Dr resorting to Name and Shame
 

Sux when you need it

Sux for a while after you have it done as well.

And yet people swear that the Medicare Advantage Plan is excellent. That because they haven't needed great care yet.

That is why I have UHC TV Advantage plan - have never had anything denied - and we have had A LOT done.

We’ve had a Florida Blue Advantage Plan for many tears. My wife has had stomach cancer surgery, a knee replacement and two hip replacements that were all easily approved, and with our PPO were able to get the facility and Dr’s she wanted. I’d consider that needed great care that was fulfilled.

You have to wonder how folks on an Advantage Plan, think it's great medical care, when the Insurance companies are offering so many incentives for folks to sign up. If it was any good, would they be offering all those "Freebies"?

I personally believe the plan is there to get the majority of seniors to fall for the advantage plan then state they are closing out original medicare and putting everyone on private insurance plans like advantage.

All those great coverages from advantage plan earlier years will be diminished or disappear and we will all be fighting the insurance companies for treatment or sub care. I personally believe it's in the works. Why else are they spamming us with those **** ads from August to December. Some providers are already refusing Advantage patients due to treatment restrictions.

To me, it kinda feels like someone offering to rake your lawn for nothing while you watch. In the interim, they have someone sneaking in the backdoor to rob you.

You never had anything denied, but how many things were never suggested or requested because the doc knew they would not be approved.

Did you have home care after all surgeries? Did you have PT after all injuries or surgeries? Were you given high quality, latest version of durable med equipment?

After knee replacement did you have to pay for the ice machine, the walker, the toilet riser?

These are things that some advantage plans deny.

You don’t know what you don’t know.

That’s my fear. If that happens, hopefully people already signed up for original Medicare, with a supplemental plan, will be grandfathered in for life?

Medicare Advantage vs Supplement
 

I like my Medicare Advantage plan.

Wifey will turn 65 in a few months and surprisingly got info in the mail from SS, including a roughly 12 page booklet describing what's what.
Jealous, I never got a booklet, I read it from cover to cover.
To my surprise, they were selling the reader on choosing a Medicare Advantage plan.

I wonder what all those 60,000 SS employees are gonna do when they no longer have to process payments ?
All work from home in their pajamas ?

when the for profit sector is involved, its all about profits, and sales for profit growth. When one profits from profit growth, its all about profits. When one gets fleeced for profits, its not so fun.

What good for profits is not good for customers/employees at times, what's good for customers/employees is not good for profits. . oldest cake and eating it too dilemma/enigma/conundrum

No, all those SS employees will be working for the private insurance industry squeezing every nickel your "wifey" needs for healthcare.

Makes me think of the old saying, "there are none so blind as those who will not see.."

I'm not sure what the long range goal is, but the cost to the government is about 6% more for Advantage Plans, over traditional Medicare ... all of which goes to the Insurance Companies. I guess that's an improvement, it was 17% more expensive, 15 years ago.

Advantage plans are not the same in different states
 

I have an advantage plan with BCBSNC and have had both knees done, back surgery, bunion surgery and currently scheduled for shoulder replacement. Nothing has ever been denied. Only $45 a month too! $20 Copay for specialist.

It’s an Aetna “thing.” I was still working and was covered by Aetna in 2020 and needed a hip replacement and was denied — bone on bone with 3 spurs. They demanded PT, which will do nothing for a non-regenerative situation. Took 2 attempts, but finally got approval. In 2021, same insurance coverage, my husband also needed a hip replacement. Again, denied by Aetna and demanded PT coverage. An appeal with a letter from a PT stating that therapy wouldn’t help the situation finally got the surgery. Our surgeon said that Aetna is one of the worst companies to get approval from. They will eventually approve.

Perhaps there's a good reason that Villages Health only accepts UHC, Florida Blue, and Humana Medicare Advantage plans.

They do NOT accept Aetna.

I've had Kaiser Permanente HMO for my entire working career, as had my wife. Always good care. First year of retirement, too before moving to The Villages. KP is also a non-profit healthcare provider.

Not all providers are for-profit.

Medicare Advantage providers are provided with an annual stipend for each person enrolled. Companies like UHC pass a sizeable portion of that annual stipend to providers like Villages Health. This provides a baseline funding for each person. Claims for procedures and tests provide additional funding to cover costs of providing care.

Yes, UHC is a for-profit insurer. That alone does not make it bad. And yes, in some states UHC has had issues.

If you are active and healthy, Medicare Advantage plan, and Villages Health could be a good fit for you.

Note well, with traditional Medicare, you may not be able to find a PCP and specialists that are accepting new Medicare patients.

What I like about Villages Health is that my PCP and her team are excellent. We've also seen specialists without waiting a long time. There have been no billing issues, and yes for some care, we've paid out of pocket. For example cataract surgery with basic lenses would normally be free or low cost. Instead we asked for and got premium multi-focal lenses that cost $$$. Neither regular Medicare nor Medicare Advantage covers those types of lenses.

I encourage people to talk to SHINE or other resources to discuss their needs and which providers would be best for them. And read everything you can!

I asked a Humana salesman after he told me all my surgeries would have cost me the same under their advantage plan vs my supplement plan, can your plan refuse medical help that my dr prescribes? He told me yes and every procedure goes thru an approval process before the subscriber can get help and he tried to justify this as a good thing. I asked him why is it a good thing when Medicare itself does not require justification?

This advantage plan approval process has been in Congress for years. Check this out:
The Improving Seniors’ Timely Access to Care Act 2024 would streamline and standardize how Medicare Advantage uses prior authorization.
Prior authorization fixes earn majority support in Congress | American Medical Association

How about all the hospitals refusing the advantage plan?

Hospitals are increasingly refusing Medicare Advantage plans due to concerns about low reimbursement rates, excessive prior authorization requirements, and high claim denial rates, which they say are impacting their financial stability and ability to provide care effectively; this means that patients with Medicare Advantage plans may not be able to access care at certain hospitals unless the situation is resolved.

Hospitals are dropping Medicare Advantage left and right - PNHP

When these plans have to make things right, they will have to raise their rates or the backing insurance company will start losing money, which won’t happen for long.

Insurance and Liability
 

This is one thing I don’t miss after retirement. Insurance holds too much sway on treatments. You certainly can’t change insurance just before a surgery. Liabilities and technical implications as well as the implementation of the procedure are impacted. What a mess.

If only changing policies was as easy as the one dimensional viewer thought it was.

You don't know what I know!!!!

"If you are active and healthy, Medicare Advantage Plan, and the Villages Health could be a good fit for you"? What the heck does that mean... don't get any older and never have a health issue for the rest of your life?

Good luck with that premise for your health care coverage.:22yikes:

Hang on to your sox, your insurance world will be changing shortly.

I have needed it and I don’t have any complaints.

We have UHC Advantage and my wife had a full knee replacement about 10 years ado, No issues with the insurance at all. Current she is fighting Breast cancer, just had surgery without issues. No delays or interruptions. We have a PPO plan that costs us $45 month each.

This Advantage Plans vs Supplemental (medigap) plans battle seems to go on forever. From my point of view it seems it's always the medigap folks who disparage the people with Advantage plans. Tales of impending disaster, refusal of services, etc. Yet people with Advantage plans seem to quite pleased or at least satisfied with their coverage. Currently in my state the least costly G plan is roughly $300 per month per person so an annual charge for he two of us would be $7200 vs the $90 per month, $1080 annually we pay now. The difference per year of roughly $6200 just about covers our max out of pocket of $7000 per year. These figures are valid for my state only. We decided on an Advantage plan about 12 years ago after starting with a medigap plan. We were both very healthy at the time although as we age there have been changes. However the savings over the last 12 years are sufficient to cover the potential out of pocket cost for many years. As a deep northern yankee the calculation of one plan vs another balanced against the possible risk seemed to favor an Advantage plan. So far that has worked out.

Rather than horror stories about Advantage plans coming primarily from those with Medigap plans I'd be more inclined to hear from people with Advantage plans talk about the good or bad experiences.

Any plan is great so long as you don’t need it. Managed Care is a boondoggle.

This has been shared before but here goes... Golfing buddy has chest pains, leaves the golf course and goes straight to the ER. After several tests in the following week, he is advised he needs stents and surgery is scheduled. His advantage health plan then nixed the surgery and told him to manage the issue with medication. Everyone gets real nervous when golfing with him now.

How would you like to be walking around knowing the cardiologists have recommended stents but insurance coverage says nope.:shocked:

Once again a second hand story without details or names. What State, what advantage plan, when? Your guy still alive?? Did he decide to go forward with the procedure w/o approval? Did he fight the insurance company? Did he do nothing and survive??

When you provide your full name, where you have lived, where you live now, all details about your health, what procedures you have elected to pay for on your own, I'll think about doing the same. Why he should have to fight with the insurance company at age 78 for coverage and no, his name will not be provided. He is a good, kind person with much to live for in his life. Why should he be denied a coverage by a private insurance company when the stents would have been covered and his blockages treated when diagnosed with original Medicare coverage. Would you like to live on blood thinners for the rest of your life if you had other options available to you?

Your statement is the same as calling someone a liar. Facts hurt your argument but I'm not about to waste my time lying to anyone. I detest liars and your innuendo.

I was recently ok for a reverse shoulder replacement by my Advantage Plan. No PT requirements, no 2nd opinions, just my Dr's diagnosis. I go in Feb 28th although thankfully the pain has gone away and I will most likely cancel. Original equipment is my preference.

Aces4, I think you are misunderstanding my comment.

There are both good and bad Medicare Advantage plans. Even the same companies that operate in each state. One ste, very good service. Other states not good at all, even though the same overall insurance company offering those MA plans.

Why? Overbilling and other billing issues.

Similarly, even normal Medicare has issues:
1. Not all doctors and specialists accept Medicare patients. Same goes for hospitals.
2. Not all doctors make a proper diagnosis and suggested procedures.

Sure, we're all in good health until we are not.

To place context in your original post, of course, we don't need the patient's name. But when saying a Medicare Advantage plan is bad, it is useful to provide the insurance provider's name and type of plan, the health organization of the patient having the issue, and whether it was a required or optional procedure. Surgery isn't always the best solution. Other treatments may be ok for some people.

Ordinary Medicare does cost, and sometimes very much. It took is NOT free healthcare.

Medicare Advantage also costs for some.

The Medicare Part B is something almost everyone pays regardless of plan.

Different plans for MA have different monthly costs as well as max out-of-pocket costs each year.

It is wrong to condemn plans that see to be working well


I know that for Villages Health, they have many great health professionals in staff. They also catalog specialists and providers that partner with them. Not all specialists and providers are accepted by Villages Health, and for various reasons.

We all know that there are both good and bad doctors, specialists, and healthcare services providers.

And hopefully our state and federal government agencies keep track of them, too.

My condemnation is the efforts being made to convert everyone to advantage Medicare. That's when the proverbial poop hits the fan. Once the private industry takes over all Medicare, there is no escaping controlled, limited medical care.

Having worked in one facet of the health insurance industry, all I can say is it's about the profits to the stockholders. The patients are a byproduct of the situation and low on the priority. Health insurance never boosts it coverages and payments under a current plan without reducing coverages somewhere else.

That's the bottom line, you're in it now so good luck down the road but I still advocate for people who want excellent medical care in their old age to stick with original Medicare.