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.

Re: Medicare time!
 

That's good to hear Nutmegger - not that you needed to use your insurance, but that you've found that it works for you :thumbup:

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.

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.

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.

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.

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?

Re: Medicare time!
 

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.

Re: Medicare time!
 

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.

Re: Medicare time!
 

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.

Reimbursement rates are not where we want them to be. Not uncommon with Aetna in this part of the world.

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.

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...

Re: Medicare time!
 

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?

Re: Medicare time!
 

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.

Re: Medicare time!
 

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.