Medicare Advantage Plans A Failed Experiment?

[Dusty_Star]

Some say that Medicare Advantage is a failed experiment. Patients get delayed & denied care, the taxpayers are paying mightily for the winners: the insurance company executives. They also say it should be discontinued or dramatically reformed.

MA was sold heavily to Congress by insurance company lobbyists on the basis that it would save money over traditional Medicare.

Is Medicare Advantage a Failed Experiment? Experts Debate - MedCity News (https://medcitynews.com/2023/10/medicare-advantage-seniors-failed-healthcare/)

[Mrprez]

If they discontinue the program then everyone on MA should be allowed into a MediGap program with no underwriting.

[retiredguy123]

Medicare Advantage may be a failed experiment, but so is Traditional Medicare. Medicare fraud is rampant. My mother spent her last 4 months in the hospital or various nursing homes. One medical doctor, who my mother never hired, followed her everywhere she went and billed Medicare for an office visit every day, 7 days per week. She was never hired, and never prescribed any medical treatment. Apparently, she posed as a hospital doctor and got my mother's SSN from her chart. Every day, she would make the rounds visiting her many "patients" in nursing homes and hospitals. Medicare has no checks and balances to determine if a provider was ever even hired by the patient. If they get a bill, they just pay it. At least Medicare Advantage providers have a profit motive to reduce fraud.

The only way to make the system more efficient is to require patients to have "skin in the game" by requiring all patients to pay a copay based on a percentage of the treatment. They need to eliminate free treatments where the patient has no incentive to reduce the cost.

[GoRedSox!]

I don't think that Medicare Advantage is correctly labeled an experiment, they have been around for over 25 years. Over 50% of all Medicare enrollees are on Medicare Advantage Plans. Most people say they are happy with their MA plan, at least as many as say they are happy with traditional Medicare.

[Stu from NYC]

We are very happy with our advantage plan

[PugMom]

it works for me. i've been able to get the care i need, when i need it, for what i want. i've never been denied, never had to sacrifice care. i'm leery of some of these stories, -they appear to be looking for some gut reaction, typically in a sensational way.

[justjim]

Let’s take Aetna (my employer’s Medicare Advantage plan) and I believe only second in Medicare plans to United Health Care the largest. Aetna net income in 2023 was just south of 6 billion dollars. With that much money at stake, the insurance companies are not going away quickly or quietly. CVS Health acquired Aetna for a sum of 69 Billion. Bottom line, instead of regular Medicare paying claims they pay the insurance companies to manage them. Cheaper for taxpayers?

The United Health Care Group revenue was over 189 billion dollar. There are costs but that is a lot of revenue. UHC reported 22 billion in profits in 2023. The CEO of UHC total compensation was 23.5 million. Obviously there is money to be made in health care insurance.

[gatorbill1]

Very happy with UHC Advantage Plan. Have never been denied any treatment needed - and it costs a lot less than a supplement plan.

[rustyp]

51% of seniors on MA plans in 2024 - I'll take my chances. Odds or on my side when a change occurs of who the vote getters protect.

[GoRedSox!]

Health Insurance companies really depend on Medicare Advantage to drive profits. They make MUCH more from a Medicare member than they do from a fully-insured member.

[Sabella]

Medicare advantage plans are very good but the older you get and the sicker you get and the more medical care you need that’s when they’re not good and a lot of things get denied that you would’ve had with original Medicare.

[La lamy]

I've never heard of medicare advantage patient being delayed or denied care. I've seen a lot of lives saved through quick emergency response or months of various treatments to fight cancer successfully. Does the OP have an agenda for spreading this 'info'?

[wsachs]

I don't think that Medicare Advantage is correctly labeled an experiment, they have been around for over 25 years. Over 50% of all Medicare enrollees are on Medicare Advantage Plans. Most people say they are happy with their MA plan, at least as many as say they are happy with traditional Medicare.
I have BCBS Medicare Advantage PPO from MI. It's great. Had it for over 25 years.

[rsmurano]

Want some proof of denials? Here are a couple but I bet you can find many hundreds of these complaints if you search:

https://www.finance.senate.gov/imo/media/doc/Deceptive%20Marketing%20Practices%20Flourish%20in% 20Medicare%20Advantage.pdf

https://legislature.idaho.gov/wp-content/uploads/sessioninfo/2023/interim/230809_mctf_Article_Sara%20Hansard_Cigna%20Patient %20Calims%20Denials.pdf

By repeatedly denying claims, Medicare Advantage plans threaten rural hospitals and patients, say CEOs (https://www.nbcnews.com/health/rejecting-claims-medicare-advantage-rural-hospitals-rcna121012)

Why does Medicare Advantage routinely deny reimbursements for necessary care? - Quora (https://www.quora.com/Why-does-Medicare-Advantage-routinely-deny-reimbursements-for-necessary-care)

Medicare Advantage plans are popular, but some seniors feel trapped when ill : Shots - Health News : NPR (https://www.npr.org/sections/health-shots/2024/01/03/1222561870/older-americans-say-they-feel-trapped-in-medicare-advantage-plans)

https://crr.bc.edu/criticisms-of-medicare-advantage-marketing-continue/

[nancyre]

My husband was told there was NO rehab that would accept Humana that could handle a patient on PD Dialysis. I later found that there was a way to make it happen but the discharge planners at Leesburg Hospital instead pushed him out without a plan. FYI 6 months Multiple hospital visits 2 almost immediate discharges at Lessburg and 3 months out having gone to Shands we find he had Pancreatic Cancer, gone under 3 months later. But can you imagine being told there is no place that will take his insurance. Meanwhile no body wanted to recognize that the VA would be paying the bill. It was just no Humana approved place.
BTW there is a BIG difference between a Medicare Advantage HMO & a PPO.

[RICH1]

I have an F PLAN with a Part D plan... when you get really sick and your Advantage Plan lets you down, you will regret your choice.., TALK TO A HOSPITAL BILLING ADMINISTRATOR

[RICH1]

Medicare advantage plans are very good but the older you get and the sicker you get and the more medical care you need that’s when they’re not good and a lot of things get denied that you would’ve had with original Medicare.
Yes, it happened to my brother....

[bowlingal]

LaLamy, yes it's true. A friend who has Medicre Advantage was denied a nuclear test. If they had a traditional they would have been covered, no problem. So, just because you never heard of it, doesn't make your statement true. The advantage plan is good as long as you don't get sick. But, no one knows when you will get sick.....and you will get sick

[golfing eagles]

I've never heard of medicare advantage patient being delayed or denied care. I've seen a lot of lives saved through quick emergency response or months of various treatments to fight cancer successfully. Does the OP have an agenda for spreading this 'info'?

Absolutely, positively 100% agree. The OP is nonsense, as is the "list" of "denials" a few posts above.

Do insurance companies occasionally deny requests for certain tests, treatments, hospitals or specialists---you bet they do. Advantage plans do, Medicare supplement plans do, private insurance does. ALL insurance plans have a set of policies and approved services. Most denials are simply because the service was not "coded" properly, others because the service might be new or considered experimental. HMOs and PPOs have a panel of approved physicians that are agreed upon by the insured when they choose that plan---it is the patient's decision. You need approval to go "out of network" or undergo a procedure that is not on the approved list. However, even with those restrictions, 99% of the time one phone call from your physician to the medical director of the insurance plan will get you approval. But that request must be medically necessary---whining that you want hospital A or physician B because your cousin's barber liked them won't do, nor should it.

Can one go on the internet and harvest a bunch of medical "horror stories"??? In a country of 330 million, no problem, since those who feel "wronged" are the first and loudest to complain. I can also find legal horror stories, automotive horror stories, daycare horror stories, and ditch digger horror stories. If someone is looking for 100% perfection in any system, might I suggest the planet Utopia?

Do you want to glean populist support? Just claim that the big, bad CEOs are making a fortune by cheating, conniving, deceiving and exploiting their workers, or the taxpayer, or the government. Readers will eat that crap up. The same readers that will pay thousands to see some guys kick a ball around a field or hear some rap crap guy "sing".

I don't know if the OP has an "agenda", but just add my wife and I to the millions that chose an advantage plan and are happy. And as many of you know I am familiar with medical insurance.

[LoisR]

Nonsense. Just have the patient sign a doctor's visitation statement.

[Marmaduke]

I've never heard of medicare advantage patient being delayed or denied care. I've seen a lot of lives saved through quick emergency response or months of various treatments to fight cancer successfully. Does the OP have an agenda for spreading this 'info'?
I've heard of many funky differences. Here's just one:

Our next door neighbor moved in and began pickleball lessons as soon as she landed.

She began practicing and then playing everyday.
Within the 1st months of play, she fell backwards and got very hurt.
Rushed to the E.R., she learned of several breaks to her elbow and needed surgery.
She is on Medicare Advantage.

She had to wait for TEN DAYS before it was approved. She was in excrusiating pain, but was given opioids to aid her.

Everyone was shocked and didn't understand. She and her husband said it was due to their Medicare Advantage Plan.
Glad we're not on that.

[R&J in NJ]

Medicare Advantage plans are good until you get really sick. Then you require specialists but the best ones are not in your plan.

[ehonour]

I've never heard of medicare advantage patient being delayed or denied care. I've seen a lot of lives saved through quick emergency response or months of various treatments to fight cancer successfully. Does the OP have an agenda for spreading this 'info'?

Delays and denials are happening frequently. I had a urine test for an infection following surgery. The doctor's office had the ability to do the test immediately in their office. Florida Blue required instead they send the test to another agency. As a result, I went through a weekend of continued agony before we could get the results and prescribe something.

A good friend this year waited FOUR MONTHS to get approval for a CANCER medication.

These two are personally known. You can easily find many, many more.

[Sandy and Ed]

Not failed. But no real oversight. HCFA (healthcare finance administration), as is most government agencies,is a bureaucratic mess. Just get “someone” in power to clean up these oversight agencies and get people to do the job they are being paid to do. Pay bonuses to employees that report fraud and abuse. Start putting people in jail. If this was another country there would be executions!!!

[golfing eagles]

Delays and denials are happening frequently. I had a urine test for an infection following surgery. The doctor's office had the ability to do the test immediately in their office. Florida Blue required instead they send the test to another agency. As a result, I went through a weekend of continued agony before we could get the results and prescribe something.

A good friend this year waited FOUR MONTHS to get approval for a CANCER medication.

These two are personally known. You can easily find many, many more.

To the extent that made sense, your urinary infection weekend is on your doctor, not the insurance plan. The proper medical procedure for a presumptive UTI is to treat empirically with antibiotics pending the result of the urine culture. It takes 2 days to grow out a culture, no physicians office is equipped to grow cultures, and if he bothered to have so much as a child's toy microscope he could have looked at the urine sample to determine if excess WBSs were present. Place the blame where it belongs.

As far as "4 months to get chemo drugs" goes, Neither of know, but I suspect that the oncologist chose a treatment protocol or chemotherapeutic agents that fell outside of the mainstream. But like I said above, it's easy to find horror stories. I also suspect the same delay would have occurred with traditional Medicare or private insurance.

[MX rider]

Absolutely, positively 100% agree. The OP is nonsense, as is the "list" of "denials" a few posts above.

Do insurance companies occasionally deny requests for certain tests, treatments, hospitals or specialists---you bet they do. Advantage plans do, Medicare supplement plans do, private insurance does. ALL insurance plans have a set of policies and approved services. Most denials are simply because the service was not "coded" properly, others because the service might be new or considered experimental. HMOs and PPOs have a panel of approved physicians that are agreed upon by the insured when they choose that plan---it is the patient's decision. You need approval to go "out of network" or undergo a procedure that is not on the approved list. However, even with those restrictions, 99% of the time one phone call from your physician to the medical director of the insurance plan will get you approval. But that request must be medically necessary---whining that you want hospital A or physician B because your cousin's barber liked them won't do, nor should it.

Can one go on the internet and harvest a bunch of medical "horror stories"??? In a country of 330 million, no problem, since those who feel "wronged" are the first and loudest to complain. I can also find legal horror stories, automotive horror stories, daycare horror stories, and ditch digger horror stories. If someone is looking for 100% perfection in any system, might I suggest the planet Utopia?

Do you want to glean populist support? Just claim that the big, bad CEOs are making a fortune by cheating, conniving, deceiving and exploiting their workers, or the taxpayer, or the government. Readers will eat that crap up. The same readers that will pay thousands to see some guys kick a ball around a field or hear some rap crap guy "sing".

I don't know if the OP has an "agenda", but just add my wife and I to the millions that chose an advantage plan and are happy. And as many of you know I am familiar with medical insurance.


Very well said! We're on UHC Advantage and like it.

Yes, there will always be "horror stories" as you pointed out. But MA plans vary, and some are better than others for sure. People need to do the research and make an informed decison.

Having a choice is a good thing, one size does not fit all.
Over 50% of new medicare enrollees chose MA plans. If they were so bad they wouldn't be so popular.

Btw, we really like the wellness and vision benefits. We get free membership to Genesis gym as a side benefit. Very nice place. My wife takes 2 fitness classes a day there 6 days a week.

[golfing eagles]

Not failed. But no real oversight. HCFA (healthcare finance administration), as is most government agencies,is a bureaucratic mess. Just get “someone” in power to clean up these oversight agencies and get people to do the job they are being paid to do. Pay bonuses to employees that report fraud and abuse. Start putting people in jail. If this was another country there would be executions!!!

Please, please, please make ME the "someone" in power as appointed dictator. I'll fix it in under a year. Of course, I'd also have to disband Congress, rewrite some laws, possibly including the constitution, kill all lobbyists and execute those who propagate ridiculous tripe online. Probably not going to happen :1rotfl::1rotfl::1rotfl:

[pendi99]

Some say that Medicare Advantage is a failed experiment. Patients get delayed & denied care, the taxpayers are paying mightily for the winners: the insurance company executives. They also say it should be discontinued or dramatically reformed.

MA was sold heavily to Congress by insurance company lobbyists on the basis that it would save money over traditional Medicare.

Is Medicare Advantage a Failed Experiment? Experts Debate - MedCity News (https://medcitynews.com/2023/10/medicare-advantage-seniors-failed-healthcare/)

Sounds like sour grapes due to a poor experience? Advantage companies negotiate rates w a small closed group of providers. Trying to go outside the group becomes very expensive. Pick the right plan for providers you want to use.

[MX rider]

Sounds like sour grapes due to a poor experience? Advantage companies negotiate rates w a small closed group of providers. Trying to go outside the group becomes very expensive. Pick the right plan for providers you want to use.

Our MA plan actually has a very large, nationwide group of providers. Before we signed up we checked here in Indiana. 90% of the hosptals we checked took it. So did the medical group we use.

[retiredguy123]

Not failed. But no real oversight. HCFA (healthcare finance administration), as is most government agencies,is a bureaucratic mess. Just get “someone” in power to clean up these oversight agencies and get people to do the job they are being paid to do. Pay bonuses to employees that report fraud and abuse. Start putting people in jail. If this was another country there would be executions!!!
I mostly agree, but paying bonuses to employees will be wasting even more money. Medicare fraud and abuse are so rampant, that reporting it will do nothing. The people in charge know it exists, but they just don't care. I laugh every time I see a TV ad asking for the public to report Medicare fraud. This is just a publicity stunt to make people think the Government is trying to reduce fraud. If you report it, they already know about it, but they have no way to stop it anyway.

[golfing eagles]

Very well said! We're on UHC Advantage and like it.

Yes, there will always be "horror stories" as you pointed out. But MA plans vary, and some are better than others for sure. People need to do the research and make an informed decison.

Having a choice is a good thing, one size does not fit all.
Over 50% of new medicare enrollees chose MA plans. If they were so bad they wouldn't be so popular.

Btw, we really like the wellness and vision benefits. We get free membership to Genesis gym as a side benefit. Very nice place. My wife takes 2 fitness classes a day there 6 days a week.

Yes, there are some side benefits as well. The gym I was paying $70/month for is now free. I just got eyeglasses for free.

But the real debate on this thread is access to care and insurance denials. I have Florida Blue MA and even Shands and Moffit are in network. The concept that we are all sacrificing our health to line the pockets of insurance company CEOs is absurd and delusional. Bottom line---most people in America don't want to be "denied" anything, even though they freely chose to save $200/month by choosing an advantage plan. No, these plans are not for everyone----If you already have multiple medical problems with established relationships with specialists who are not in network----skip to traditional Medicare. If you have some rare condition that might require travel to a nationally recognized center, advantage is not for you either. But if you are relatively healthy these plans are just fine, and the chances of developing a condition that would cause you a problem with insurance are quite low---unless you are one of the whiners who specifically want to see the doctor that your barber's cousin in Atlanta likes.

Now, if we're looking for something to bankrupt advantage plans of drive the cost up, consider all the ads for so-called "Medicare advantage dual coverage plans" These are not just health insurance plans. They are for those with both Medicare and Medicaid, and now forgive the $174 /month premium for part B, and pay for "rent, groceries, and utilities". This is nothing more than Robin Hood backdoor welfare on the backs of taxpayers hidden under the guise of "Medicare Advantage"---that's the real deceit, and not by CEOs

Lastly, if you want a "horror" story, my wife's late husband had UHC The Villages Medicare Advantage plan and developed a rare form of myelodysplasia requiring bone marrow transplants that was not on the approved "list of treatments" at the time and could only be done at Moffit, which wasn't in that network. However, with a knowledge of how to navigate the system (she's a nurse with Master's in both nursing and healthcare administration), he got all the treatment he needed at Moffit, but unfortunately was unsuccessful.

[golfing eagles]

I mostly agree, but paying bonuses to employees will be wasting even more money. Medicare fraud and abuse are so rampant, that reporting it will do nothing. The people in charge know it exists, but they just don't care. I laugh every time I see a TV ad asking for the public to report Medicare fraud. This is just a publicity stunt to make people think the Government is trying to reduce fraud. If you report it, they already know about it, but they have no way to stop it anyway.

These numbers are out of date, about 15 years ago, but at the time Medicare budget was $600 billion/year, fraud was estimated at $8 billion/year and the government was spending $12 billion/year to fight it, without success. If that were a private company and you were CEO, what would you do????

The sad part is that it should have only cost 1% of that to find the frauds----just print out a list of the highest Medicare billers that are not institutions and start there. Number one on the list was a Florida solo cardiologist who billed $55 million in one year. Who thinks that was legitimate?????

Really want to cut healthcare cost? Eliminate the continuing practice of defensive medicine that costs over $1 TRILLION/ year by eliminating runaway jury malpractice verdicts (or killing all the lawyers:1rotfl::1rotfl::1rotfl:)

[Susan1717]

I have a MA PPO and have been extremely happy. I’ve never had a problem even when I travel.

[M2inOR]

This is a thread for residents of The Villages, but not one mention of Villages Health.

We have Villages Health and the United HealthCare (UHC) Medicare Advantage Plan. Villages Health only accepts UHC, Florida Blue, and Humana.

The federal government gives a lump sum for each Medicare Advantage subscriber to UHC and other insurance companies.

Villages Health gets a portion of that from UHC, Florida Blue, and Humana. This lets Villages Health build a team of PCP and other staff to service it's members.

Many of the other Medicare Advantage plans DO NOT pass along enough of the federal dollars.

Villages Health selects only certain specialists to service their members, considering their reputation and other factors. Not all specialists qualify to be within the Villages Health network.

We've been a member of Kaiser Permanente HMO for all our adult life before moving to The Villages. We never had any issues being handled within their network. Same has been true being under the Medicare Advantage plan with UHC/Villages Health.

I might suggest that many of the Medicare Advantage problems are with other providers here.

Many retired employees have "free" healthcare from lesser Medicare Advantage providers that Villages Health does not accept. It could be that those companies don't comply with Villages Health expectations or requirements for services and billings.

Your experieces might be different. We are very happy with UHC and Villages Health Their combined network has been excellent for us.

[opinionist]

My mother had traditional Medicare, but the system failed badly. She had dementia when she fell and broke her hip. She spent 3 days at the hospital before being transferred to a rehab facility, but she was not officially in the hospital for three days. Medicare refused to pay anything for rehab, and her secondary insurance refused to pay anything because of the decision by Medicare. If ever a patient needed a rehab facility, it was my mother. I was forced to pay out of pocket for a month of rehab, and that would not occur with Medicare Advantage.

[CoachKandSportsguy]

I've never heard of medicare advantage patient being delayed or denied care. I've seen a lot of lives saved through quick emergency response or months of various treatments to fight cancer successfully. Does the OP have an agenda for spreading this 'info'?

We have friends with denials from MA and Private insurance, had to go to medicare.

The typical MA denial is post injury/operation rehab . . . rehab has a long tail of expenses.

[BOWRUNNER]

Some say that Medicare Advantage is a failed experiment. Patients get delayed & denied care, the taxpayers are paying mightily for the winners: the insurance company executives. They also say it should be discontinued or dramatically reformed.

MA was sold heavily to Congress by insurance company lobbyists on the basis that it would save money over traditional Medicare.

Is Medicare Advantage a Failed Experiment? Experts Debate - MedCity News (https://medcitynews.com/2023/10/medicare-advantage-seniors-failed-healthcare/) I've been inroad to Medicare Advantage for 16 years, works for me

[MX rider]

We have friends with denials from MA and Private insurance, had to go to medicare.

The typical MA denial is post injury/operation rehab . . . rehab has a long tail of expenses.

We're on UHC Advantage and like it. I had a compound fracture of my tib and fib, and also broke my ankle in a dirt bike wreck about a year ago. I got great care through the surgery and rehab, and I'm now 100%. After care was very good and everywhere I needed to go here in Indiana took UHC. No denials or pre approval.

We were in TV all winter, and there were plenty of choices for me there as well if I needed anything.
Btw, medicare is not without denials.

[Wondering]

Some say that Medicare Advantage is a failed experiment. Patients get delayed & denied care, the taxpayers are paying mightily for the winners: the insurance company executives. They also say it should be discontinued or dramatically reformed.

MA was sold heavily to Congress by insurance company lobbyists on the basis that it would save money over traditional Medicare.

Is Medicare Advantage a Failed Experiment? Experts Debate - MedCity News (https://medcitynews.com/2023/10/medicare-advantage-seniors-failed-healthcare/)
This topic was on Next Door and comments from people who are on a Medicare Advantage Plan total disagree with your analysis. I have never been denied procedures, that my doctor prescribe. It's a lot cheaper than standard Medicare, when you have to purchase a supplemental program to cover costs. In addition, I receive money back from my SS assessment for Medicare. Your source sites two experts who disagree on the topic. The source who is positive on Medicare Advantage made more sense and has better arguments to support its' existence.

[Michael 61]

Reading these threads you have “die hards” supporting traditional Medicare and those that champion Medicare advantage plans. For those under 65, this is a major decision you will have to eventually make. Research is key. Everyone’s personal situation is unique, and one’s health history needs to be taken into consideration. Someone who is very healthy, and goes to the doctor just once a year for their annual checkup will probably rave about how much they love their advantage plan. When it comes to quality health care, cost (though important) should not be the over-riding decision as to which way to go. I personally would want to talk to people well into their 80s, who have multiple health issues going on, who have had multiple hospital stays and rehab, and ask them how their coverage and the plan they selected has worked out for them.

[MrFlorida]

UHC Advantage plan works for me.

[Dusty_Star]

I've never heard of medicare advantage patient being delayed or denied care. I've seen a lot of lives saved through quick emergency response or months of various treatments to fight cancer successfully. Does the OP have an agenda for spreading this 'info'?

No. But it was kind of you to ask.

[golfing eagles]

My mother had traditional Medicare, but the system failed badly. She had dementia when she fell and broke her hip. She spent 3 days at the hospital before being transferred to a rehab facility, but she was not officially in the hospital for three days. Medicare refused to pay anything for rehab, and her secondary insurance refused to pay anything because of the decision by Medicare. If ever a patient needed a rehab facility, it was my mother. I was forced to pay out of pocket for a month of rehab, and that would not occur with Medicare Advantage.

This was always an uphill battle with Medicare. For some reason the policy was a patient needed three days in the hospital prior to transfer to a skilled nursing facility for Medicare to pay. This was a catch 22 when there was no need for a patient to stay 3 days----without medical necessity they wouldn't pay the hospital and without 3 days inpatient they wouldn't pay the nursing home/rehab. It was always a conflict between utilization reviewers and discharge planners. Stupid rule IMHO since the inpatient days cost more than nursing home days.

[gatorbill1]

Probably same amount of problems with regular Medicare. A lot more people are happy with MA plans than not

[Sandy and Ed]

We have friends with denials from MA and Private insurance, had to go to medicare.

The typical MA denial is post injury/operation rehab . . . rehab has a long tail of expenses.
I have an MRI diagnosed/confirmed impingement on the sciatic nerve at the L4/5 level. I am not a doctor so I just listen to what I am told. Surgery was recommended. Scheduled but my Medicare Advantage would not approve. Wanted me to do Physical Therapy first!! Huh??? Are they nuts, I thought. Ok. Went to PT. Therapist diagnosed Periformis syndrome. Deep massage on my butt cheek located the muscle and was able to relax its hold on my sciatic nerve. Maybe in this case the denial was warranted?? Again I’m no doctor just a cynical patient. You ask a plumber to check your plumbing ….what are the chances he’ll find something wrong?

[sallyg]

We'd be broke without our Medicare advantage plan. It has been absolutely problem free great coverage. The best insurance we've ever had.
Not sure what this post is about?? Stirring the pot?

[sallyg]

it works for me. i've been able to get the care i need, when i need it, for what i want. i've never been denied, never had to sacrifice care. i'm leery of some of these stories, -they appear to be looking for some gut reaction, typically in a sensational way.
Agree!

[MSGirl]

LaLamy, yes it's true. A friend who has Medicre Advantage was denied a nuclear test. If they had a traditional they would have been covered, no problem. So, just because you never heard of it, doesn't make your statement true. The advantage plan is good as long as you don't get sick. But, no one knows when you will get sick.....and you will get sick

Traditional Medicare doesn’t cover everything either. And there are drs who won’t accept any Medicare. Fortunately in The Villages drs can’t survive without Medicare

[Sandy and Ed]

LaLamy, yes it's true. A friend who has Medicre Advantage was denied a nuclear test. If they had a traditional they would have been covered, no problem. So, just because you never heard of it, doesn't make your statement true. The advantage plan is good as long as you don't get sick. But, no one knows when you will get sick.....and you will get sick
Interesting. I had a lung resection due to cancer. Had follow-up treatments with proton therapy (SBRT) four separate times over the years - latest this past March at Moffitt. Aetna Medicare Advantage paid for it.

[Karmanng]

I don't think that Medicare Advantage is correctly labeled an experiment, they have been around for over 25 years. Over 50% of all Medicare enrollees are on Medicare Advantage Plans. Most people say they are happy with their MA plan, at least as many as say they are happy with traditional Medicare.

ALOT of these plans are going to go away and many hospitals are not taking these plans either...........traditional is the only way to go for sure........at least i know they are not going to change my drs on me when they feel like it !!! That happened many times to my folks.........

[Karmanng]

Traditional Medicare doesn’t cover everything either. And there are drs who won’t accept any Medicare. Fortunately in The Villages drs can’t survive without Medicare

BUT they slight the ones who dont want to use the Advantage plans either...........

[golfing eagles]

I have an MRI diagnosed/confirmed impingement on the sciatic nerve at the L4/5 level. I am not a doctor so I just listen to what I am told. Surgery was recommended. Scheduled but my Medicare Advantage would not approve. Wanted me to do Physical Therapy first!! Huh??? Are they nuts, I thought. Ok. Went to PT. Therapist diagnosed Periformis syndrome. Deep massage on my butt cheek located the muscle and was able to relax its hold on my sciatic nerve. Maybe in this case the denial was warranted?? Again I’m no doctor just a cynical patient. You ask a plumber to check your plumbing ….what are the chances he’ll find something wrong?

Unless there is neurologic impairment or severe interference with ADLs, a trial of PT is almost always warranted.

[MSGirl]

Some say that Medicare Advantage is a failed experiment. Patients get delayed & denied care, the taxpayers are paying mightily for the winners: the insurance company executives. They also say it should be discontinued or dramatically reformed.

MA was sold heavily to Congress by insurance company lobbyists on the basis that it would save money over traditional Medicare.

Is Medicare Advantage a Failed Experiment? Experts Debate - MedCity News (https://medcitynews.com/2023/10/medicare-advantage-seniors-failed-healthcare/)

Next year, under Part D, the donut hole for prescription drugs is supposed to be eliminated. I heard that there are BIG changes coming to the cost per month for traditional Medicare and Medicare Advantage plans. The actual changes have not been leaked, but we should all know in the coming months.

[Karmanng]

it works for me. i've been able to get the care i need, when i need it, for what i want. i've never been denied, never had to sacrifice care. i'm leery of some of these stories, -they appear to be looking for some gut reaction, typically in a sensational way.


those stories are actually true my parents were on the advantage plans and they changed there drs all the time towards the end......I wont go with that plan just because of that plus you cant go to alot of places either with advantge such as mayo clinic...........most hospitals and drs are actually trying to get out of the ma plans fyi

[Sandy and Ed]

Please, please, please make ME the "someone" in power as appointed dictator. I'll fix it in under a year. Of course, I'd also have to disband Congress, rewrite some laws, possibly including the constitution, kill all lobbyists and execute those who propagate ridiculous tripe online. Probably not going to happen :1rotfl::1rotfl::1rotfl:
Probably not….but I do like your thinking…even if only in jest. Maybe some one at the “top” of HCFA need to be replaced by someone who would insure oversight and logical procedures and policies. Too many knee jerk decisions

[golfing eagles]

ALOT of these plans are going to go away and many hospitals are not taking these plans either...........traditional is the only way to go for sure........at least i know they are not going to change my drs on me when they feel like it !!! That happened many times to my folks.........

"A LOT"????? How many??? What percentage of these plans???? Big ones or just Mom and Pop plans????? Where??? What states????

You see, there is "a lot" to "A LOT" :1rotfl::1rotfl::1rotfl:

[retiredguy123]

Traditional Medicare doesn’t cover everything either. And there are drs who won’t accept any Medicare. Fortunately in The Villages drs can’t survive without Medicare
Not just in The Villages. I cannot believe that a doctor anywhere can survive treating patients who are over 65 without accepting any Medicare.

[Sandy and Ed]

These numbers are out of date, about 15 years ago, but at the time Medicare budget was $600 billion/year, fraud was estimated at $8 billion/year and the government was spending $12 billion/year to fight it, without success. If that were a private company and you were CEO, what would you do????

The sad part is that it should have only cost 1% of that to find the frauds----just print out a list of the highest Medicare billers that are not institutions and start there. Number one on the list was a Florida solo cardiologist who billed $55 million in one year. Who thinks that was legitimate?????

Really want to cut healthcare cost? Eliminate the continuing practice of defensive medicine that costs over $1 TRILLION/ year by eliminating runaway jury malpractice verdicts (or killing all the lawyers:1rotfl::1rotfl::1rotfl:)
There are too too many issues to list here. We’ve been chasing our tails for so long we don’t know where we originally wanted to go

First it was doctors who always sent you for an MRI at a company that they owned under another corporate name.

Therapists milking therapy sessions to the maximum that Medicare would pay

Nursing homes with different wings so facility and sundry expenses for private pay and VA pay could be bundled with Medicare costs

A lot of creative accounting. A lot of organizational gyrations to hide fraud and abuse.

I remember way back in the 80’s (?) when at Senate hearings testimony got uncomfortably close to opening up the nursing home industry to a deep dive investigation on how Medicare was paying non-Medicare related costs. Almost comical to see on tv how the questions were backpedaled. Almost an “aha” moment. No one seemed to want to go there. Lobbyists be dammned

[Terrynmarty]

We have MA BCBS.
Same coverage as MA traditional due to it being from employer.
They changed last year.

Only issue we had was with a breathing doctor husband had.
Because small office, they don’t take MA.
Reason: MA requires more paperwork.

Hmmmm

That made me think MA checks to be sure valid.
The office never forwarded all our records.

Otherwise everywhere we go it has been accepted without question.

[Joe C.]

There's a simple fix for Medicare fraud.
1st offense - $1million fine.
2nd offense - $5million fine and 5 years prison
3rd offense - Seizure of all assets and death penalty.

[golfing eagles]

There's a simple fix for Medicare fraud.
1st offense - $1million fine.
2nd offense - $5million fine and 5 years prison
3rd offense - Seizure of all assets and death penalty.

Or even simpler: Yank licenses and prohibit payments from Medicare

[Rainger99]

BTW there is a BIG difference between a Medicare Advantage HMO & a PPO.

What is the difference??

[Rich42]

You can say what you want, but I have had United’s Advantage plan (paid for by the company I retired from 20 yrs ago) and NEVER had any kind of acceptance or payment problem. A recent hospital stay resulted in a bill for $105,000. I paid $75!

[Pat2015]

ALOT of these plans are going to go away and many hospitals are not taking these plans either...........traditional is the only way to go for sure........at least i know they are not going to change my drs on me when they feel like it !!! That happened many times to my folks.........
The Medicare Advantage plans are not going to go away and all of the hospitals in local TV area accept them. Not sure what the basis is for either comment?

[Marine1974]

Medicare Advantage may be a failed experiment, but so is Traditional Medicare. Medicare fraud is rampant. My mother spent her last 4 months in the hospital or various nursing homes. One medical doctor, who my mother never hired, followed her everywhere she went and billed Medicare for an office visit every day, 7 days per week. She was never hired, and never prescribed any medical treatment. Apparently, she posed as a hospital doctor and got my mother's SSN from her chart. Every day, she would make the rounds visiting her many "patients" in nursing homes and hospitals. Medicare has no checks and balances to determine if a provider was ever even hired by the patient. If they get a bill, they just pay it. At least Medicare Advantage providers have a profit motive to reduce fraud.

The only way to make the system more efficient is to require patients to have "skin in the game" by requiring all patients to pay a copay based on a percentage of the treatment. They need to eliminate free treatments where the patient has no incentive to reduce the cost.

What is a Medicare Provider Number (MPN)?

A Medicare/Medicaid Provider Number (MPN) verifies that a provider has been Medicare certified and establishes the type of care the provider can perform. This identifier is a six-digit number. The first two digits specify the state in which the provider is located, and the last four digits indicate the type of facility. For ambulatory surgery centers, the MPN is 10 digits — with the first two digits representing the state where the surgery center is located.

[GoRedSox!]

The biggest single issue, in my opinion, of Traditional Medicare, is that there is an unlimited co-insurance out-of-pocket expense. In other words, there is no cap on the 20% co-insurance. In the old days when medical treatment was not that expensive, this was not a deal breaker for many. And in the old days, there was no Medicare Advantage. But today, 20% of expensive treatment can quickly add up to a lot. So it seems to me that the two options are Traditional Medicare with a supplemental plan, and Medicare Advantage. The supplemental plans are good, but you could be looking at an additional $3,000 or more in premiums each year, depending on which plan you choose. Medicare Advantage can be the most practical choice for many, and as we see from the stats, the majority of Medicare enrollees have chosen Medicare Advantage. Most plans provide at least some extras that Medicare does not, and most plans have 0 additional premium. They are not perfect, but nothing is. I try not to let perfect be the enemy of good.

[JMintzer]

I've never heard of medicare advantage patient being delayed or denied care. I've seen a lot of lives saved through quick emergency response or months of various treatments to fight cancer successfully. Does the OP have an agenda for spreading this 'info'?

As someone (from a provider's prospective) who has dealt with regular Medicare and all of the Medicare "Advantage" type plans, I can tell you from experience, you couldn't be more wrong...

We've had patients denied care on countless occasions. Those "lives saved" were not saved because someone had an Advantage Plan..

Do you have an agenda for spreading that (incorrect) information?

[JMintzer]

Absolutely, positively 100% agree. The OP is nonsense, as is the "list" of "denials" a few posts above.

Do insurance companies occasionally deny requests for certain tests, treatments, hospitals or specialists---you bet they do. Advantage plans do, Medicare supplement plans do, private insurance does. ALL insurance plans have a set of policies and approved services. Most denials are simply because the service was not "coded" properly, others because the service might be new or considered experimental. HMOs and PPOs have a panel of approved physicians that are agreed upon by the insured when they choose that plan---it is the patient's decision. You need approval to go "out of network" or undergo a procedure that is not on the approved list. However, even with those restrictions, 99% of the time one phone call from your physician to the medical director of the insurance plan will get you approval. But that request must be medically necessary---whining that you want hospital A or physician B because your cousin's barber liked them won't do, nor should it.

Can one go on the internet and harvest a bunch of medical "horror stories"??? In a country of 330 million, no problem, since those who feel "wronged" are the first and loudest to complain. I can also find legal horror stories, automotive horror stories, daycare horror stories, and ditch digger horror stories. If someone is looking for 100% perfection in any system, might I suggest the planet Utopia?

Do you want to glean populist support? Just claim that the big, bad CEOs are making a fortune by cheating, conniving, deceiving and exploiting their workers, or the taxpayer, or the government. Readers will eat that crap up. The same readers that will pay thousands to see some guys kick a ball around a field or hear some rap crap guy "sing".

I don't know if the OP has an "agenda", but just add my wife and I to the millions that chose an advantage plan and are happy. And as many of you know I am familiar with medical insurance.

Doc,

Like you, I was in practice (I still am, albeit part time) for almost 40 years...

But I'm going to have to disagree with you on this one. If it were a simple "coding error", then the non-advantage plans would also deny the care (which they don't).

We call to get pre-authorization all of the time. They pre-authorize the care, then they deny payment, stating the pre-authorization was never actually a promise to pay.

Now, granted, we've also occasionally had that happen with commercial insurance companies, but it much, much more rare...

[JMintzer]

Nonsense. Just have the patient sign a doctor's visitation statement.

I have no idea that those words mean...

[JMintzer]

Please, please, please make ME the "someone" in power as appointed dictator. I'll fix it in under a year. Of course, I'd also have to disband Congress, rewrite some laws, possibly including the constitution, kill all lobbyists and execute those who propagate ridiculous tripe online. Probably not going to happen :1rotfl::1rotfl::1rotfl:

Can I be in charge of "killing all of the lobbyists"? I'd even give them a running start... :1rotfl::1rotfl::1rotfl:

[retiredguy123]

What is a Medicare Provider Number (MPN)?

A Medicare/Medicaid Provider Number (MPN) verifies that a provider has been Medicare certified and establishes the type of care the provider can perform. This identifier is a six-digit number. The first two digits specify the state in which the provider is located, and the last four digits indicate the type of facility. For ambulatory surgery centers, the MPN is 10 digits — with the first two digits representing the state where the surgery center is located.
I'm confused. I never said anything about a Medicare provider number.

[JMintzer]

Traditional Medicare doesn’t cover everything either. And there are drs who won’t accept any Medicare. Fortunately in The Villages drs can’t survive without Medicare

You post has noting to do with the pluses and minuses of Traditional MC vs MC Advantage plans...

[JMintzer]

Interesting. I had a lung resection due to cancer. Had follow-up treatments with proton therapy (SBRT) four separate times over the years - latest this past March at Moffitt. Aetna Medicare Advantage paid for it.

I'm glad you received the care you needed. But one anecdotal case does not a trend make...

[Lyarham]

Some say that Medicare Advantage is a failed experiment. Patients get delayed & denied care, the taxpayers are paying mightily for the winners: the insurance company executives. They also say it should be discontinued or dramatically reformed.

MA was sold heavily to Congress by insurance company lobbyists on the basis that it would save money over traditional Medicare.

Is Medicare Advantage a Failed Experiment? Experts Debate - MedCity News (https://medcitynews.com/2023/10/medicare-advantage-seniors-failed-healthcare/)
Our advantage plans are great

[JMintzer]

Or even simpler: Yank licenses and prohibit payments from Medicare

I've been investigated by Medicare 4 times. The first time, I owed them about $114.00..

The 2nd time, THEY owed ME about 95.00...

The 3rd time, I owed them about about $34.00. For a grand total of about $50... All of them were simple coding errors...

How many thousands of dollars did the spend to recoup $50?

The last investigation?

They accused me of treating a dead person.

No, I may hav nodded off a time or two in Med school, but I'm pretty sure I was awake during the "How to tell if your patient is ALIVE" lecture!

Turns out, I did a wound care consult on a patient during my lunch hour. Later that evening, around 8-9 pm, the patient coded and died...

I had to go to medical records, dig up the chart and copy the entire day's progress notes, including the vital signs taken in the am, lunch time, my consult, early evening vital signs , as well as the "code blue" event...

I sent it all to Medicare and received a very formal letter that simply said, "Never mind"... No apology, "Oops on our part, sorry for the stress we put you thru..."

It was kinda' like getting a threatening letter from the IRS, when the error was on their part. Not good for the heart!

[golfing eagles]

Doc,

Like you, I was in practice (I still am, albeit part time) for almost 40 years...

But I'm going to have to disagree with you on this one. If it were a simple "coding error", then the non-advantage plans would also deny the care (which they don't).

We call to get pre-authorization all of the time. They pre-authorize the care, then they deny payment, stating the pre-authorization was never actually a promise to pay.

Now, granted, we've also occasionally had that happen with commercial insurance companies, but it much, much more rare...

You haven't had care denied by straight Medicare, supplements, and private insurance????? OMG are you lucky. We had 5 FTEs dealing with all those problems---fighting denials cost us over 1/4 million/year-----which is a fraction of what it cost the government to create those denials in the first place. A vicious circle with no winners.

[JMintzer]

One other thing to consider is that once you are in an Advantage plan, it can be quite difficult to go back to traditional MC (if that is what you choose to do).

Traditional MC cannot deny coverage for new patients, but those who chose to go with an Advantage plan may have to go thru an underwriting process to re-enroll in traditional MC...

Just food for thought...

[golfing eagles]

I've been investigated by Medicare 4 times. The first time, I owed them about $114.00..

The 2nd time, THEY owed ME about 95.00...

The 3rd time, I owed them about about $34.00. For a grand total of about $50... All of them were simple coding errors...

How many thousands of dollars did the spend to recoup $50?

The last investigation?

They accused me of treating a dead person.

No, I may hav nodded off a time or two in Med school, but I'm pretty sure I was awake during the "How to tell if your patient is ALIVE" lecture!

Turns out, I did a wound care consult on a patient during my lunch hour. Later that evening, around 8-9 pm, the patient coded and died...

I had to go to medical records, dig up the chart and copy the entire day's progress notes, including the vital signs taken in the am, lunch time, my consult, early evening vital signs , as well as the "code blue" event...

I sent it all to Medicare and received a very formal letter that simply said, "Never mind"... No apology, "Oops on our part, sorry for the stress we put you thru..."

It was kinda' like getting a threatening letter from the IRS, when the error was on their part. Not good for the heart!

Yep, that's fun too. Fortunately, the only time a Medicare audit found anything wrong with my billing they stated I coded a 99213 and it should have been a 99214---they sent me a check for $46. Like you, I wonder how much it cost HCFA to give me that $46.

[golfing eagles]

One other thing to consider is that once you are in an Advantage plan, it can be quite difficult to go back to traditional MC (if that is what you choose to do).

Traditional MC cannot deny coverage for new patients, but those who chose to go with an Advantage plan may have to go thru an underwriting process to re-enroll in traditional MC...

Just food for thought...

I think they allow it once, but that's it.

[MX rider]

those stories are actually true my parents were on the advantage plans and they changed there drs all the time towards the end......I wont go with that plan just because of that plus you cant go to alot of places either with advantge such as mayo clinic...........most hospitals and drs are actually trying to get out of the ma plans fyi

Like some here you're painting with a broad brush and thats not accurate. Some MA plans are much better than others.

Many people on here have had major medical issues and are happy with their MA plan coverage, despite you telling them they shouldn't be. I'll take their word for it.

[JMintzer]

One more thing, the wife and I enrolled in MC this past Fall.

I had CFBS thru my office that covered us and my employees.

Since I was a small business, the only thing available was thru the "Affordable Care Act".

I was paying over $1300/month for my self and my wife (over $2600 total), with a $4000 deductible...

My employees cost the same per person... Luckily, they also went on Medicare about a year ago...

Since October, we now pay $174/month each, plus another $225-ish) for AARP UHC.

Our Part D is $0.40 (yes FOURTY CENTS)/month. I pay ZERO for my BP meds (2 low dose diuretics) and $9 and change for my 3 month supply of cholesterol meds. My wife pays a bit more for her cholesterol meds (different meds)...

Since October, I've had a metric ton of tests, scans, etc, a 3 day hospital stay for a GI bleed (all healed), and an Aortic Valve replacement...

Total out of pocket cost? $0.00

Of course, YMMV...

[JMintzer]

You haven't had care denied by straight Medicare, supplements, and private insurance????? OMG are you lucky. We had 5 FTEs dealing with all those problems---fighting denials cost us over 1/4 million/year-----which is a fraction of what it cost the government to create those denials in the first place. A vicious circle with no winners.

Did you miss the last sentence of my post? ;)

"Now, granted, we've also occasionally had that happen with commercial insurance companies, but it much, much more rare..."

[LG999]

Some say that Medicare Advantage is a failed experiment. Patients get delayed & denied care, the taxpayers are paying mightily for the winners: the insurance company executives. They also say it should be discontinued or dramatically reformed.

MA was sold heavily to Congress by insurance company lobbyists on the basis that it would save money over traditional Medicare.

Is Medicare Advantage a Failed Experiment? Experts Debate - MedCity News (https://medcitynews.com/2023/10/medicare-advantage-seniors-failed-healthcare/)

We have had Medicare Advantage plans since we retired over ten years ago. We have used UHC except for one year when we had Aetna, which was pretty good too.We are happy with the plans especially this current one. We have both worked for companies that offered excellent medical insurance and this UHC advantage plan surpasses those employer plans.

Perhaps Advantage plans do not address the needs of people who need expensive medications or have medical conditions that are expensive to deal with.

If you are pretty healthy Advantage plans can work for you. I use Latanoprost eye drops for glaucoma which have a $0 copay. I do not use any other prescription meds. All of my surgeries & hospital bills have been covered. I pay a low co-pay for doctor visits but my PCP is $0 no matter how many times I see her. Gym memberships are $0. There are other freebies. I can't complain.

[Stu from NYC]

We have had Medicare Advantage plans since we retired over ten years ago. We have used UHC except for one year when we had Aetna, which was pretty good too.We are happy with the plans especially this current one. We have both worked for companies that offered excellent medical insurance and this UHC advantage plan surpasses those employer plans.

Perhaps Advantage plans do not address the needs of people who need expensive medications or have medical conditions that are expensive to deal with.

If you are pretty healthy Advantage plans can work for you. I use Latanoprost eye drops for glaucoma which have a $0 copay. I do not use any other prescription meds. All of my surgeries & hospital bills have been covered. I pay a low co-pay for doctor visits but my PCP is $0 no matter how many times I see her. Gym memberships are $0. There are other freebies. I can't complain.

You can when they run out of money

[golfing eagles]

You can when they run out of money

They won't. Governments love to control people above all else. By limiting choices, they maintain control, so you can bet they will throw whatever money is needed in the direction of advantage plans.

[SusanStCatherine]

So you can easily go from a traditional Medicare supplement to an Advantage plan without medical underwriting. But not the other way. So one of the best things about the Affordable Care Act (ACA or Obamcare) was the elimination of preexisting conditions. Achieve Medicare age and now preexisting conditions come into play again (unless you live in one of four states where your premiums are higher for this privilege). So many different plans and different rates it is a wonder a person of much below average intelligence can navigate. Plan F is not available to new enrollees. What else will change in the future? If you are currently paying higher rates anticipating future medical needs you are not going to want all the people who savined money on Advantage plans in their healthier younger years to be allowed back to regular Medicare when they get sicker. But hey, things can change at any time.

[Rzepecki]

NRLN President's Forum
Authors Conclude
Medicare Advantage
Should be Abolished

An analysis in the JAMA (Journal of the American Medical Association) Internal Medicine on June 10 concluded: "We think the time has come to declare MA [Medicare Advantage] a failed experiment and abolish it. That would allow redeploying the $88 billion taxpayers will overpay MA this year to upgrade benefits for all Medicare beneficiaries."

The conclusion was based on the high cost of MA compared to traditional Medicare. For example:

Medicare Payment Advisory Commission (MedPAC), the nonpartisan agency reporting to Congress, recently estimated that MA overpayments added $82 billion to taxpayers' costs for Medicare in 2023 and $612 billion between 2007 and 2024. Two insurer strategies drive MA overpayments: diagnosis upcoding and avoiding enrollees who are ill and do not contribute to profits.

Although MA insurers must accept all applicants in counties where they offer a plan, they are also free to withdraw from counties where they are accumulating unprofitable enrollees.

Only 2% of Fee-for-Service (FFS) Medicare expenditures go for overhead. But MA insurers incur extra expenses for television advertisements, health care network management, benefit design, executive salaries, health care utilization review, prior authorization, and shareholder profits, driving their overhead up to 14%.

This is according to a report from Milliman, an international actuarial and consulting firm, on MA financial results for 2022. Milliman estimates applied to subsequent years' payments, MA overhead for 2007 to 2024 totals $592 billion--equivalent to 97% of taxpayers' $612 billion overpayments to them during that period.

The authors closed their analysis stating, "A smarter, thriftier way to expand benefits and lower out-of-pocket costs is possible for all Medicare beneficiaries, but first, we must eliminate MA and double down on traditional Medicare, covering all enrollees in an expanded and improved Medicare program. That would be a good deal for patients and taxpayers."

The NRLN has advocated for 10 years that it is time to end taxpayer rebates to the healthcare insurance industry for MA This year rebate payments will equal 17% of every benefit dollar Medicare pays to private insurers. Private plans hold a 54% share of the Medicare market but Medicare payments per enrollee are 22% higher than we pay for Fee-for-Service (FFS) enrollee. Income taxes paid support 76% of Medicare B and D.

Yet 301 bipartisan members in Congress lobby for more rebates hoping they can eliminate the "third rail" risk and gain votes from 33 million over age 65 retirees in MA in their states. They don't care about the other 27 million seniors back home who don't get over $2,000 a year in rebate paid extra benefits. These 27 million are actually more in need according to MedPAC. Private plan insurers focus on enrolling younger, more healthy retirees.

Congress' own commission, MedPAC, produced a report and charts in 2020 showing members of Congress that 25% of the FFS beneficiaries over age 65 account for 85% of Medicare spending! MedPAC's report states that "Costly beneficiaries tend to be those who have multiple chronic conditions, are using inpatient hospital services, are dually eligible for Medicare and Medicaid, and are in the last year of life."

The NRLN and most Americans support competition from private healthcare plans and the NRLN understands the financial challenges ahead for Medicare and the federal budget. However, we do not support MA taxpayer bonuses and rebate subsidies, or anti-competitive restrictions placed on original Medicare FFS just to preserve the notion that private insurance plans may be more cost effective or provide better care than FFS, when the record shows they are not.

We have repeatedly pointed out to members of Congress that the chronic benefits provided to the 33 million enrollees in MA plans are denied to the 27 million participants in traditional Medicare. If Congress is going to continue funding MA with taxpayer money, those in traditional Medicare should receive the same benefits.

Bill Kadereit, President
National Retiree Legislative Network

[Pennyt]

Some say that Medicare Advantage is a failed experiment. Patients get delayed & denied care, the taxpayers are paying mightily for the winners: the insurance company executives. They also say it should be discontinued or dramatically reformed.

MA was sold heavily to Congress by insurance company lobbyists on the basis that it would save money over traditional Medicare.

Is Medicare Advantage a Failed Experiment? Experts Debate - MedCity News (https://medcitynews.com/2023/10/medicare-advantage-seniors-failed-healthcare/)

I have traditional Medicare and my agent told me to not switch to an Advantage plan because everyone will be required to be on Advantage plans in the future. He said I'd be able to stay on traditional if I kept it. I go to doctors at Moffitt Cancer in Tampa and they do not accept Advantage plans. He thought traditional Medicare was better.

[M2inOR]

RE: National Retiree Legislative Network

What is missing is how the cancellation of Medicare Advantage and using the funds to "fix" traditional Medicare will actually be accomplished.

The Federal government gives Medicare Advantage providers a fixed amount per year, per client. This enables the provider to have a budget to fund a care team that is at the ready to service it's clients. There are also incentives in place to reward providers for keeping their clients healthier.

Yes, of course there are inefficient providers who don't have any idea how to have a profitable business. No provider can afford to operate a business that continually loses money treating its patients.

Someone complained that their doctors were always changing. You might want to consider using a provider that knows how to better operate their business providing healthcare.

For me, I want the best doctor available to treat me when needed. I don't need to see the same person each and every time. Fortunately for me my PCP is available when I make appointments for the future. And if I need someone ASAP, Villages Health delivers; a simple call tells me where to go if someone is needed immediately. This may be someone on my PCP's team, an urgent care clinic, or an emergency room. Fortunately the latter can be whomever is convenient.

Don't forget, the Federal Government has deep pockets, but the depth is not infinite.

[Stu from NYC]

They won't. Governments love to control people above all else. By limiting choices, they maintain control, so you can bet they will throw whatever money is needed in the direction of advantage plans.

At some point all of these deficits causing more and more borrowing is going to reach a point where nobody is going to want to finance them.

We will probably long gone but this cannot go on forever

[Topspinmo]

Laughing out loud! ACA was supposed fix healthcare. It might have had chance if they would have read it before they passed it. IMO and I can have one IT just MADE it worse…….>

[Topspinmo]

They won't. Governments love to control people above all else. By limiting choices, they maintain control, so you can bet they will throw whatever money is needed in the direction of advantage plans.

Kickbacks?????

[golfing eagles]

NRLN President's Forum
Authors Conclude
Medicare Advantage
Should be Abolished

An analysis in the JAMA (Journal of the American Medical Association) Internal Medicine on June 10 concluded: "We think the time has come to declare MA [Medicare Advantage] a failed experiment and abolish it. That would allow redeploying the $88 billion taxpayers will overpay MA this year to upgrade benefits for all Medicare beneficiaries."

The conclusion was based on the high cost of MA compared to traditional Medicare. For example:

Medicare Payment Advisory Commission (MedPAC), the nonpartisan agency reporting to Congress, recently estimated that MA overpayments added $82 billion to taxpayers' costs for Medicare in 2023 and $612 billion between 2007 and 2024. Two insurer strategies drive MA overpayments: diagnosis upcoding and avoiding enrollees who are ill and do not contribute to profits.

Although MA insurers must accept all applicants in counties where they offer a plan, they are also free to withdraw from counties where they are accumulating unprofitable enrollees.

Only 2% of Fee-for-Service (FFS) Medicare expenditures go for overhead. But MA insurers incur extra expenses for television advertisements, health care network management, benefit design, executive salaries, health care utilization review, prior authorization, and shareholder profits, driving their overhead up to 14%.

This is according to a report from Milliman, an international actuarial and consulting firm, on MA financial results for 2022. Milliman estimates applied to subsequent years' payments, MA overhead for 2007 to 2024 totals $592 billion--equivalent to 97% of taxpayers' $612 billion overpayments to them during that period.

The authors closed their analysis stating, "A smarter, thriftier way to expand benefits and lower out-of-pocket costs is possible for all Medicare beneficiaries, but first, we must eliminate MA and double down on traditional Medicare, covering all enrollees in an expanded and improved Medicare program. That would be a good deal for patients and taxpayers."

The NRLN has advocated for 10 years that it is time to end taxpayer rebates to the healthcare insurance industry for MA This year rebate payments will equal 17% of every benefit dollar Medicare pays to private insurers. Private plans hold a 54% share of the Medicare market but Medicare payments per enrollee are 22% higher than we pay for Fee-for-Service (FFS) enrollee. Income taxes paid support 76% of Medicare B and D.

Yet 301 bipartisan members in Congress lobby for more rebates hoping they can eliminate the "third rail" risk and gain votes from 33 million over age 65 retirees in MA in their states. They don't care about the other 27 million seniors back home who don't get over $2,000 a year in rebate paid extra benefits. These 27 million are actually more in need according to MedPAC. Private plan insurers focus on enrolling younger, more healthy retirees.

Congress' own commission, MedPAC, produced a report and charts in 2020 showing members of Congress that 25% of the FFS beneficiaries over age 65 account for 85% of Medicare spending! MedPAC's report states that "Costly beneficiaries tend to be those who have multiple chronic conditions, are using inpatient hospital services, are dually eligible for Medicare and Medicaid, and are in the last year of life."

The NRLN and most Americans support competition from private healthcare plans and the NRLN understands the financial challenges ahead for Medicare and the federal budget. However, we do not support MA taxpayer bonuses and rebate subsidies, or anti-competitive restrictions placed on original Medicare FFS just to preserve the notion that private insurance plans may be more cost effective or provide better care than FFS, when the record shows they are not.

We have repeatedly pointed out to members of Congress that the chronic benefits provided to the 33 million enrollees in MA plans are denied to the 27 million participants in traditional Medicare. If Congress is going to continue funding MA with taxpayer money, those in traditional Medicare should receive the same benefits.

Bill Kadereit, President
National Retiree Legislative Network

Bottom line: An opinion from someone who probably also has an agenda.

[golfing eagles]

I have traditional Medicare and my agent told me to not switch to an Advantage plan because everyone will be required to be on Advantage plans in the future. He said I'd be able to stay on traditional if I kept it. I go to doctors at Moffitt Cancer in Tampa and they do not accept Advantage plans. He thought traditional Medicare was better.

NOT TRUE. Both Moffit and Shands are in network for the Florida Blue advantage plan.

[golfing eagles]

Kickbacks?????

More like the quote from Star wars episode 3------"All those who have power are afraid to lose it"

[SusanStCatherine]

If they discontinue the program then everyone on MA should be allowed into a MediGap program with no underwriting.

I agree no underwriting. But the premiums should be higher compared to those already paying higher Medigap premiums. Maybe a sliding scale based on age.

[SusanStCatherine]

It does not seem right that some retirees are only given the choice of an Advantage plan. Medical and employer relationship should have been decoupled a long time ago.

[SusanStCatherine]

I had CFBS thru my office that covered us and my employees.

Since I was a small business, the only thing available was thru the "Affordable Care Act".

I was paying over $1300/month for my self and my wife (over $2600 total), with a $4000 deductible...


Ah. The Affordable Care Act which was supposed to make health care affordable. We suffered for many years with the same high premiums but our deductibles were higher. Our employers did not offer healthcare. So basically paying an extra $30K per year and not have anything covered since the deductible was so high. It truly caused us financial distress. Rates are not determined by gender or health status or preexisting conditions - but wait - rates determined by age! And oh my gosh are the rates astronomical the years leading up to Medicare.

[SusanStCatherine]

Hospitals (and doctors) across the country are dropping access to Medicare Advantage plans and a simple internet search will show that this is true. Virtually all hospitals accept Medigap policy.

[SusanStCatherine]

The Pharmaceutical companies are way too powerful. The pharmacy benefit managers dictate what drugs go on the formulary and are available to you. So the formulary is based on maximum profit, not the most therapeutic drugs. There are no drugs on my formulary for my condition below tier four. I filed an exception and pre-approval and was granted it. What did that buy me? A chance to pay full price for the drug until my deductible is met and then I can pay half price for it. The half price they quoted me is more than the GoodRx price of $75 and this is a generic.

[Stu from NYC]

Laughing out loud! ACA was supposed fix healthcare. It might have had chance if they would have read it before they passed it. IMO and I can have one IT just MADE it worse…….>

Remarkable how few people who voted for it took the time to read what they were voting for

[golfing eagles]

Remarkable how few people who voted for it took the time to read what they were voting for

You’re forgetting “you have to pass it to find out what’s in it “😂😂😂

[JMintzer]

Ah. The Affordable Care Act which was supposed to make health care affordable. We suffered for many years with the same high premiums but our deductibles were higher. Our employers did not offer healthcare. So basically paying an extra $30K per year and not have anything covered since the deductible was so high. It truly caused us financial distress. Rates are not determined by gender or health status or preexisting conditions - but wait - rates determined by age! And oh my gosh are the rates astronomical the years leading up to Medicare.

When the ACA was first passed, my deductible a $7K/year. And, like you, since my deductible was so high, the only thing covered was my yearly physical and my wife's yearly physical and mammogram... Everything else was "out of pocket"...

Only be choosing a lower coverage level was I able to reduce my deductible to $4K, and keep my premium increase to a less insane amount.


However, my monthly premiums increased...

[JMintzer]

NOT TRUE. Both Moffit and Shands are in network for the Florida Blue advantage plan.

What other Advantage Plans do they accept?

[JMintzer]

You’re forgetting “you have to pass it to find out what’s in it “😂😂😂

I'm still ****ed about that comment...:censored::censored::censored:

[tophcfa]

Laughing out loud! ACA was supposed fix healthcare. It might have had chance if they would have read it before they passed it. IMO and I can have one IT just MADE it worse…….>

Depends on one’s income. For some it made healthcare more affordable, but for others it made it significantly more expensive. It’s a zero sum game, one person’s subsidized healthcare premiums are ultimately paid for by others increased premiums or those actually paying income taxes. In a way, it was simply a government mandated redistribution of wealth.

[GoRedSox!]

While the ACA is far from perfect, it is much better than the alternative—nothing. The main detractors of the ACA have had 14 years to come up with a “repair and replace” plan and they have never put forward any concrete proposal. The ACA now covers over 40 million Americans, including over 21 million in marketplace plans. There are many challenges with our health care delivery system. These challenges were not caused by the ACA. We really don’t want to go back to the days of pre-existing conditions and catastrophic plans. As an FYI, there is no Pre-existing condition limitation on Medicare Supplemental plans if you sign up at the time of eligibility. No underwriting, no pre-ex. Must issue at age 65.

[SusanStCatherine]

While the ACA is far from perfect, it is much better than the alternative—nothing. The main detractors of the ACA have had 14 years to come up with a “repair and replace” plan and they have never put forward any concrete proposal. The ACA now covers over 40 million Americans, including over 21 million in marketplace plans. There are many challenges with our health care delivery system. These challenges were not caused by the ACA. We really don’t want to go back to the days of pre-existing conditions and catastrophic plans. As an FYI, there is no Pre-existing condition limitation on Medicare Supplemental plans if you sign up at the time of eligibility. No underwriting, no pre-ex. Must issue at age 65.

But when signing up at age 65 and selecting an Advantage plan, it is basically the selection for the rest of your life (you can change within first six months or something like that). But selecting a MediGap plan allows you to switch to Advantage later, but not the other direction. Some states allow the change. A fair number of people don't understand this. Also some people don't know your Medicare premiums can double or more depending on your income. My widowed cousin sold her house and is now stuck paying double for two years - pretty sad.

[Justputt]

I have no problem using my MA plan as a snowbird in NY or FL. Spent 4 decades in healthcare and neither is perfect, and both have issues. The biggest problem we had with Medicare, MA, and private insurance was the SLOOWWWW play. It often seems like the deny claims for as long as possible so they can hold onto money longer and gain interest, etc. Then there's the Medicare RAC audits which cover many years, they start out claiming you own a ton of money from overpayments, etc., and if you did your paperwork right, you end up owing little to nothing!!! If you don't keep your paper straight, you pay BIG!!! The main difference between Medicare and MA is Medicare doesn't require preauthorization and MA's sometimes do but they still cover the same things. MA are required to cover whatever Medicare covers, but they through in dental, vision, etc. as inducements. Medicare and MA generally use the same guidelines for what is and is not covered, e.g. if Medicare won't authorize a procedure for something, chances are good MA won't either; that's just the way it works. So, what's the fix? I suspect it'll end up being Case Rate, no more prior authorization, etc., e.g. stage IIB lung cancer and you (hospital, clinic, etc.) get paid $60k and the care which they and the patient pick. I would like to see legislation for prompt pay, but insurance companies have generally shot it down. Slow pay cases should include significant interest as a penalty.

[RICH1]

And yet, in Florida, we rewarded one of those fraudsters by making him governor and then making him a US senator!
you speak the Truth .... finally someone who remembers

[LarryL]

Go to this website and see what this group of Doctors think about our current "healthcare" system: Physicians' Proposal - PNHP (https://pnhp.org/what-is-single-payer/physicians-proposal/)

[Ken D.]

LaLamy, yes it's true. A friend who has Medicre Advantage was denied a nuclear test. If they had a traditional they would have been covered, no problem. So, just because you never heard of it, doesn't make your statement true. The advantage plan is good as long as you don't get sick. But, no one knows when you will get sick.....and you will get sick
I had that very test, MA paid for the test, but I was responsible for 20% of the cost for the “nuclear injection”, which equates to approximately $970.

[MSGirl]

Reading these threads you have “die hards” supporting traditional Medicare and those that champion Medicare advantage plans. For those under 65, this is a major decision you will have to eventually make. Research is key. Everyone’s personal situation is unique, and one’s health history needs to be taken into consideration. Someone who is very healthy, and goes to the doctor just once a year for their annual checkup will probably rave about how much they love their advantage plan. When it comes to quality health care, cost (though important) should not be the over-riding decision as to which way to go. I personally would want to talk to people well into their 80s, who have multiple health issues going on, who have had multiple hospital stays and rehab, and ask them how their coverage and the plan they selected has worked out for them.

I chose UHC MA and am very happy with it. I’ve had numerous surgeries and health issues and had no problems with my MA plan. I don’t pay a monthly fee for a supplement. However, with my plan I had to pay a co-pay for the surgi center /hospital. $150 per day. Up to $2400 out of pocket max. A supplement policy would cost me $2400+ per year. I see it as you either pay at the front end with a supplement or the back end with an MA plan. Plus you get some perks, dental, optical, gym membership, Part D meds.

[GoRedSox!]

Depends on one’s income. For some it made healthcare more affordable, but for others it made it significantly more expensive. It’s a zero sum game, one person’s subsidized healthcare premiums are ultimately paid for by others increased premiums or those actually paying income taxes. In a way, it was simply a government mandated redistribution of wealth.In the original ACA, everyone had to have insurance. There was an individual mandate. If everyone was insured, the burden of those who can't or don't pay for care would have been eliminated. One way or another, we all pay for those who don't have insurance, and in 2010, there was 50 million uninsured Americans.

The individual mandate was thrown out, that took many healthy young people out of the pool and increased costs dramatically.

I can't tell you how many people I have heard complaining about the ACA, while their own kids got to stay on their parents health insurance until they were 26 years old. The number of uninsured Americans has dropped by more than 20 million since 2010.

The biggest reason that it is costly is because there is no pre-existing condition limitation and the people who need care the most are the most likely people to sign up for it. And it required all insurance policies to include certain essential benefits so that insurance companies weren't selling plans to people which were so skinnied down that they didn't pay for much of the care that people needed.

The United States remains the only industrialized democracy in the entire world where health care is a privilege and not a right. We are the only country that ties health insurance to employment. We also spend far more than any other country per capita on health care and our outcomes are not superior.

Saying all of this does not make me a communist or a socialist. The US is the only outlier. Millions of Americans routinely travel to other countries to receive care, the nickname for this is medical tourism.

Many folks think that a government health care system is socialism. But we already have tens of millions of people in a government health care system who are on Medicare and Medicaid, and generally, the folks who are covered are ok with their coverage and don't see themselves as participating in a socialist system. There is no reason that Medicare can't be expanded to cover everyone.

For those who would not want everyone to be covered by Medicare, do you think it's better run by a handful of gigantic for-profit health insurance companies, big pharma advertising all over TV, and conglomerate health care systems buying up individual practices?

[kendi]

MA works great for my mother. She never leaves her home city and is in a medical system that accepts her plan. Not so much for a woman I know who lost her life cause she wasn’t approved for the specialized medical facility she needed in Florida. All depends on what MA plan you get and where you live. As for myself, I stay far away from the MA plans. Don’t want an insurance company making my medical decisions for me.

[tophcfa]

The supplemental plans are good, but you could be looking at an additional $3,000 or more in premiums each year, depending on which plan you choose.

How is that a problem? That’s chump change compared to what we pay through Obamacare! And the Medicare Supplement benefits blow away the ACA benefits. $3K in premiums per year for outstanding benefits, a national network, and no referrals, absolutely blows away close to $3 k per MONTH for inferior benefits, with a limited local network, needing referrals for everything, and dealing with co-pays and max out of pockets.

[Peachbelle]

Heres what's currently going on with MA plans in Congress. These plans are funded 80% by Federal funds. Congress wants to lower that 80% funding given to insurance companies. When they do lower it you can bet that benefits with MA plans will be lowered. Once on MA plan you cannot change back to Medicare. Do you now get the "hook and bait" that Congress had planned?

[Mrprez]

Heres what's currently going on with MA plans in Congress. These plans are funded 80% by Federal funds. Congress wants to lower that 80% funding given to insurance companies. When they do lower it you can bet that benefits with MA plans will be lowered. Once on MA plan you cannot change back to Medicare. Do you now get the "hook and bait" that Congress had planned?

Stop the BS. You can always switch back to regular Medicare.

Joining a plan | Medicare (https://www.medicare.gov/basics/get-started-with-medicare/get-more-coverage/joining-a-plan)

[retiredguy123]

Heres what's currently going on with MA plans in Congress. These plans are funded 80% by Federal funds. Congress wants to lower that 80% funding given to insurance companies. When they do lower it you can bet that benefits with MA plans will be lowered. Once on MA plan you cannot change back to Medicare. Do you now get the "hook and bait" that Congress had planned?
Does the 80 percent include the Medicare Part B premiums paid by the retirees, or do the MA plans also receive those premiums in addition to the 80 percent?

Also, how much does it cost to operate the traditional Medicare program, to include the benefits paid to medical providers, and the salaries and benefits of the Government employees and contractors who manage the program (including lifetime pension and SS monthly payments after they retire)?

[tophcfa]

Stop the BS. You can always switch back to regular Medicare.

Joining a plan | Medicare (https://www.medicare.gov/basics/get-started-with-medicare/get-more-coverage/joining-a-plan)

You can always ATTEMPT to switch back, with medical underwriting, and you will most likely get rejected if you have a history of expensive health conditions. Insurance isn’t designed to allow people, with minimal health care needs, to get free/inexpensive coverage and then be able to switch to better/more expensive coverage when they get a serious/expensive health condition.

[SusanStCatherine]

Stop the BS. You can always switch back to regular Medicare.

Joining a plan | Medicare (https://www.medicare.gov/basics/get-started-with-medicare/get-more-coverage/joining-a-plan)

When switching from a Medicare Advantage plan you are not guaranteed issue of a MediGap policy if you have preexisting conditions unless you live in one of these four states:
Connecticut
Maine
New York
Vermont
If you are issued a Medigap plan, you may be charged higher rates.
There may be a few exceptions such as if your MA plan is dropped.

[Mrprez]

When switching from a Medicare Advantage plan you are not guaranteed issue of a MediGap policy if you have preexisting conditions unless you live in one of these four states:
Connecticut
Maine
New York
Vermont
If you are issued a Medigap plan, you may be charged higher rates.
There may be a few exceptions such as if your MA plan is dropped.

Medigap is not Medicare. I am talking about the often repeated misinformation that once on MA, you can’t go back to Medicare. Patently false. Medigap is a whole other subject.

[Mrprez]

You can always ATTEMPT to switch back, with medical underwriting, and you will most likely get rejected if you have a history of expensive health conditions. Insurance isn’t designed to allow people, with minimal health care needs, to get free/inexpensive coverage and then be able to switch to better/more expensive coverage when they get a serious/expensive health condition.

Again, you are talking about Medigap. I am talking about Medicare. Huge difference.

[rjm1cc]

We have the Humana Advantage plan. Unfortunately we have made extensive use of the plan over a number of years and we never felt that we were being denied needed services. My guess is that we would have paid more if we had the traditional medicare plans due to the traditional co pays.
However some plans do give you a lot of "non medical monthly benefits" so I can see that they may not have the desire to fund some medical needs. Just have to be selective of the plan you pick.

[retiredguy123]

Medigap is not Medicare. I am talking about the often repeated misinformation that once on MA, you can’t go back to Medicare. Patently false. Medigap is a whole other subject.
True, but as I understand it, Medigap is a supplement to Medicare that covers the 20 percent of coinsurance costs that Medicare doesn't cover. That can be a substantial amount of money that could bankrupt a lot of people. So, switching from an advantage plan to Medicare without Medigap could be a disaster for many people.

[GoRedSox!]

How is that a problem? That’s chump change compared to what we pay through Obamacare! And the Medicare Supplement benefits blow away the ACA benefits. $3K in premiums per year for outstanding benefits, a national network, and no referrals, absolutely blows away close to $3 k per MONTH for inferior benefits, with a limited local network, needing referrals for everything, and dealing with co-pays and max out of pockets.I wasn't comparing Medicare Supplemental Plans to ACA plans. Those are not comparable, one is a government benefit that YOU PAID INTO your entire life to get the plan at that cost, the other is a fully-insured plan run by a for profit health insurance company that if it's not subsidized by the government, is going to cost a lot of money.

I was comparing the cost of Medicare Supplement plans to the Cost of Medicare Advantage. It could easily cost $3,000 more and that's not chump change to a number of people.

[Mrprez]

True, but as I understand it, Medigap is a supplement to Medicare that covers the 20 percent of coinsurance costs that Medicare doesn't cover. That can be a substantial amount of money that could bankrupt a lot of people. So, switching from an advantage plan to Medicare without Medigap could be a disaster for many people.

True, but that’s beside the point. I’m merely refuting her statement that once you sign up for MA you are stuck for life and can’t go back to Medicare.

[Mrprez]

I wasn't comparing Medicare Supplemental Plans to ACA plans. Those are not comparable, one is a government benefit that YOU PAID INTO your entire life to get the plan at that cost, the other is a fully-insured plan run by a for profit health insurance company that if it's not subsidized by the government, is going to cost a lot of money.

I was comparing the cost of Medicare Supplement plans to the Cost of Medicare Advantage. It could easily cost $3,000 more and that's not chump change to a number of people.

Supplement plans are run by insurance companies, not the government. Jeez!

[GoRedSox!]

Supplement plans are run by insurance companies, not the government. Jeez!I am not articulating myself as well as I should, but my point is that one cannot compare the cost of traditional Medicare, which people paid into their entire lives to get this at age 65 at this price plus Medicare Supplement which will cost about $3000 a year to the ACA plans. Especially if the ACA plan is not subsidized. Of course $3,000 will seem like a bargain compared to the ACA plan, but that was not what I was comparing it to. I was comparing Medicare Supplemental vs. Medicare Advantage. The $3,000 more in premium costs for Supplemental vs. Advantage is not chump change to many seniors.

That's why more far more people are on Traditional Medicare and Medicare Advantage Plans than are on Supplemental Plans. About 20% of Medicare enrollees have Medicare Supplemental Plans. A little more than 50% of Medicare enrollees have Medicare Advantage Plans. The rest are traditional Medicare members, but some people have Medicaid in addition, some have some previous employer coverage in addition, and some just go with traditional Medicare alone.

[Pat2015]

But when signing up at age 65 and selecting an Advantage plan, it is basically the selection for the rest of your life (you can change within first six months or something like that). But selecting a MediGap plan allows you to switch to Advantage later, but not the other direction. Some states allow the change. A fair number of people don't understand this. Also some people don't know your Medicare premiums can double or more depending on your income. My widowed cousin sold her house and is now stuck paying double for two years - pretty sad.
That increase will only be for one year as they look at your income two years prior to establish your rate each year. It will go back down the following year.

[Pat2015]

Hospitals (and doctors) across the country are dropping access to Medicare Advantage plans and a simple internet search will show that this is true. Virtually all hospitals accept Medigap policy.
All the local hospitals in the TV area accept Medicare Advantage and while recently traveling to Oregon and ending up in an ER there, the insurance was also accepted. Yes, there are some places that don’t accept this type of insurance, but many places do thus there’s no problem at present to obtain care.

[JMintzer]

And yet, in Florida, we rewarded one of those fraudsters by making him governor and then making him a US senator!

you speak the Truth .... finally someone who remembers

Good thing politics are not allowed to be discussed on this site...

[JMintzer]

In the original ACA, everyone had to have insurance. There was an individual mandate. If everyone was insured, the burden of those who can't or don't pay for care would have been eliminated. One way or another, we all pay for those who don't have insurance, and in 2010, there was 50 million uninsured Americans.

The individual mandate was thrown out, that took many healthy young people out of the pool and increased costs dramatically.

I can't tell you how many people I have heard complaining about the ACA, while their own kids got to stay on their parents health insurance until they were 26 years old. The number of uninsured Americans has dropped by more than 20 million since 2010.

The biggest reason that it is costly is because there is no pre-existing condition limitation and the people who need care the most are the most likely people to sign up for it. And it required all insurance policies to include certain essential benefits so that insurance companies weren't selling plans to people which were so skinnied down that they didn't pay for much of the care that people needed.

The United States remains the only industrialized democracy in the entire world where health care is a privilege and not a right. We are the only country that ties health insurance to employment. We also spend far more than any other country per capita on health care and our outcomes are not superior.

Saying all of this does not make me a communist or a socialist. The US is the only outlier. Millions of Americans routinely travel to other countries to receive care, the nickname for this is medical tourism.

Many folks think that a government health care system is socialism. But we already have tens of millions of people in a government health care system who are on Medicare and Medicaid, and generally, the folks who are covered are ok with their coverage and don't see themselves as participating in a socialist system. There is no reason that Medicare can't be expanded to cover everyone.

For those who would not want everyone to be covered by Medicare, do you think it's better run by a handful of gigantic for-profit health insurance companies, big pharma advertising all over TV, and conglomerate health care systems buying up individual practices?

Your complaint that "children" could stay on their parent's plan was and integral part of the ACA by design. It was a bone thrown to help it get passed.

My 2 younger kids could stay on my plan (until age 26), but neither one had to. They were both covered by their employers. Employers found it cheaper to offer health insurance rather than higher pay.

My oldest had to pay her own way.

Your other claim that we spend more with no better results is an outcome of our legal system.

No other industrial country has the medical malpractice industry that is seen in the US.

Docs here MUST practice defensive medicine, and order too many tests or risk being sued.

[JMintzer]

All the local hospitals in the TV area accept Medicare Advantage and while recently traveling to Oregon and ending up in an ER there, the insurance was also accepted. Yes, there are some places that don’t accept this type of insurance, but many places do thus there’s no problem at present to obtain care.

That doesn't change the fact that what SusanStCathrerine is true...

[tophcfa]

I was comparing the cost of Medicare Supplement plans to the Cost of Medicare Advantage. It could easily cost $3,000 more and that's not chump change to a number of people.

Totally true. But that $3,000 in savings will rapidly disappear, and then possibly way more, if/when the MA insured individual has a medical event that requires more than basic wellness medical care. There are easily many real world scenarios where spending the $3 grand on a supplemental plan will indeed appear like chump change at the end of the year compared to TOTAL health care expenditures if one opts to choose a MA plan.

Choosing a MA plan, versus Medigap, is akin to gambling one’s finances on their future health care needs. The biggest problem with MA plans is that when you win the gamble, you can save around $3 grand per year, when you loose the gamble it can be catastrophic. That’s not a risk/reward scenario I’m willing to take.

[JMintzer]

Medigap is not Medicare. I am talking about the often repeated misinformation that once on MA, you can’t go back to Medicare. Patently false. Medigap is a whole other subject.

Wrong...

Again, you are talking about Medigap. I am talking about Medicare. Huge difference.

And wrong again...

No one is confusing a Medigap policy with a Medicare Advantage Plan (except for you...)

If you choose a Medicare Advantage Plan, yes, you can switch to regular Medicare (with no penalty), BUT ONLY WITHIN THE FIRST THREE MONTS OF YOUR INITIAL ENROLLMENT.

After that tine period, if you want to switch back the regular Medicare, YOU MUST go thru an underwriting process... PERIOD.

[JMintzer]

True, but that’s beside the point. I’m merely refuting her statement that once you sign up for MA you are stuck for life and can’t go back to Medicare.

The statement you are attempting to refute is true. UNLESS you go thru an underwriting process...

[Sabella]

Maybe you need to do more research

[Caymus]

Wrong...



And wrong again...

No one is confusing a Medigap policy with a Medicare Advantage Plan (except for you...)

If you choose a Medicare Advantage Plan, yes, you can switch to regular Medicare (with no penalty), BUT ONLY WITHIN THE FIRST THREE MONTS OF YOUR INITIAL ENROLLMENT.

After that tine period, if you want to switch back the regular Medicare, YOU MUST go thru an underwriting process... PERIOD.

Depends on your official state of residence. Massachusetts (and I think) a few others do not require underwriting for supplement plans.

[golfing eagles]

Totally true. But that $3,000 in savings will rapidly disappear, and then possibly way more, if/when the MA insured individual has a medical event that requires more than basic wellness medical care. There are easily many real world scenarios where spending the $3 grand on a supplemental plan will indeed appear like chump change at the end of the year compared to TOTAL health care expenditures if one opts to choose a MA plan.

Choosing a MA plan, versus Medigap, is akin to gambling one’s finances on their future health care needs. The biggest problem with MA plans is that when you win the gamble, you can save around $3 grand per year, when you loose the gamble it can be catastrophic. That’s not a risk/reward scenario I’m willing to take.

Interesting, since my Florida Blue MA plan has a MAXIMUM $2,400 out of pocket expense. Not much of a gamble.

[nn0wheremann]

Some say that Medicare Advantage is a failed experiment. Patients get delayed & denied care, the taxpayers are paying mightily for the winners: the insurance company executives. They also say it should be discontinued or dramatically reformed.

MA was sold heavily to Congress by insurance company lobbyists on the basis that it would save money over traditional Medicare.

Is Medicare Advantage a Failed Experiment? Experts Debate - MedCity News (https://medcitynews.com/2023/10/medicare-advantage-seniors-failed-healthcare/)
Like many insurance plans, these are a great success until you need them.

[JMintzer]

Depends on your official state of residence. Massachusetts (and I think) a few others do not require underwriting for supplement plans.

And the 4 States that are exceptions to the rule have been mentioned, multiple times...

Picking a few nits doesn't change my point, since the person to whom I responded never brought up those 4 States...

[GoRedSox!]

There are some terms which have been used interchangeably throughout this thread which are not necessarily interchangeable.

Traditional Medicare: This is standard Medicare, around since the mid-60's when the program was created. There is a Medicare Part B premium of $174.70 in 2024 that is deducted from your Social Security payment, or billed quarterly if you have not yet started taking Social Security. Traditional Medicare basically pays 80% of the Medicare fee after the deductible is met. There is no limit to the 20% patient responsibility.

Medicare Advantage: The government pays a private insurance company to provide your Medicare coverage. Plans often include extra benefits such as dental, gym benefits, and eye care not available from Traditional Medicare, and often for no additional premium beyond the $174.70 already being deducted. There is a limit on out of pocket costs. The plan can require you to have a PCP, referrals, and require you to stay in their network. They can also limit you to a specific service area for non-urgent/emergent care. Medicare Part D is almost always wrapped in as a pharmacy benefit.

Medicare Supplemental (Medigap): This is insurance sold by private insurance companies that pairs with Traditional Medicare to insure the 20% coinsurance or some portion of the coinsurance. Part D coverage has to be bought separately. The benefits to this type of coverage is that it works all over the US with all doctors who accept Medicare and there are no referrals, networks, PCP's and pre-cert requirements beyond what Traditional Medicare requires. There are various plans to choose from, but the most comprehensive typically costs between $250-300 per month depending on Zip Code.

The Medicare Supplemental (Medigap) Open Enrollment time period is within the six months after you turn 65 and go on Medicare Part B. If you buy a plan during this time period, it's not subject to medical underwriting.

If you choose Medicare Supplemental (Medigap) at age 65 when you are first eligible, you can enroll with no medical underwriting. If you subsequently decide you want to switch to Medicare Advantage, you have one year to try it out and you can switch back to your old Medicare Supplemental plan if you don't like it.

If you are on Medicare Advantage, you can switch to traditional Medicare within 90 days of original enrollment. You can always switch back to traditional Medicare from Medicare Advantage during Open Enrollment periods.

I think the point that many folks are talking about here is that there is limited opportunity to buy Medicare Supplemental without medical underwriting if you don't choose it within the first six months of being eligible when you are 65. Unless you live in the four states (Connecticut, Maine, Massachusetts and New York) which don't require medical underwriting of Medicare Supplemental policies regardless of when you enroll.

[retiredguy123]

There are some terms which have been used interchangeably throughout this thread which are not necessarily interchangeable.

Traditional Medicare: This is standard Medicare, around since the mid-60's when the program was created. There is a Medicare Part B premium of $174.70 in 2024 that is deducted from your Social Security payment, or billed quarterly if you have not yet started taking Social Security. Traditional Medicare basically pays 80% of the Medicare fee after the deductible is met. There is no limit to the 20% patient responsibility.

Medicare Advantage: The government pays a private insurance company to provide your Medicare coverage. Plans often include extra benefits such as dental, gym benefits, and eye care not available from Traditional Medicare, and often for no additional premium beyond the $174.70 already being deducted. There is a limit on out of pocket costs. The plan can require you to have a PCP, referrals, and require you to stay in their network. They can also limit you to a specific service area for non-urgent/emergent care. Medicare Part D is almost always wrapped in as a pharmacy benefit.

Medicare Supplemental (Medigap): This is insurance sold by private insurance companies that pairs with Traditional Medicare to insure the 20% coinsurance or some portion of the coinsurance. Part D coverage has to be bought separately. The benefits to this type of coverage is that it works all over the US with all doctors who accept Medicare and there are no referrals, networks, PCP's and pre-cert requirements beyond what Traditional Medicare requires. There are various plans to choose from, but the most comprehensive typically costs between $250-300 per month depending on Zip Code.

The Medicare Supplemental (Medigap) Open Enrollment time period is within the six months after you turn 65 and go on Medicare Part B. If you buy a plan during this time period, it's not subject to medical underwriting.

If you choose Medicare Supplemental (Medigap) at age 65 when you are first eligible, you can enroll with no medical underwriting. If you subsequently decide you want to switch to Medicare Advantage, you have one year to try it out and you can switch back to your old Medicare Supplemental plan if you don't like it.

If you are on Medicare Advantage, you can switch to traditional Medicare within 90 days of original enrollment. You can always switch back to traditional Medicare from Medicare Advantage during Open Enrollment periods.

I think the point that many folks are talking about here is that there is limited opportunity to buy Medicare Supplemental without medical underwriting if you don't choose it within the first six months of being eligible when you are 65. Unless you live in the four states (Connecticut, Maine, Massachusetts and New York) which don't require medical underwriting of Medicare Supplemental policies regardless of when you enroll.
To clarify, the Traditional Medicare premium is not $174.70 for all enrollees. Depending in your income, it can be more than 3 times that amount for the exact same coverage.

[Carla B]

There are some terms which have been used interchangeably throughout this thread which are not necessarily interchangeable.

Traditional Medicare: This is standard Medicare, around since the mid-60's when the program was created. There is a Medicare Part B premium of $174.70 in 2024 that is deducted from your Social Security payment, or billed quarterly if you have not yet started taking Social Security. Traditional Medicare basically pays 80% of the Medicare fee after the deductible is met. There is no limit to the 20% patient responsibility.

Medicare Advantage: The government pays a private insurance company to provide your Medicare coverage. Plans often include extra benefits such as dental, gym benefits, and eye care not available from Traditional Medicare, and often for no additional premium beyond the $174.70 already being deducted. There is a limit on out of pocket costs. The plan can require you to have a PCP, referrals, and require you to stay in their network. They can also limit you to a specific service area for non-urgent/emergent care. Medicare Part D is almost always wrapped in as a pharmacy benefit.

Medicare Supplemental (Medigap): This is insurance sold by private insurance companies that pairs with Traditional Medicare to insure the 20% coinsurance or some portion of the coinsurance. Part D coverage has to be bought separately. The benefits to this type of coverage is that it works all over the US with all doctors who accept Medicare and there are no referrals, networks, PCP's and pre-cert requirements beyond what Traditional Medicare requires. There are various plans to choose from, but the most comprehensive typically costs between $250-300 per month depending on Zip Code.

The Medicare Supplemental (Medigap) Open Enrollment time period is within the six months after you turn 65 and go on Medicare Part B. If you buy a plan during this time period, it's not subject to medical underwriting.

If you choose Medicare Supplemental (Medigap) at age 65 when you are first eligible, you can enroll with no medical underwriting. If you subsequently decide you want to switch to Medicare Advantage, you have one year to try it out and you can switch back to your old Medicare Supplemental plan if you don't like it.

If you are on Medicare Advantage, you can switch to traditional Medicare within 90 days of original enrollment. You can always switch back to traditional Medicare from Medicare Advantage during Open Enrollment periods.

I think the point that many folks are talking about here is that there is limited opportunity to buy Medicare Supplemental without medical underwriting if you don't choose it within the first six months of being eligible when you are 65. Unless you live in the four states (Connecticut, Maine, Massachusetts and New York) which don't require medical underwriting of Medicare Supplemental policies regardless of when you enroll.

Good explanation. We gave up the IBEW program provided to my husband. In my case it was nine years after first becoming eligible for a Medicare supplement. Yes, we had to go underwriting, which consisted of six questions being answered satisfactorily.

[GoRedSox!]

To clarify, the Traditional Medicare premium is not $174.70 for all enrollees. Depending in your income, it can be more than 3 times that amount for the exact same coverage.This is correct. If you have a higher income, the Income-Related Monthly Adjustment Amount (IRMAA) may kick in. This applies to both the Medicare Parts A&B premium, and the Part D Prescription premium.

To determine if a surcharge is applied, Medicare looks the last income tax return provided by the IRS. They look at the Modified Adjusted Gross Income (MAGI), which is AGI plus tax-exempt interest. The first MAGI threshold where a surcharge kicks in is at $206,000 for couples filing jointly. The surcharge is $69.90. However, at $258,000, the surcharge is equal to the premium, $174.70. For singles, the threshold is half, so the increased premium starts at $103,000. The top surcharge is an additional $419.30 for couples over $750,000 and singles over $500,000.

I think that if I consistently had an income of $750,000 a year, I am ok with paying $594 a month for Medicare....however, it seems most of the complaints around IRMAA come from people who have a capital gain from the sale of stock or a house and that one event is what causes their monthly premiums to go up. Also, $129,000 for an individual is not really that huge of an income to trigger a doubling of the premium.

[tophcfa]

Interesting, since my Florida Blue MA plan has a MAXIMUM $2,400 out of pocket expense. Not much of a gamble.

Fair point. Everyone’s situation is different and their choices reflect that. However, not all MA plans are equal, especially if you have more than one home and travel extensively. You obviously did your research and selected one of the better ones, most likely not one of the little to no cost plans that offer free stuff to suck you in. We would possibly consider a plan like that if we had a single home, spent almost all our time in that one location, all our doctors participated in that network, and we had the patience to deal with referrals. The reason we strongly prefer a supplemental plan is because we split our time between two far away locations and hope to travel extensively throughout the country. Plus, all Supplemental plans in each lettered category are required to offer identical benefits. MA plans benefits can change each renewal period, making the selection process an annual event. For us, the Supplemental part G plan is ideal. It has a national network, no referrals, an annual deductible/max out of pocket of about $250, and the benefits from year to year are consistent. And after being on Obamacare since its inception, both the cost and benefits of a Supplemental plan are a great relative value.

Here is hoping neither of us will ever need to use our selected plans for anything more than wellness checks : )

[MX rider]

Fair point. Everyone’s situation is different and their choices reflect that. However, not all MA plans are equal, especially if you have more than one home and travel extensively. You obviously did your research and selected one of the better ones, most likely not one of the little to no cost plans that offer free stuff to suck you in. We would possibly consider a plan like that if we had a single home, spent almost all our time in that one location, all our doctors participated in that network, and we had the patience to deal with referrals. The reason we strongly prefer a supplemental plan is because we split our time between two far away locations and hope to travel extensively throughout the country. Plus, all Supplemental plans in each lettered category are required to offer identical benefits. MA plans benefits can change each renewal period, making the selection process an annual event. For us, the Supplemental part G plan is ideal. It has a national network, no referrals, an annual deductible/max out of pocket of about $250, and the benefits from year to year are consistent. And after being on Obamacare since its inception, both the cost and benefits of a Supplemental plan are a great relative value.

Here is hoping neither of us will ever need to use our selected plans for anything more than wellness checks : )

AARP UHC Advantage has a huge national network. No pre aprrovals needed and has an out of pocket max. We travel between 2 homes in Florida and Indiana. It works well for us and we use the wellness benifits.

[Blueblaze]

Is Medicare Advantage a failed experiment? No more than Medicare or "health" insurance in general.

The moment you expect insurance to pay for anything non-catastrophic, the wheels come off. Just like when people expect their home insurance to buy them a roof when the old one is still there, and then can't figure out why EVERYONE'S insurance quadrupled in three years. Medicare WILL go bankrupt -- and probably in our lifetime. There is simply not enough money in the Gooberment's magic money machine to pay all the crooks who got in line the moment the word got out about Uncle Sam's deep pockets.

My grandfather was insulin-dependent for the last half of his life. The only "health" insurance he ever had was original Medicare -- a pure catastrophic hospitalization policy that he couldn't have afforded on a Coleman lantern assembly line salary. It never paid a dime for his diabetes. Most of his life he had NO insurance. So he paid for his doctor out of pocket. And he bought his insulin out of pocket. And that was possible because everyone else was doing the same thing, so a doctor's visit was only about $5 in the 60's. And his insulin was pennies a day -- back when they had to slaughter pigs to get it, instead of merely growing it in a vat like they do today, using some eternally-patented process, that for some bogus reason costs 1,000 times more than extracting insulin from pig pancreases.

Even my own daughters' well-baby appointments were only $15, back in the '80's. That wasn't the insurance co-pay, because that farce hadn't been invented yet. $15 was the entire bill. My company only provided hospitalization, which only paid the catastrophic costs of a hospital stay, like for when they were born. It didn't pay for doctors, and therefore, doctors were affordable.

And then Blue Cross invented the "HMO", which paid for everything, so long as it was "in-network". And the wheels came off. By the time I retired, my copay was $35 per visit, and I was paying over $350/month for "health insurance", while my company picked up the rest of the tab -- $1200/month. Effectively, $18,000/year of my salary went to pay for health care BEFORE I EVER EVEN SAW A DOCTOR!

Then I retired, 3 years short of medicare, and was forced to go on Obamacare. Since I was considered "wealthy", I was stuck with the entire cost -- $12,000/year for a $10,000 deductible, which left me on the hook for $22,000, before "insurance" paid a dime for a catastrophe that never came. Well, except for the "free" $12,000 annual physical.

But glory be! I finally made it to 65 and government "Medicare Advantage" insurance, courtesy of some crooked insurance company that gets a big cut from the gooberment to tell me which doctors I can see and which drugs I can take. And it only costs us $500/month for the privilege -- at least until Medicare goes belly-up in 10 years.

Reagan was right. The most terrifying words in the English language are "I'm from the government and I'm here to help".

The 2nd most terrifying words are "I'm from the Insurance company..."

[GoRedSox!]

Is Medicare Advantage a failed experiment? No more than Medicare or "health" insurance in general.

The moment you expect insurance to pay for anything non-catastrophic, the wheels come off. Just like when people expect their home insurance to buy them a roof when the old one is still there, and then can't figure out why EVERYONE'S insurance quadrupled in three years. Medicare WILL go bankrupt -- and probably in our lifetime. There is simply not enough money in the Gooberment's magic money machine to pay all the crooks who got in line the moment the word got out about Uncle Sam's deep pockets.

My grandfather was insulin-dependent for the last half of his life. The only "health" insurance he ever had was original Medicare -- a pure catastrophic hospitalization policy that he couldn't have afforded on a Coleman lantern assembly line salary. It never paid a dime for his diabetes. Most of his life he had NO insurance. So he paid for his doctor out of pocket. And he bought his insulin out of pocket. And that was possible because everyone else was doing the same thing, so a doctor's visit was only about $5 in the 60's. And his insulin was pennies a day -- back when they had to slaughter pigs to get it, instead of merely growing it in a vat like they do today, using some eternally-patented process, that for some bogus reason costs 1,000 times more than extracting insulin from pig pancreases.

Even my own daughters' well-baby appointments were only $15, back in the '80's. That wasn't the insurance co-pay, because that farce hadn't been invented yet. $15 was the entire bill. My company only provided hospitalization, which only paid the catastrophic costs of a hospital stay, like for when they were born. It didn't pay for doctors, and therefore, doctors were affordable.

And then Blue Cross invented the "HMO", which paid for everything, so long as it was "in-network". And the wheels came off. By the time I retired, my copay was $35 per visit, and I was paying over $350/month for "health insurance", while my company picked up the rest of the tab -- $1200/month. Effectively, $18,000/year of my salary went to pay for health care BEFORE I EVER EVEN SAW A DOCTOR!

Then I retired, 3 years short of medicare, and was forced to go on Obamacare. Since I was considered "wealthy", I was stuck with the entire cost -- $12,000/year for a $10,000 deductible, which left me on the hook for $22,000, before "insurance" paid a dime for a catastrophe that never came. Well, except for the "free" $12,000 annual physical.

But glory be! I finally made it to 65 and government "Medicare Advantage" insurance, courtesy of some crooked insurance company that gets a big cut from the gooberment to tell me which doctors I can see and which drugs I can take. And it only costs us $500/month for the privilege -- at least until Medicare goes belly-up in 10 years.

Reagan was right. The most terrifying words in the English language are "I'm from the government and I'm here to help".

The 2nd most terrifying words are "I'm from the Insurance company..."I can agree with many of your points here, but five things really are responsible for the explosion of health care costs, in my opinion.

1. There are so many profit centers all over the American healthcare delivery system. It accounts for 1/6 of our entire economy. Many of these profit centers, including the insurance companies, are publicly traded corporations. When you have a fiduciary responsibility to shareholders, I don’t know how patients can be the number 1 priority.
2. Prescription drug costs are extremely high. We are one of the few countries in the world which allows direct marketing to patients. All those ads cost a lot of money.
3. We have a litigious society and the lawyers want their slice of the healthcare pie.
4. A very legitimate reason is we have added so many new treatments and technologies and it’s all very expensive. We didn’t have a heart transplant until the late 60’s. We didn’t have CT’s and MRI’s and many modern technology. It all comes at a cost.
5. 50% of all healthcare costs go to treat folks in the final year of life. Believe it or not, historically, this was not the case.

There are many more than this, but I think these are the top 5.

[dhdallas]

Some say that Medicare Advantage is a failed experiment. Patients get delayed & denied care, the taxpayers are paying mightily for the winners: the insurance company executives. They also say it should be discontinued or dramatically reformed.

MA was sold heavily to Congress by insurance company lobbyists on the basis that it would save money over traditional Medicare.

Is Medicare Advantage a Failed Experiment? Experts Debate - MedCity News (https://medcitynews.com/2023/10/medicare-advantage-seniors-failed-healthcare/)

I love my Medicare Advantage plan. I never wait for referrals, procedures, appointments, etc. and that is in both Florida and Pennsylvania.

[golfing eagles]

This is correct. If you have a higher income, the Income-Related Monthly Adjustment Amount (IRMAA) may kick in. This applies to both the Medicare Parts A&B premium, and the Part D Prescription premium.

To determine if a surcharge is applied, Medicare looks the last income tax return provided by the IRS. They look at the Modified Adjusted Gross Income (MAGI), which is AGI plus tax-exempt interest. The first MAGI threshold where a surcharge kicks in is at $206,000 for couples filing jointly. The surcharge is $69.90. However, at $258,000, the surcharge is equal to the premium, $174.70. For singles, the threshold is half, so the increased premium starts at $103,000. The top surcharge is an additional $419.30 for couples over $750,000 and singles over $500,000.

I think that if I consistently had an income of $750,000 a year, I am ok with paying $594 a month for Medicare....however, it seems most of the complaints around IRMAA come from people who have a capital gain from the sale of stock or a house and that one event is what causes their monthly premiums to go up. Also, $129,000 for an individual is not really that huge of an income to trigger a doubling of the premium.

Good post and 99% accurate. However, the IRMA "look back" at tax returns is 2 years, not 1. My wife worked right up to age 65 and was stuck paying double for those 2 years. What's even worse, even though she chose an advantage plan and therefore no part D coverage, the law required her to pay IRMA on part D----not a part D premium, just the IRMA. Just another example of Robin Hood wealth redistribution----well-hidden just like these "dual coverage" advantage plans that forgive the part B premiums and pay for groceries, utilities and rent-----punishing the successful and those that planned ahead by handing it over to others who suck off the gov't teat.

[Stu from NYC]

Good post and 99% accurate. However, the IRMA "look back" at tax returns is 2 years, not 1. My wife worked right up to age 65 and was stuck paying double for those 2 years. What's even worse, even though she chose an advantage plan and therefore no part D coverage, the law required her to pay IRMA on part D----not a part D premium, just the IRMA. Just another example of Robin Hood wealth redistribution----well-hidden just like these "dual coverage" advantage plans that forgive the part B premiums and pay for groceries, utilities and rent-----punishing the successful and those that planned ahead by handing it over to others who suck off the gov't teat.

True. We used to be a very independent people.

[golfing eagles]

True. We used to be a very independent people.

Yes I call it “euro trash contamination “😂😂😊

[retiredguy123]

Regarding IRMAA, how would you like to go to Best Buy to buy a television advertised for $2,000, but they charged you $6,000 because of your income?

[golfing eagles]

Regarding IRMAA, how would you like to go to Best Buy to buy a television advertised for $2,000, but they charged you $6,000 because of your income?

And do that so they can give 2 others a free tv

[GoRedSox!]

Good post and 99% accurate. However, the IRMA "look back" at tax returns is 2 years, not 1. My wife worked right up to age 65 and was stuck paying double for those 2 years. What's even worse, even though she chose an advantage plan and therefore no part D coverage, the law required her to pay IRMA on part D----not a part D premium, just the IRMA. Just another example of Robin Hood wealth redistribution----well-hidden just like these "dual coverage" advantage plans that forgive the part B premiums and pay for groceries, utilities and rent-----punishing the successful and those that planned ahead by handing it over to others who suck off the gov't teat.I think we are essentially saying the same thing, because the most recent tax information that is provided by the IRS is typically two years prior.

IRMAA can be appealed if the change in income is due to a life-changing event, the most common of which is retirement. So if income has dropped precipitously due to retirement, an IRMAA appeal may be successful. But one-time events that spike income for one year, such as a capital gain or ROTH IRA conversion or large withdrawal from an IRA are really not appealable.

I probably disagree somewhat on IRMAA, but I don't disagree entirely. If someone converts to a Roth IRA, their entire IRA is recognized as income, but they may not have taken a penny of it. The IRMAA premium increase could be very difficult for them to afford. I hope that most folks 63 and older are aware of this when they decide on a Roth conversion. I also think that the threshold of $103,000 for an individual is too low. But if a retiree has an income of $300k or more, I am ok with higher premiums because the trust fund is going to stop being able to pay full benefits soon and it is for the greater good. If my wife and I had a joint income of $258k in retirement, we would each have to pay an extra $174.70 for premiums or about $700 total, instead of $350. I am ok with that but I know not everyone is. It is redistribution but that's what a progressive tax code is by definition.

Currently, 7% of Medicare beneficiaries pay some IRMAA surcharge.

As an aside, I think the most unfair tax in America is the tax on Social Security income. For the first 50 years of Social Security, benefits were not subject to the income tax. Reagan changed that, gradually increasing the age for full retirement benefits to 67, and taxing Social Security for the first time. But the thresholds were not indexed to inflation, and are the same today as they were over 40 years ago. In 1985, only 9% of Social Security recipients paid income tax on their benefits, today, it's approaching 60% if not more by now, and especially with inflation, more and more ordinary taxpayers are paying income taxes on up to 85% of their benefits.

[golfing eagles]

I think we are essentially saying the same thing, because the most recent tax information that is provided by the IRS is typically two years prior.

IRMAA can be appealed if the change in income is due to a life-changing event, the most common of which is retirement. So if income has dropped precipitously due to retirement, an IRMAA appeal may be successful. But one-time events that spike income for one year, such as a capital gain or ROTH IRA conversion or large withdrawal from an IRA are really not appealable.

I probably disagree somewhat on IRMAA, but I don't disagree entirely. If someone converts to a Roth IRA, their entire IRA is recognized as income, but they may not have taken a penny of it. The IRMAA premium increase could be very difficult for them to afford. I hope that most folks 63 and older are aware of this when they decide on a Roth conversion. I also think that the threshold of $103,000 for an individual is too low. But if a retiree has an income of $300k or more, I am ok with higher premiums because the trust fund is going to stop being able to pay full benefits soon and it is for the greater good. If my wife and I had a joint income of $258k in retirement, we would each have to pay an extra $174.70 for premiums or about $700 total, instead of $350. I am ok with that but I know not everyone is. It is redistribution but that's what a progressive tax code is by definition.

Currently, 7% of Medicare beneficiaries pay some IRMAA surcharge.

As an aside, I think the most unfair tax in America is the tax on Social Security income. For the first 50 years of Social Security, benefits were not subject to the income tax. Reagan changed that, gradually increasing the age for full retirement benefits to 67, and taxing Social Security for the first time. But the thresholds were not indexed to inflation, and are the same today as they were over 40 years ago. In 1985, only 9% of Social Security recipients paid income tax on their benefits, today, it's approaching 60% if not more by now, and especially with inflation, more and more ordinary taxpayers are paying income taxes on up to 85% of their benefits.

I agree. And here is something more unfair: If you are self-employed, you pay 6.4 % SS tax up to whatever the current limit is, and 1.25% Medicare tax, no limit on income. But you pay DOUBLE that since you are your own employer, 15.3% off the top. But wait, there's more-----you pay income tax on that 15.3% that you never see!!!!!! Yes kiddies, that's right. Let's say you made 100,000. You pay 15,300 in FICA, then income tax on the full 100K. DOUBLE TAXATION!!!!! Robin Hood strikes again.

[biker1]

If you are self employed, you get to deduct half of the self employment tax (aka FICA). That makes it essentially the same as if you worked for a company as they would be able to deduct their portion of FICA as a business expense.

I agree. And here is something more unfair: If you are self-employed, you pay 6.4 % SS tax up to whatever the current limit is, and 1.25% Medicare tax, no limit on income. But you pay DOUBLE that since you are your own employer, 15.3% off the top. But wait, there's more-----you pay income tax on that 15.3% that you never see!!!!!! Yes kiddies, that's right. Let's say you made 100,000. You pay 15,300 in FICA, then income tax on the full 100K. DOUBLE TAXATION!!!!! Robin Hood strikes again.

[Topspinmo]

you speak the Truth .... finally someone who remembers

1 out of hundreds of thousands.

[Topspinmo]

I agree. And here is something more unfair: If you are self-employed, you pay 6.4 % SS tax up to whatever the current limit is, and 1.25% Medicare tax, no limit on income. But you pay DOUBLE that since you are your own employer, 15.3% off the top. But wait, there's more-----you pay income tax on that 15.3% that you never see!!!!!! Yes kiddies, that's right. Let's say you made 100,000. You pay 15,300 in FICA, then income tax on the full 100K. DOUBLE TAXATION!!!!! Robin Hood strikes again.

Refer back to who makes laws? Lawyers so NO matter what they get paid. Winning or losing has nothing to do with it. It all about lawyers welfare program.

[golfing eagles]

If you are self employed, you get to deduct half of the self employment tax (aka FICA). That makes it essentially the same as if you worked for a company as they would be able to deduct their portion of FICA as a business expense.

Hardly. Let’s say your employer half is $10,000. You spend $10,000 and get about $4,000 as a tax savings

[biker1]

The point is what you stated is not correct. Yes, it could be better but not bad as you stated.

Hardly. Let’s say your employer half is $10,000. You spend $10,000 and get about $4,000 as a tax savings

[golfing eagles]

The point is what you stated is not correct. Yes, it could be better but not bad as you stated.

Correct

[keepsake]

I might as well vent here ...

The wife and I have had Devoted PPO for a few years. We decided to use the Wellness Bucks benefit and Devoted scammed us out of reimbursement. We spent nearly $550 that we wouldn't have spent if we knew Devoted was going to scam us.

[CoachKandSportsguy]

I might as well vent here ...

The wife and I have had Devoted PPO for a few years. We decided to use the Wellness Bucks benefit and Devoted scammed us out of reimbursement. We spent nearly $550 that we wouldn't have spent if we knew Devoted was going to scam us.

The whole article is behind a paywall, but there is enough visible to get the sense that private MA is a money losing proposition without scale. That means that the only players which will remain are large, national level insurance providers. . . but large profitable means profit motive conflicts with customer service in health insurance. . . in either price or service or both.

Devoted Health’s losses in Medicare Advantage persist (https://www.statnews.com/2024/02/05/devoted-health-losses-medicare-advantage/)

[GoRedSox!]

The whole article is behind a paywall, but there is enough visible to get the sense that private MA is a money losing proposition without scale. That means that the only players which will remain are large, national level insurance providers. . . but large profitable means profit motive conflicts with customer service in health insurance. . . in either price or service or both.

Devoted Health’s losses in Medicare Advantage persist (https://www.statnews.com/2024/02/05/devoted-health-losses-medicare-advantage/)I don't think that large, for-profit national health insurers are evil. But we have to accept what the American healthcare delivery system is. It is filled with profit centers at multiple points throughout the process. Big Pharma is in there as well, with all the direct-to-consumer marketing. The health insurers keep getting bigger and bigger, and competition lessens.

It is what it is. Since publicly traded companies have a fiduciary responsibility to shareholders, it's hard to argue that the patient is the first priority.

[golfing eagles]

I might as well vent here ...

The wife and I have had Devoted PPO for a few years. We decided to use the Wellness Bucks benefit and Devoted scammed us out of reimbursement. We spent nearly $550 that we wouldn't have spent if we knew Devoted was going to scam us.

They scammed you????? "They" SCAMMED you?????

Gee, I wish I had set up and insurance company----seed money, venture capital, infrastructure and employees, jumped through a zillion regulatory hoops to "scam" you out of $550.

Are you sure you didn't mean "deny us a benefit we felt we were owed" rather than "scam"?????

[CoachKandSportsguy]

I don't think that large, for-profit national health insurers are evil. But we have to accept what the American healthcare delivery system is. It is filled with profit centers at multiple points throughout the process. Big Pharma is in there as well, with all the direct-to-consumer marketing. The health insurers keep getting bigger and bigger, and competition lessens.

It is what it is. Since publicly traded companies have a fiduciary responsibility to shareholders, it's hard to argue that the patient is the first priority.


What's evil is that the procedure rates / expected costs are unpublished. Like drugs at the pharmacy, the cash price might be lower than the insurance price, due to profit requirements. The cash price might also be discounted for same day pay to eliminate billing costs. Now, part of that is the complexity and uniqueness of each event, and part of is that each insurance company has contracted rates and coverages. However, that is just a math problem from the hospital's point of view. They can blend rates, they can average out procedures and normalize, and use statistics for standard deviations, etc.

The other evil part is that there are two classes of payers, the US government, and private insurers. From a hospital profitability point of view, and profitability means profits to invest in better outcomes, the US govt contracts the lowest margin / losing rates, and the private insurance has to make up the remaining difference. When payers such as UHC wants to contract rates lower than the US govt. . the hospitals can't repay both their employees and bonds and interest on their bonds. . . ie they go bankrupt. .

When UHC had a virus and caused physicians not to be able to bill and get reimbursed timely, UHC offered the physicians' offices LOANS with INTEREST . . . umm . . . that's evil. . .

monopolies are good if they are regulated with an oversite body representing the public.
oligopolies are better, as they try poaching customers from the others. .
competition is the best, but what good for the consumer is not great for companies and investment returns. . . that's the trap door of competition -> it all works great until one company reaches the ultimate corporate end goal -> MONOPOLY STATUS

Should health insurance be a utility financial model, with a limiting cap on profitability for the benefit of the population?

[GoRedSox!]

I have been out of this game for 4 years (happily retired). I did read about the data breach/ransom and that loans were made to doctors. I do not know the details around that, but many states have prompt pay laws that require electronic claims to be paid within 30 days. In NY, the interest rate was 12%. CT was 15%. NJ was 12%. These rates were high enough to motivate the insurers to pay timely. Also, all states could impose prompt pay fines on top of the interest. I think that CMS requires interest on late payment of Medicare claims by Medicare Advantage providers as well.

[collie1228]

Ten years on Careplus Medicare Advantage and I'm a big fan.

[Marathon Man]

Some say that Medicare Advantage is a failed experiment. Patients get delayed & denied care, the taxpayers are paying mightily for the winners: the insurance company executives. They also say it should be discontinued or dramatically reformed.

MA was sold heavily to Congress by insurance company lobbyists on the basis that it would save money over traditional Medicare.

Is Medicare Advantage a Failed Experiment? Experts Debate - MedCity News (https://medcitynews.com/2023/10/medicare-advantage-seniors-failed-healthcare/)

Such as???