[ROCKETMAN]

I don’t understand how advantage plans work. If I have a ten thousand dollar hospital bill, the most I pay is $1200.00, paying nothing days 6-90. Does Medicare reimburse freedom for the rest of my bill? Freedom charges no monthly fee so has no income by itself. I pay nothing for primary care dr. And nothing for drugs, all generic. Had mri, cat scans, imaging and pay a small co pay so again freedom must be reimbursed. Next year get $202 reimbursed for part b and $500 Mastercard to play golf and $45 a month for over the counter. Who pays for all this?

[biker1]

You can easily research this yourself with a few Google searches. There are numerous YouTube videos that you can watch. The nice folks at SHINE can probably help you also. I will, however, give you the very short story.

Medicare Advantage Plans typically have annual out-of-pocket maximums around $5000 so you could wind up paying that. YMMV. There are also, typically, co-pays and perhaps other charges, for example, certain medications. YMMV. The Government typically pays the Medicare Advantage Plan provider about $15,000 per year per patient to manage their healthcare. YMMV. With a Medicare Advantage Plan, the Government has essentially subcontracted your healthcare management to a private company. The advantage to you is potentially lower cost than someone who opts for traditional Medicare and a Supplemental Plan, plus some freebies such as some dental benefits. You will continue to pay your Part B premium, typically subtracted directly from your Social Security benefit, if you select a Medicare Advantage Plan. Depending on the plan, your network of providers may be limited when compared to traditional Medicare with a Supplemental Plan. YMMV. My Medicare broker summed it up as follows: If you don't need any "work" done then a Medicare Advantage Plan will save you money over traditional Medicare with a Supplmental Plan since you avoid the Supplemental Plan premiums. If you need to have some "work" done then the higher out-of-pocket maximums might make it more costly than traditional Medicare with a Supplemental Plan.

So, to summarize your financial question, it is essentailly paid for by direct payments from the Government, out-of-pocket charges, co-pays and other charges, and your Part B premium.

Originally Posted by ROCKETMAN

I don’t understand how advantage plans work. If I have a ten thousand dollar hospital bill, the most I pay is $1200.00, paying nothing days 6-90. Does Medicare reimburse freedom for the rest of my bill? Freedom charges no monthly fee so has no income by itself. I pay nothing for primary care dr. And nothing for drugs, all generic. Had mri, cat scans, imaging and pay a small co pay so again freedom must be reimbursed. Next year get $202 reimbursed for part b and $500 Mastercard to play golf and $45 a month for over the counter. Who pays for all this?

[ThirdOfFive]

Originally Posted by ROCKETMAN

I don’t understand how advantage plans work. If I have a ten thousand dollar hospital bill, the most I pay is $1200.00, paying nothing days 6-90. Does Medicare reimburse freedom for the rest of my bill? Freedom charges no monthly fee so has no income by itself. I pay nothing for primary care dr. And nothing for drugs, all generic. Had mri, cat scans, imaging and pay a small co pay so again freedom must be reimbursed. Next year get $202 reimbursed for part b and $500 Mastercard to play golf and $45 a month for over the counter. Who pays for all this?

OP, is "Freedom" the insurance company that manages your Medicare/Medical Advantage programs?

If so, then they do get paid, and handsomely. These companies that manage the above have contracts with the government that mandate the government reimburses the insurance company "X" number of dollars per client, per diagnosis, per year. In other words if someone insured under the plan has (say) a diagnosis of COPD, the government reimburses the insurance company that insures that person "X" number of dollars, on an annual basis, for that diagnosis. It is their "fee", so to speak, for doing the government's work handling the claims that that person has for health care.

But it doesn't stop at just one diagnosis. The more diagnoses the medical system can hang on a person, the more money the insurance company gets. Have you checked your list of diagnoses recently? Are there any on that list that you were unaware of? There was for me about a year ago. In visiting with my primary last year for my annual checkup I noted "congestive heart failure" on my list of diagnoses. Not ever recalling any tests specifically for that (nor had I ever even heard it mentioned before) I questioned it. Doc launched into a long, involved discussion that went something like "well, at your age and with this-or-that already-diagnosed condition together with your lifestyle and.....etc. etc., the system concluded that you have it" (or words to that effect). I didn't know. But you can bet the farm that the insurance company did.

The above is a quick and dirty explanation of a pretty long (and pretty esoteric) process. Insurance plans incorporating Medicare and Medicare Advantage are reimbursed according to a Hierarchical Condition Category (CMS-HCC) by which the companies are reimbursed. Too long to discuss here but reading it is fun.

And it doesn't stop at Doc's office. Several insurers have gotten into some deep doo-doo with the DOJ for their practice of sending Nurse Practitioners into insured's homes for a FREE ANNUAL EXAM AND WELLNESS CHECK, then tagging them with new diagnoses (previously without the patient's knowledge) but not following up with care recommendations based on them. Our company offers (or did, I don't know if they still do) a FREE $50 GIFT CARD!!!! if you acquiesce and admit said NP to your home for such a checkup. We didn't.

So--yeah. Those companies aren't doing anything out of the goodness of their hearts. What some of them DO appear to be doing, is milking a system for all the $$$$$ they can get./

[BrianL99]

Originally Posted by ROCKETMAN

Who pays for all this?

We all do.

& thank you for your post. While you apparently don't understand some of the process & how it works, very few others do, also.

The more people read (& hopefully, at least partially understand), the more likely we are to get Health Insurance reform in the USA.

As national health policies go, we're way behind most of the civilized world and the results (in general), don't reflect the money that's spent on healthcare in the USA.

The greatest country in the world could do much better at managing the health needs of its citizens. JMOYMMV.