do that! However, I was put in the plan by an extremely competent HI broker with whom I have worked for decades, and he said he had always recommended staying away from Advantage plans until this specific one came on the market.
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Old Sep 3rd 2020, 2:10 pm
  #49  
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Default Re: Medicare time!

I must admit that I am not as familiar with Aetna as pretty much all the others - they are the only one that we are out of network with.
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Old Sep 3rd 2020, 2:38 pm
  #50  
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Default Re: Medicare time!

Originally Posted by Nutmegger
Nine months into the Aetna plan that I wrote about earlier in this thread I have had no problems with it, despite, unusually for me, having to actually use it a few times this year. It has also paid for dental work and contact lenses that I have never been reimbursed for in the past. Perhaps not all plans are created equal?
Some work out well for patients it just requires a lot of work to stay on top of what’s covered and what’s not. Also who accepts it and who doesn’t. There is a lot of fraud in the fact that Medicare pays them a lump sum yearly to provide treatment that is tiered based on patient health. If the insurance company can make a patients health status classified worse than it actually is they get more money with less risk.
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Old Sep 3rd 2020, 3:38 pm
  #51  
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Default Re: Medicare time!

Originally Posted by ddsrph
Some work out well for patients it just requires a lot of work to stay on top of what’s covered and what’s not. Also who accepts it and who doesn’t. There is a lot of fraud in the fact that Medicare pays them a lump sum yearly to provide treatment that is tiered based on patient health. If the insurance company can make a patients health status classified worse than it actually is they get more money with less risk.
There is a great deal of scrutiny paid to this aspect - the risk adjusted score that drives the reimbursement rate. I believe it's hard to fraud. The thing is, you don't have to engage in fraud. I worked for a company that helped insurance companies get more money, but it was all quite legitimate and above board. Basically, with an ageing population of 'clients', all you have to do is test them; common sense dictates their health is getting worse by the day, so the more frequently you 'examine' them, the more frequently you can adjust their score.

What we did was determine which sub-set of clients (medicare advantage clients) would most likely benefit from an examination, and then send a nurse to their home to examine them. Out of the hundreds of thousands of clients, we had clever algorithms that would identify those clients most likely to have worsening health, then we would offer them an in-home visit. We never tried to cheat in terms of stating what their health condition was, it was the simple fact that people get worse as they age that we took advantage of. First of all, which people hadn't seen a doctor in >1 year? Target them. Which people had diabetes; which people had two or more conditions? etc etc. Out of hundreds of thousands of potentials, we determined the ones most likely to be 'sicker than last time' and then examined them.

We charged for the cost of the home visit, plus a profit. The insurance companies happily paid us because even with all that, their reimbursements went up by enough to cover it and then some. This is certainly a dubious practice, but there was no actual fraud involved - our nurses never tried to exaggerate or mis-state the condition of the client - they didn't need to.

Last edited by Steerpike; Sep 3rd 2020 at 3:40 pm.
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Old Sep 3rd 2020, 3:45 pm
  #52  
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Default Re: Medicare time!

Originally Posted by civilservant
If you can possibly avoid it, stay off of Medicare Advantage plans. Inviting an insurance company to administer what are otherwise guaranteed benefits is a pretty daft idea.

The number of older people I see that need care that they would get under traditional Medicare that gets turned down by Advantage plans for 'medical necessity' is staggering - but not surprising.
Originally Posted by civilservant
Come back to me when you have a large medical expense, I suspect you will feel differently.

You are correct that not all plans are created equal though, even across state lines.
I don't doubt the truth of what you say. Do you have any good reference material to support this? My g/f recently turned 65, and signed up for an MA plan. She was convinced it was the best option, without regard to price (she was willing to pay any amount for the 'best' coverage). I'd love to try to convince her otherwise.

Originally Posted by civilservant
I must admit that I am not as familiar with Aetna as pretty much all the others - they are the only one that we are out of network with.
Does that in itself tell us something, that Aetna are not in your network?
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Old Sep 3rd 2020, 3:49 pm
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Default Re: Medicare time!

Originally Posted by BennyBall
I appreciate that you recently posted a reply to me on the military and WEP and I’m still investing that, I also found this old post on Medicare so thought I’d seek your advice again.
I am just about to hit sixty and am covered with TriCare Prime .... Spouse is the same as you on TriCare for life.
so am I correct in saying that I won’t require an advantage plan ?.. like you I’d prefer not to have one if I could avoid. Also seems like I’ll have to switch from prime to TriCare for life when MediCare kicks in ?
One other point, when you turn 65 and get on Tricare for life it includes a free Medicare part D to pay for drugs. So basically once on Medicare and Tricare for life the only medical expense you will ever have is just paying your Medicare premiums for Part A and B. Their is no fine print with Tricare for life. If Medicare covers it Tricare for life picks up what Medicare would normally have you pay.

Last edited by ddsrph; Sep 3rd 2020 at 4:17 pm.
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Old Sep 3rd 2020, 3:55 pm
  #54  
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Default Re: Medicare time!

Originally Posted by Steerpike
There is a great deal of scrutiny paid to this aspect - the risk adjusted score that drives the reimbursement rate. I believe it's hard to fraud. The thing is, you don't have to engage in fraud. I worked for a company that helped insurance companies get more money, but it was all quite legitimate and above board. Basically, with an ageing population of 'clients', all you have to do is test them; common sense dictates their health is getting worse by the day, so the more frequently you 'examine' them, the more frequently you can adjust their score.

What we did was determine which sub-set of clients (medicare advantage clients) would most likely benefit from an examination, and then send a nurse to their home to examine them. Out of the hundreds of thousands of clients, we had clever algorithms that would identify those clients most likely to have worsening health, then we would offer them an in-home visit. We never tried to cheat in terms of stating what their health condition was, it was the simple fact that people get worse as they age that we took advantage of. First of all, which people hadn't seen a doctor in >1 year? Target them. Which people had diabetes; which people had two or more conditions? etc etc. Out of hundreds of thousands of potentials, we determined the ones most likely to be 'sicker than last time' and then examined them.

We charged for the cost of the home visit, plus a profit. The insurance companies happily paid us because even with all that, their reimbursements went up by enough to cover it and then some. This is certainly a dubious practice, but there was no actual fraud involved - our nurses never tried to exaggerate or mis-state the condition of the client - they didn't need to.
The more I read about the health insurance industry in the US, the grubbier it sounds. That's not intended as a slight against you or any individual, it's the system in its entirety that stinks.
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Old Sep 3rd 2020, 3:56 pm
  #55  
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Default Re: Medicare time!

I don't doubt the truth of what you say. Do you have any good reference material to support this? My g/f recently turned 65, and signed up for an MA plan. She was convinced it was the best option, without regard to price (she was willing to pay any amount for the 'best' coverage). I'd love to try to convince her otherwise.
Not really, it's more experiential - mostly in regards to 'ongoing' services such as therapy. With Medicare as long as the provider can reasonably claim it is medically necessary then they will continue to treat. Not so with a Medicare Advantage plan. If you have one week where you are struggling to meet your goals (for whatever reason) you're dropped ASAP. These older people if course have multiple comorbidities that might mean they are less able to go something one week, but no accounting is taken for that by MA companies.

Does that in itself tell us something, that Aetna are not in your network?
Reimbursement rates are not where we want them to be. Not uncommon with Aetna in this part of the world.
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Old Sep 3rd 2020, 4:09 pm
  #56  
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Default Re: Medicare time!

Applied for Medicare in July... still waiting for approval. Offices are closed and the person supposedly handling my application never responds to my calls. Ugh.
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Old Sep 3rd 2020, 4:22 pm
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Default Re: Medicare time!

Originally Posted by Steerpike
I don't doubt the truth of what you say. Do you have any good reference material to support this? My g/f recently turned 65, and signed up for an MA plan. She was convinced it was the best option, without regard to price (she was willing to pay any amount for the 'best' coverage). I'd love to try to convince her otherwise.
I believe all MA plans in the Bay Area are HMO (not PPO) plans. For some people, that's a non-starter. Also, the geographic limitations of where your HMO network is are quite severe. I would have to change my primary care doctor of 30 years if I got a MA plan in SF.

Also beware that once you get past the initial six months (?) of eligibility for Medicare, you generally will have to provide evidence of insurability for a Medicare supplement plan. That's a gotcha that MA sales agents rarely mention...
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Old Sep 3rd 2020, 4:35 pm
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Default Re: Medicare time!

Originally Posted by Giantaxe
I believe all MA plans in the Bay Area are HMO (not PPO) plans. For some people, that's a non-starter. Also, the geographic limitations of where your HMO network is are quite severe. I would have to change my primary care doctor of 30 years if I got a MA plan in SF.

Also beware that once you get past the initial six months (?) of eligibility for Medicare, you generally will have to provide evidence of insurability for a Medicare supplement plan. That's a gotcha that MA sales agents rarely mention...
I'll find out what the g/f's plan is. I believe it's with UHC.

Can you elaborate on what your last paragraph is telling me? Is 'medicare supplement plan' different from a medicare advantage plan?
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Old Sep 3rd 2020, 4:39 pm
  #59  
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Default Re: Medicare time!

Is 'medicare supplement plan' different from a medicare advantage plan?
Yes it is. A Medicare Supplement Plan only applies when one is on traditional Medicare, not an MA plan.

The supplement plan covers most of the out of pocket expenses that Medicare has. As an example, it usually covers the inpatient hospital co-insurance charges (usually at 100%)

It's more commonly know as a Medigap policy in certain parts of the US, but it's actual name is a Part F plan. Medicare Advantage Plans are Part C plans.

Last edited by civilservant; Sep 3rd 2020 at 4:42 pm. Reason: Added Part C plan information.
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Old Sep 3rd 2020, 4:53 pm
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Default Re: Medicare time!

Originally Posted by spouse of scouse
The more I read about the health insurance industry in the US, the grubbier it sounds. That's not intended as a slight against you or any individual, it's the system in its entirety that stinks.
The whole “system” sucks. It’s overly generous to even call it a system. I have heard, with some verification that hospital administrators pressure their ER’s to admit patients or maybe look for another job. If you show up with some symptoms plus a great health insurance plan you could get admitted to run a bunch of expensive tests that can be rationalized but maybe not justified.
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