Medicare time!

Old Oct 27th 2019, 3:16 pm
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Default Medicare time!

So it's now official. I will have Medicare starting January 1st 2020! I thought I would sail through this mess of information and forms etc after our first go round earlier this year with M but of course not.

So far the Medicare part has been easy and yesterday our nice insurance brokers set us up with our Medicare supplement which we are happy with. But the social security part was not so easy.
I have worked in the US for just over 30 years but only 14 of them were paying into Social Security the other 16 have been with an alternate social security ( it's a government thing) so I knew my s/s would be reduced but the first person I spoke to when signing the forms to claim benefits told me I would be penalised and would get just a very small portion of the amount I had paid in to. She then seemed to have a problem with my identification even though I gave her my SS card, drivers license and I also signed into mysocialsecurity on the screen in front of me. She wanted me to return with my birth certificate and marriage certificate ( husband was sitting next to me with all his proof as well!) A week later I went back and breezed through the whole procedure with another assistant. No need for birth certificate or marriage certificate and he also came up with a higher monthly payment than the previous helper. I even asked him to double check so he had his supervisor check it and they came up with the same amount. Hopefully I have less problems with my claim for my alternate benefit!

It's getting real!
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Old Oct 27th 2019, 4:58 pm
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Default Re: Medicare time!

Sounds like the Windfall Elimination Provision, WEP, they were hitting you with.

PS. Congrats on the Medicare!
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Old Oct 27th 2019, 10:51 pm
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Default Re: Medicare time!

If it is WEP there is a calculator on the SSA web site, this is the online version https://www.ssa.gov/planners/retire/anyPiaWepjs04.html Put your figures into that and it will work it out for you. That way you can double check which one of the "helpers" got it right. If you haven't got the figures for each year, you can get them from your SS account online.

We found SS easier than medicare. Our doctor stopped taking our medicare plan from next year and we have had to sort out a new one. Figuring out all the choices and options was like being on Mastermind. Mrs L has changed her mind 3 times so far. Don't forget to check if you can claim State pension from the UK.

Last edited by lansbury; Oct 27th 2019 at 10:56 pm.
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Old Oct 27th 2019, 11:02 pm
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Default Re: Medicare time!

Originally Posted by lansbury View Post
If it is WEP there is a calculator on the SSA web site, this is the online version https://www.ssa.gov/planners/retire/anyPiaWepjs04.html Put your figures into that and it will work it out for you. That way you can double check which one of the "helpers" got it right. If you haven't got the figures for each year, you can get them from your SS account online.

We found SS easier than medicare. Our doctor stopped taking our medicare plan from next year and we have had to sort out a new one. Figuring out all the choices and options was like being on Mastermind. Mrs L has changed her mind 3 times so far.
Thanks. The second guy explained that to me but now I have the link I will see for myself.

I was going to go on the same plan that M has had since August but we found out it is no longer unavailable . So yesterday we started again for both of us and found a plan that our PCP takes and cardiologist and gastroenterologist so we are happy. We also found most of our meds are Tier 1 which also helps.

I hope this all works out. It is crazy that the older you get the more complicated life can get!
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Old Oct 27th 2019, 11:10 pm
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Default Re: Medicare time!

I prefer to stay with regular Medicare and buy a supplement versus going with an Advantage Plan which may be limited on which doctors will accept. You are locked in for a year and if planning to move during that time you could end up outside the area of coverage for an advantage plan. In my case advantage is a non issue as I have a free Medicare supplement from military retirement.
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Old Oct 27th 2019, 11:18 pm
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Default Re: Medicare time!

Originally Posted by ddsrph View Post
I prefer to stay with regular Medicare and buy a supplement versus going with an Advantage Plan which may be limited on which doctors will accept. You are locked in for a year and if planning to move during that time you could end up outside the area of coverage for an advantage plan. In my case advantage is a non issue as I have a free Medicare supplement from military retirement.
If you move out of a plans coverage area, you are entitled to take out a new plan covering the area you move to. You are not locked into the original plan in those circumstances. A lot of doctors in our area will not accept regular Medicare, you have to have an advantage plan. My PCP is one of them.
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Old Oct 27th 2019, 11:22 pm
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Default Re: Medicare time!

Originally Posted by lansbury View Post
Don't forget to check if you can claim State pension from the UK.
They have moved the goal posts and I have to wait until 2021 before I can do that!
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Old Oct 28th 2019, 12:57 am
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Default Re: Medicare time!

Originally Posted by ddsrph View Post
I prefer to stay with regular Medicare and buy a supplement versus going with an Advantage Plan which may be limited on which doctors will accept. You are locked in for a year and if planning to move during that time you could end up outside the area of coverage for an advantage plan. In my case advantage is a non issue as I have a free Medicare supplement from military retirement.
We didn't find that to be true at all. Our Advantage Plan is Aetna Advantage and while it originates in New York State via the union, we use it down here in Mississippi without any problem. We pay for Medicare and separately for Aetna.
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Old Oct 28th 2019, 3:05 am
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Having just about got used to Tax Return Season, now facing the new challenge of Medicare Plan Season.
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Old Oct 28th 2019, 2:05 pm
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Default Re: Medicare time!

Originally Posted by Rete View Post
We didn't find that to be true at all. Our Advantage Plan is Aetna Advantage and while it originates in New York State via the union, we use it down here in Mississippi without any problem. We pay for Medicare and separately for Aetna.
There are many advantage plans and some are a lot more regional than others. I trust Medicare more that advantage plans right or wrong. Advantage plans receive a yearly fee from govt to pay for ones care. Any money spent to provide that care detracts from their bottom line. That type of incentive does not give me confidence they have my best interest at heart. When the Republicans came up with Advantage plans their reasoning was to save money. The reality is it cost the govt 15 to 20% more for each person than traditional Medicare. Factor out the huge increase in advertising and administrative costs of dozens of plans plus profit and bonuses for executives how much is left over for actual healthcare?
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Old Oct 28th 2019, 3:27 pm
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As it was explained to us, Aetna is sent the medical bills, not medicare, and Aetna pays the bill and then bills medicare. In the 6 years I've had the plan and the 8 years my husband has had the plan, never once have we been billed for a medical service, never have had the charge for a medical service or hospital stay or surgery questioned by Aetna or medicare.

Yes, unfortunately not all healthcare plans are the same. We lucked out and are glad to have the supplemental plan that we have.
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Old Oct 28th 2019, 5:58 pm
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Default Re: Medicare time!

Originally Posted by ddsrph View Post
...
I trust Medicare more that advantage plans right or wrong. Advantage plans receive a yearly fee from govt to pay for ones care. Any money spent to provide that care detracts from their bottom line. That type of incentive does not give me confidence they have my best interest at heart. When the Republicans came up with Advantage plans their reasoning was to save money. The reality is it cost the govt 15 to 20% more for each person than traditional Medicare. Factor out the huge increase in advertising and administrative costs of dozens of plans plus profit and bonuses for executives how much is left over for actual healthcare?
I believe the bolded part is true. The fee paid by the government to the plan is based on demographics, and is quite complex. The biggest factor is the 'risk adjustment score' of each individual participant, and age/sex. Your 'score' is based on your medical 'condition'. So your score will be higher if you have heart disease, or diabetes, or whatever. The higher your score, the more the reimbursement is, based on a fairly sound statistical model that correlates cost to medical condition. The reasoning for this is that the government does not want to provide an incentive for doctors to provide services. It also greatly reduces the level of paperwork, because the amount paid is a fairly simple calculation based on this 'score'. Otherwise, every 'medical event' would result in a pass-through from the ins. co to the government.

This article explains it well - https://www.modernhealthcare.com/art...-reimbursement
The CMS pays Medicare Advantage organizations a per member, per month fee to care for seniors enrolled in the plans. Since the 1980s, that payment has been adjusted based on demographic information such as age and sex. But in 2004, the government implemented a new risk-adjustment model that tweaked payment based on demographic information and the health conditions of each member.

Each Medicare Advantage beneficiary is assigned a risk score based in part on their health diagnoses. Insurers are supposed to be paid more for sicker members with higher risk scores because they use more resources to care for them, while plans receive a lower payment for healthier-than-average members with lower risk scores. The payment system is designed to prevent health insurers from cherry-picking only healthy members and it has worked to that effect.

At the same time the system created strong incentives for health insurers to report as many diagnosis codes as possible because that can lead to higher risk scores and higher payments from the CMS. The annual payment to an Advantage plan for an 84-year-old male patient with diabetes without complications who is not eligible for Medicaid would be $6,765, according to the Medicare Payment Advisory Commission. But tack on a diagnostic code for vascular disease and that same diabetic patient's Medicare payment would jump to $9,796.
Every time you visit your doctor, your condition is 'coded' and that coding adjusts your score. However, doctors are notoriously bad at this part of their job, so the insurance companies engage 3rd party 'coders' who read the charts and adjust the coding to be more accurate.
Originally Posted by Rete View Post
As it was explained to us, Aetna is sent the medical bills, not medicare, and Aetna pays the bill and then bills medicare. In the 6 years I've had the plan and the 8 years my husband has had the plan, never once have we been billed for a medical service, never have had the charge for a medical service or hospital stay or surgery questioned by Aetna or medicare.

Yes, unfortunately not all healthcare plans are the same. We lucked out and are glad to have the supplemental plan that we have.
The bolded part above is not accurate I don't believe for the reasons I gave above. Aetna, in this case, already got paid an amount by CMS (medicare) for having you 'on the books'. That amount they got for you was based on your age, sex, and 'health condition'.

Despite the potential for problems, however, most people I know choose Medicare Advantage plans and are not unhappy with the result. I think the insurance companies know they are onto a good thing with this arrangement and don't rock the boat by denying service. They just bill medicare a lot of money. My g/f recently turned 65 and chose an MA plan; I'm fast approaching and will also likely choose one.

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Old Oct 28th 2019, 6:19 pm
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Default Re: Medicare time!

One of the ways advantage plans defraud the govt is inflating risk scores to receive the higher rate.As I understand it the risk score is only calculated once a year and the amount the insurance company gets is paid in a lump sum.
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Old Oct 28th 2019, 6:30 pm
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Default Re: Medicare time!

Originally Posted by ddsrph View Post
One of the ways advantage plans defraud the govt is inflating risk scores to receive the higher rate.As I understand it the risk score is only calculated once a year and the amount the insurance company gets is paid in a lump sum.
I had the dubious honor of working for a company that was involved in doing 'risk adjustment' for MA plans. The penalties for falsifying / exaggerating the 'scores' are severe. But the great irony is - you don't have to falsify or exaggerate! All you have to do is accurately report the condition of a patient and the score increases. Why? Because the majority of people don't visit their doctor that often, and thus, their score remains stagnant based on their last visit. You said 'the risk score is only calculated once a year...' I think it's more accurate to say, it can only be adjusted 'at most' once a year, but if you don't visit the doctor the score cannot change. So what you do is - look at all the patients who haven't seen a doctor in at least a year, then figure out which ones are likely to have deteriorated over the past year, and then give them a free checkup. Patient gets a free checkup, score naturally increases because ... well ... they are getting older ... and reimbursement goes up. Everyone wins except the government ....
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Old Oct 28th 2019, 6:46 pm
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Default Re: Medicare time!

In my mind all health insurance companies are crooks until proven otherwise. In my case I could never go on a Advantage plan as I have Tricare for Life thru military retirement. It’s a free supplement to Medicare which also has drug coverage. In the end I pay nothing except Medicare A&B
and no copays for any treatment or hospital stays. I heard of a few uniformed cheapskates who decided since they had Tricare they would save money and not enroll in Medicare. A big healthcare expense later they learn they have no insurance at all.
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