Medicare time!
#46
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.
You are correct that not all plans are created equal though, even across state lines.
#47
Re: Medicare time!
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?
#48
Re: Medicare time!
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.
#49
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.
#50
BE Forum Addict
Joined: Jun 2015
Location: Near Lynchburg Tennessee, home of Jack Daniels
Posts: 1,379
Re: Medicare time!
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?
#51
Re: Medicare time!
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.
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.
#52
Re: Medicare time!
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.
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.
Does that in itself tell us something, that Aetna are not in your network?
#53
BE Forum Addict
Joined: Jun 2015
Location: Near Lynchburg Tennessee, home of Jack Daniels
Posts: 1,379
Re: Medicare time!
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 ?
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 ?
Last edited by ddsrph; Sep 3rd 2020 at 4:17 pm.
#54
Re: Medicare time!
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.
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.
#55
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.
Does that in itself tell us something, that Aetna are not in your network?
#56
Lost in BE Cyberspace
Joined: Jan 2006
Location: San Francisco
Posts: 12,852
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.
#57
Lost in BE Cyberspace
Joined: Jan 2006
Location: San Francisco
Posts: 12,852
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.
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...
#58
Re: Medicare time!
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...
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...
Can you elaborate on what your last paragraph is telling me? Is 'medicare supplement plan' different from a medicare advantage plan?
#59
Re: Medicare time!
Is 'medicare supplement plan' different from a medicare advantage 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.
#60
BE Forum Addict
Joined: Jun 2015
Location: Near Lynchburg Tennessee, home of Jack Daniels
Posts: 1,379
Re: Medicare time!