[Altavia]

A friend was devastated when her Advantage Plan dumped her Doc and hospital half way through her chemo treatments and she was forced to walk away from people she trusted to find new care.

[lawgolfer]

This post gives another reason to not enroll in an Advantage plan.

It's easy to be taken in by the TV ads put out by Advantage plans. Everyone wants "free things". You will get a gym membership, a small allowance for dental care and, sometimes, money back.

However, when "the rubber meets the road", Advantage plans are lacking. You will be limited to the doctors and medical groups in the Advantage plan. That seems O.K. until you want to be treated by a particular specialist. The plan will have to provide you with a doctor in the particular speciality you need. However, you have little control over which specialist. If you go to a doctor outside the plan, you will have a fight with the Advantage plan and will have a large co-pay which quickly eats up any savings you made by enrolling in the plan.

In contrast, regular Medicare allows you to be treated by any doctor in a needed specialty who will accept Medicare as payment in full. In The Villages, this means nearly every doctor. It also means that if you want to return to the specialist in your home town who treated you before you moved to TV, you can do so, provided you pay your travel expenses. In effect, you can go to most every doctor anywhere in the country except for the Mayo Clinic which will not accept Medicare. Regular Medicare is one of the best insurance plans available, and, is a relative bargain compared to the benefits it provides.

Before enrolling in an Advantage plan, think long and hard about being starting over with a new specialist, an oncologist or cardiologist, with whom you are not familiar, or returning to the one who has successfully treated you for years.

[Vermilion Villager]

Originally Posted by retiredguy123

An advantage plan is Medicare Part C. It replaces and covers most things that Part B (doctor visits and surgery) and Part D (drugs) cover. Part A is hospitalization.

As Paul Harvey used to say "and now you know the rest of the story"
Why do you think you see all of these Medicare part C plan commercials… And where do you think the money comes from to pay for all of these commercials you see? It's because they are extremely profitable to the insurance company… At the expense of you.
As an investor I have seen their business model. they put a tremendous amount of money into advertisement with the sole purpose of getting as many people on the plan as they can. They then package these as investment portfolios that are bought and sold.
They make it sound very lucrative to the potential buyer of the insurance. They exploit the notion many older people especially those of conservative ilk believe that the government is bad and private industry is good.
These Medicare part C plans everybody seems to think is such a great deal because they have been duped into thinking it saves them so much money. Actually is a borderline scam. They are not concerned at all that physicians will not take them because that is not what they're about. They are all about getting money from you and then turning around and providing the most restrictive coverages they can.

[mrf0151]

Originally Posted by jswirs

Just recently my PCP cancelled my appointments because it was decided that patients with my particular Medicare Advantage Plan are no longer being accepted, unless I pay "out of pocket" cost. (For personal and financial reasons I decided not to pay "out of pocket"). This information was not given to me until I called the office one week before my appointment.
I understand a doctor's decision to do this, however, I was not informed by my insurance people, Medicare, or my doctor's office. If I did not happen to call the office I would have shown up for an appointment that no longer existed.
I know I am not the only person this has happened to, so, my question is: "Why can't the doctor's office inform patients when the decision is made to drop those patients who have a particular insurance plan?"
I was told that the responsibility to do this falls on the insurance company. But the insurance company may have tens of thousands of people on their books, leaving the possibility of overlooking someone.
The way I see it, if a doctor can confirm every appointment by texting, why couldn't a simple "FYI" text be sent to patients when their appointments are cancelled because of an insurance decision? (There are some states that require a doctor's office to inform patients with a 60 day notice before any existing appointments are cancelled.)
I know there are a few MD's, as well as insurance folks, on this forum, and I thank them and anyone else who may reply.

Just another case in point to have a Medicare (Supplement ) Plan like F or G where you have freedom to choose any and all doctors, and are not limited to a small pool of doctors in the Medicare ( Disadvantage ) Plan.

[Notsocrates]

Originally Posted by jswirs

I thank you for your reply, but, as I stated previously, my doctor cancelled my appointments, meaning, I no longer had those appointments. WITHOUT any notification from anyone.
Also, as I previously stated, for personal and financial reasons, I decided NOT to pay out of pocket.

If they cancelled, they have an obligation to inform you just as you do if you cancel.

[jswirs]

Originally Posted by thevillages2013

Your appointment was not canceled you were given the opportunity to pay outside the insurance coverage

I'm sorry but I must correct your statement. I'm not sure who you are to speak with such certainty, and while I have due respect for all who may reply to my post, I must tell you that you are incorrect. My appointments were no longer on the books...or...at least that is what I was told.

[Villages Kahuna]

Every Medicare Advantage Plan has well-publicized co-pay amounts for appointments or procedures provided by doctors or specialists. Usually your appointments with your primary care doctor is free, as long as he is “in network” for your insurance plan. There is always a co-pay for appointments with specialists. But there is also a maximum out-of-pocket amount which caps what you might have to pay each year.

All this information is published and available to people before they sign up for a plan. If you didn’t investigate whether your doctors were in network or out of network, or what the co-pays were, the cause of the problem is your failure to do the research.

But all is not lost. It is never publicized, but Medicare members can change their choice of plans during January through March each year. You are not limited to just the November to early December sign-up period. So you still have almost an entire month to change plans if you so choose. You would be well-served to visit an insurance broker—one not affiliated with a particular company—to have the costs and benefits of various plans explained to you. I’d start with one of The Villages insurance offices. But ask to see a broker. Otherwise you are almost certain to get an agent for United Healthcare.

[Villages Kahuna]

OP says “… In effect, you can go to most every doctor anywhere in the country except for the Mayo Clinic which will not accept Medicare.…”

This is incorrect. There are quite a number of doctors and hospitals, including most of the very best in the country, which do not accept any of the Medicare plans. Even The Villages Health only accepts the Medicare Advantage plans offered by United Healthcare, Florida Blue and Humana if you are Medicare-eligible.

[Roron123]

Originally Posted by villagetinker

OP, very sorry this happened to you, and this is one (of many) reasons that we choose to stay with Medicare and supplemental plan. We were on advantage plan for a short period when Villages Health decided to stop grandfathering of supplemental plans. We had some problems and were able to get back to supplemental WITHOUT the underwriting requirement. We will never go back to an advantage plan.

Yes totally agree! On Advantage plans you can only go to Drs on that plan and hospitals that are on that plan you cannot choose out of their list! I went back to Medicare and UHC because of that reason as I had to travel in order to get certain tests and could not stay with my Cardiologist!

As an Administrator of medical practice for over 25 years I would have my staff call the patients on that plan and give them an option of ash or leave!

[Rickanvic]

If you are required to have a primary care physician, the insurance company would be required to notify you that you need to select a new provider. Otherwise, in our office, we only check benefits a few days before the appointment. Benefits can change on a monthly basis. Patients change appointments all the time. We will check your benefits 3 to 4 days before your appointment. We will then call you to discuss if somthing has changed with your coverage.

[retiredguy123]

Note that Medicare Advantage plans are run by private companies that have a profit motive. So, they can maximize their profit by screening out providers based on how many claims and the types of claims they submit. And, that is why they require patient copays. Also, they have an incentive to prevent fraudulent claims and wasteful claims.

By contrast, Original Medicare is run by a bureaucratic Federal Government agency that has no profit motive. They have no incentive to reduce costs by screening out any providers, regardless of how many claims they submit. With a Supplement plan, the patient can avoid copays. And, they make very little effort to prevent fraudulent and wasteful claims.

Just my observation. I don't know which system is better for the patient, but I think the Advantage model makes more sense for the taxpayers.

[Villages Kahuna]

What you described is perfectly legal. You aren’t being prevented from seeing your PCP, as a Medicare participant he must see you and treat you. Medicare will pay for 80% of his normal and customary charges. What’s changed is that you must pay for 20% of his charges instead of some form of Medicare supplemental insurance.

[retiredguy123]

Originally Posted by Villages Kahuna

What you described is perfectly legal. You aren’t being prevented from seeing your PCP, as a Medicare participant he must see you and treat you. Medicare will pay for 80% of his normal and customary charges. What’s changed is that you must pay for 20% of his charges instead of some form of Medicare supplemental insurance.

I'm confused. Are you saying that the OP can take advantage of the Original Medicare Part B insurance even though he does not have Medicare Part B insurance? I don't think that is the way it works. The out-of-network doctor may be limited in the amount he can charge the OP, but I don't think the OP can benefit from both Medicare Advantage and Original Medicare at the same time. If he has an Advantage plan (Part C), I don't think he will get the 80 percent Part B reimbursement. He would need to pay the full Medicare amount to the doctor.

[nevjudbaker]

Originally Posted by jswirs

Just recently my PCP cancelled my appointments because it was decided that patients with my particular Medicare Advantage Plan are no longer being accepted, unless I pay "out of pocket" cost. (For personal and financial reasons I decided not to pay "out of pocket"). This information was not given to me until I called the office one week before my appointment.
I understand a doctor's decision to do this, however, I was not informed by my insurance people, Medicare, or my doctor's office. If I did not happen to call the office I would have shown up for an appointment that no longer existed.
I know I am not the only person this has happened to, so, my question is: "Why can't the doctor's office inform patients when the decision is made to drop those patients who have a particular insurance plan?"
I was told that the responsibility to do this falls on the insurance company. But the insurance company may have tens of thousands of people on their books, leaving the possibility of overlooking someone.
The way I see it, if a doctor can confirm every appointment by texting, why couldn't a simple "FYI" text be sent to patients when their appointments are cancelled because of an insurance decision? (There are some states that require a doctor's office to inform patients with a 60 day notice before any existing appointments are cancelled.)
I know there are a few MD's, as well as insurance folks, on this forum, and I thank them and anyone else who may reply.

This happened to me in Jacksonville. The specialist stopped taking United Health. They didn’t tell me until I arrived at the appointment. They called me two days prior to confirm my appointment & never informed me they no longer took my insurance. I drove 10 miles to this doctor in heavy traffic. I was furious.
I wasn’t disappointed losing the doctor. I didn’t like him. I found a great specialist who really helped me. I sometimes wonder if our insurance didn’t cancel him.

[rustyp]

So much misinformation here about advantage plans. One type of advantage plan is a PPO. In my opinion much more flexible than an Advantage HMO plan.The Villages Health Care accepts this plan. Here is a link to a one page synopsis by Medicare.gov that will educate you about choice of doctors, specialists, etc.


Preferred Provider Organization (PPO) | Medicare

1 FYI when you do your analysis don't forget to multiply your supplemental premium by 12 and then compare to your advantage plans out of pocket max.
2 No one is guaranteed their doctors will continue to accept any plan including straight forward Medicare.
3 If you need some world renown specialist at our ages your close to cashing in your chips. In today's electronic communication age most doctors and organizations are up to date on gold standards. For me it's quality of life (including the burden I may submit my family to) Vs quantity.