[retiredguy123]

Originally Posted by nn0wheremann

All Medicare claim processing is done by private sector contractors. Some Federal workers do audits and policy work, and initial application to determine entitlement.

The claim processing may be done by private companies, but, they don't have the same profit motive to reduce fraudulent claims like the companies who operate the advantage plans on a per capita basis. And, they have no incentive to reduce the number of claims submitted by Medicare providers. Also, if a patient has a zero copay, they have no incentive to seek out cost effective treatments.

[Joeint]

Originally Posted by skyking

???? You have no idea how Medicare Advantage works.

1. They are paid a monthly per Capita amount not per service billed.
2. The plans do not maintain medical records. The contracted providers do.
3. If the plans are paid a fixed amount (based on age and sex of the beneficiary) they have no incentive to "provide unnecessary services" or medications.
4. Plans are typically paid 95% or less of average cost per beneficiary in the county of residence.

There is so much over utilization in healthcare that they can provide free extra benefits by managing utilization and quality.

Maybe I don't have any idea how Advantage plans work. I did a search on Medicare Advantage fraud it directed me to the CMS.gov website, it shows that each point I made is given as an example of fraud.

[mtdjed]

Originally Posted by MidWestIA

Only if there are not many massive med bills -

The government pays Medicare Advantage plans a set rate per person, per year (around $12,000 in 2019, not including Part D–related expenses) under what is called a “risk-based” contract. That means that each plan agrees to assume the full risk of providing all care for that inclusive amount.

Why Medicare Advantage costs taxpayers billions more than it should – Center for Public Integrity

There seems to be a further factor included into the meaning of "risk based" contract and the set rate per person? Refer you to the article above which adds a further definition of "Risk Based" and how the government pays the set rate. While the contracted MA Plan assumes full risk of providing all care for those persons insured, there appears to be a "Risk Factor" negotiated by the contractor and CMS regarding the severity of needs of the pool of covered personnel.

Excerpt from cited article.

"Risk score:
Since 2004, CMS has paid Medicare Advantage plans based on a risk score that is supposed to assess the overall health of each patient. Medicare pays higher rates for sicker patients that are likely to require more costly medical services and less for healthy people."

This Risk Factor negotiation has been a topic cited as a source of potential abuse of the MA plans.

[TedfromGA]

When you think about gov't and related costs for any gov't program you just have to wonder....

I've been to the CMS headquarters (7500 Security Boulevard, Baltimore, MD 21244). It is massive - 3 huge multi floor buildings full of people. You have got to wonder what they all do!

If you could gather all the real estate and people asssociated with administrating CMS it would be mind blowing - you might conclude their must be a better way....

[MSGirl]

Originally Posted by Happydaz

I was taking with a friend today and I had mentioned that Advantage plans cost the Medicare program more per patient than regular Medicare. He was very surprised to hear that since Advantage plans were originally developed to save money as regular Medicare costs were at that time increasing at a rapid rate. These Advantage plans were supposed to save the Medicare fund money by having drug choice restrictions, physician choice restrictions, specialist access restrictions, etc. Unfortunately, due to bonus payments and other unseen costs the average Advantage patient costs Medicare $321 more than a regular Medicare part B patient!

Where can we find this information?

[MSGirl]

Originally Posted by mtdjed

I thank you for bringing this topic to attention. I did a Google search and found an interesting article which describes the process. As any article could be subject to being biased and incorrect, one must be suspect to the article and to interpretation. The article is on this link.

Why Medicare Advantage costs taxpayers billions more than it should – Center for Public Integrity

So, my simplistic interpretation is "Fraud", not by users or providers, but rather by the Medicare Advantage Programs providing the networks. Apparently, the initial program was meant to eliminate fraud by individual claims and this program was conjured up to eliminate that. Seems that the original program was a one cost covers all and some Advantage programs cherrypicked participants to sign up only the healthiest to minimize costs. The program was then changed to add a risk factor for severity of participants needs. Supposedly, that has been abused by some Advantage programs by getting higher funding for participants with higher risks.

Seems that the other benefits offered such as freebies are not the driver since they are not covered by Medicare.

Again, this is my interpretation of the article (which may or may not be true). I would expect the normal on line experts will be around to correct my interpretation and the source that I found.

I am not a user of Medicare Advantage. I have original Medicare and a Supplement program which also now pays for Gym membership. Supplement payment is now about $160/Month. Gym membership was $55/Month and now is free, covered by the Supplement which is still $160 / Month. Hmm! Wonder where that extra $55 came from. Maybe the theory is that I am heathier and require less medical care

Which Supplemental plan do you have? My mother had Plan F, which cost her close to $300 per month. Do you also have Part D ( the drug plan) ? What do you pay for that? Do you have a supplemental dental and optical plan as well?

[Happydaz]

Originally Posted by MSGirl

Where can we find this information?

See post #31. The topic is the comparison of the actual total cost of Advantage Plans compared to traditional Medicare to the Medicare program, not the nominal cost an individual has to pay out of pocket for co pays and premiums, etc..

[retiredguy123]

Originally Posted by TedfromGA

When you think about gov't and related costs for any gov't program you just have to wonder....

I've been to the CMS headquarters (7500 Security Boulevard, Baltimore, MD 21244). It is massive - 3 huge multi floor buildings full of people. You have got to wonder what they all do!

If you could gather all the real estate and people asssociated with administrating CMS it would be mind blowing - you might conclude their must be a better way....

LOL. No need to wonder. They are wasting your money. I have been there also, and the parking lot is so huge, that you may need to call a taxi to get from your car to the building. I once had a Government benefits approval expert tell me that they actually trained their employees with the motto "When in doubt, shell it out".

[justjim]

Ask Mr. Google salary of CEO of United Health Care - 12.8 million. UHC profits were 17.3 billion. These insurance companies make money on Medicare or they wouldn’t be in the business. Capitalism at its best.

[Quixote]

Originally Posted by MSGirl

Which Supplemental plan do you have? My mother had Plan F, which cost her close to $300 per month. Do you also have Part D ( the drug plan) ? What do you pay for that? Do you have a supplemental dental and optical plan as well?

There is a crucially important point here which some (many?) of us are not aware of. I wasn't until our former employer chose to go out of the 'health care for retirees' business.

(Aside: Can an employer really do that? Evidently, because our employer did. We were left with a buyout plus dental and vision benefits. And why? Because these were union negotiated benefits! Think about that....)

Suddenly the choice of Medicare Supplement plan or Advantage plan was dropped in our laps. That was when we discovered—and this is the part that's crucially important—that insurance companies can charge whatever they wish for coverage in, as in the quote above, Plan F, but the reality is that Plan F is Plan F!

The benefits of the different Supplement plans are negotiated between the insurance compnuhj Medicare, and the benefits of every Plan F are identical to the benefits of every other Plan F! (Same, of course, for all the other Medicare Supplement plans. When we retirees had to take over, we found that our employer had us all in a Mutual of Omaha Medicare Supplement plan, which cost almost exactly $100 more per month than the Supplement plan identical in every way sponsored by United HealthCare!

[kathyspear]

Originally Posted by MSGirl

Which Supplemental plan do you have? My mother had Plan F, which cost her close to $300 per month. Do you also have Part D ( the drug plan) ? What do you pay for that? Do you have a supplemental dental and optical plan as well?

One factor in setting the premium is the age at which the plan was initiated. I (stupidly) stayed on hubby's work insurance until I was 68 or 69. I pay about $200 per month for Florida Blue plan G. It would be less if I had signed up at 65.

FWIW, switching to traditional Medicare and FL Blue was a great move for me. I have had significant medical bills this year and have paid nothing out of pocket other than my plan G deductible which is about $200 per year.

k.

[Hardlyworking]

Originally Posted by kathyspear

One factor in setting the premium is the age at which the plan was initiated. I (stupidly) stayed on hubby's work insurance until I was 68 or 69. I pay about $200 per month for Florida Blue plan G. It would be less if I had signed up at 65.

FWIW, switching to traditional Medicare and FL Blue was a great move for me. I have had significant medical bills this year and have paid nothing out of pocket other than my plan G deductible which is about $200 per year.

k.

So, $2600 then. Not bad. Did you have any issues getting through underwriting?

[kathyspear]

Originally Posted by Hardlyworking

So, $2600 then. Not bad. Did you have any issues getting through underwriting?

Not that I recall. I signed up for FL Blue when I signed up for Medicare Part B. I did it online and I don’t recall what all they asked me. Maybe underwriting doesn’t apply if you sign up for both at the same time even if you are older than 65. I don’t know.

k.

[Hardlyworking]

Originally Posted by kathyspear

Not that I recall. I signed up for FL Blue when I signed up for Medicare Part B. I did it online and I don’t recall what all they asked me. Maybe underwriting doesn’t apply if you sign up for both at the same time even if you are older than 65. I don’t know.

k.

If you signed up before 65 1/2 you were in a guaranteed issue time period.

[M2inOR]

We were in an HMO for most of our working years, Kaiser Permanente. Thru our employers, Kaiser provided our healthcare and prescriptions, for a monthly fee, and co-pays when there were office visits, procedures, or hospitalization.

We were very happy. Thankful for our good health.

When we retired and moved to The Villages, we looked at traditional Medicare with Supplemental, as well as Medicare Advantage plans, choosing the latter, as Villages Health seemed quite like what are Jasper experience has been. No need to search for doctors when something required attention. Our PCP took care of things or referred us to a specialist if needed.

While premiums and co-pays are quite low, they monthly total cost is determined by income. The amount paid to CMS can get larger due to IRMAA. Your monthly Part B payment to CMS is based on your 1040 income.

For regular healthcare, you must use services provided in your service area.

Emergency or Urgent Care is covered across the US. Foreign coverage is not included, so consider paying out of pocket, or separate travel insurance.

We are happy so far with Villages Health and United Healthcare.

And yes, UHC/Villages Health DOES get a fixed amount from CMS regardless of how much healthcare we get each year. They are also reimbursed for certain things over and above that annual payment. They are also rewarded with incentives for keeping patients healthy.