Replying to comment #80. Good comment overall.
Quote:
Originally Posted by Blueblaze
Yes, I complain about the lousy primary care doctors that are available here in-network, but I'm not convinced that paying an extra $1000/month between the two of us would improve our choices much in this healthcare desert.....
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I am unconvinced of this also. Just because a claim is made with TM that you can choose whatever specialist you want doesn't mean that Doc is taking new patients. Many of the experienced ones aren't; they're full.
Quote:
Originally Posted by Blueblaze
I confess, I don't understand how MA stays in business giving insurance way for free. I suspect it has something to do with those $500 office.....
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If I understand what you're saying here... you mean how does the
insurer stay in business? It is as follows (I'm no expert here if anyone wants to provide more detail on this).
The Fed Gov pays insurers approx $1000 monthly for each Advantage plan enrollee they have. So, Humana is getting about $12,000 p/year for you. BCBS gets the same for me. They're insurers so, they know how to manage risk, benefit and P&L. So, they can offer benefits back to enrollees from the money they're taking in every month.
In the plan you chose, they kick back part of the $1000 to you as reimbursement for what you mandatorily pay into Medicare each month ($180 or so). I could have chosen one of those plans but, decided to pick a BCBS plan that, instead of that, offers a generous allowance - $3500 p/yr - that can be used for dental (no implants), vision or hearing -- or any combo of those. I was anticipating dental work this year so....
I'm trying to use some of that this year but, haven't been happy with the periodontal practice I chose. So, am going to go to another one. But, here I can answer the question posed in comment #54 - asking whether others have had treatments denied by an MA insurer. It's a classic example of the devil is in the details.
I had one denied by BCBS related to this dental work. But, guess what? It was the vendors fault, they installed something in the treatment plan that is not covered and that exception (bone grafting, implants) is fully disclosed up-front in the plan so, I don't know why they did that.
That part of the authorization was denied, of course. So,
it makes you wonder how many of the denials of treatment related to MA plans are actually screw-ups by the med practices? Either erroneously filed outright (like my case) or the wrong procedure codes were used causing a denial. See?
Two more things to add: I do see in the details of the work I want to have done that the insurer isn't going to cover every aspect of the procedure - some aspect codes I would have to pay out-of pocket. So, for the total procedure, I may have to pay for about 40% of it. I don't love that and it feels a little like a bait-and-switch but, I also get that they're not going to let someone just easily blow that $3500 - they want them to have skin in the game and that probably helps keep the medical provider from simply selling a patient on anything to get their piece of that allowance.
Also, the other allowances related to my plan are $135 p/quarter to spend on OTC items (via a loaded debit card), Silver Sneakers membership, regular annual dental care, eye exam and new glasses every year, no cost for Tier 3 and 4 prescriptions. No monthly premium for the plan.
I mention all that because it's not just the lack of paying a monthly premium that is saved,
BCBS is actually paying me. If I use all of the allowances provided, it will
net me over $4000 p/yr.
Lastly, I would caution anyone, regarding
any life issue against making a decision today for a 'maybe' of what might happen a two decades from now. That could cost a boatload of money over time and many things are going to change anyway, that's guaranteed.