Here's How Much We Paid With Medicare | Medicare Supplement vs Advantage

[Michael]

DeusxMac wrote:
Michael, thanks for the comprehensive response.

But you should be aware that "if you are enrolled in a Medicare Advantage (MA) plan, doctors do not necessarily need to accept your insurance even if they accept Medicare. This is because doctors have separate contracts with private insurers."

And it may require a pre-approval to access medical services outside the Advantage plan's network; meaning emergency services or other immediate needs could NOT be pre-approved, and consequently NOT covered.

Thanks for the information. We actually do have one doctor who won't bill United Healthcare for us. So I presume he won't accept the insurance. But it's a sort of strange thing because when we get his bill he has the bill total but then he reduces it by what Medicare would reduce it by and we pay that reduced amount. Then I send the whole thing to United Healthcare and they reimburse me for their part of it. It all ends up costing me what I would expect if he was somebody who did directly bill. It's the only time we've had to submit anything to United Healthcare.

I'm familiar with the pre-approval thing. They did pre-approve me for the prostate aquablation procedure based on what the urologist's office sent in. Some of their requirements seemed sort of silly, but there you go. And they haven't resisted paying anything at all.

Perhaps we're lucky that our policies are explicit that emergency coverage anywhere (in the world!) is covered. ER costs $120 in or out of network in the US and $0 in other countries. They have a statement about, "What if it really wasn't an emergency?" and they say they will cover it for the listed cost if, "...you reasonably thought your health was in serious danger." (it would be interesting to see how they determine that!) If they decide I wasn't reasonable about thinking it was an emergency then they cover it by procedure and whether the place is in or out of network. The last time I went to the ER (20 years ago, maybe?) our work insurance allowed us to call a nurse practitioner and get their referral to the ER and that guaranteed ER payment. One day I was using a tool I had no business using and cut the back of my hand near my middle finger to the point where I could see the extensor tendon. As soon as I mentioned that tendon to the nurse she told me to go, right now! to the ER and the insurance company covered it. The United Healthcare Medicare Advantage program has a "Nurse on Call" that will help determine whether somebody should go to the ER but they're silent concerning whether that would guarantee the ER payment. If they're silent, it means they probably don't guarantee that coverage if the nurse refers somebody to the ER.

But, your point is well-taken. I know we're in a less-secure situation than Medicare and a supplement policy. But, since we have a maximum out of pocket, we'll avoid catastrophe if it all goes south on us.

[mattkime]

As someone who's a couple of decades away from needing this, I understand almost nothing said in this thread and in the video and I just hope the system changes before I need to deal with this.

[zachdog]

Be careful. My wife works with older patients on the hearts floor at her hospital and non-Medicare patients are frequently denied coverage. Many people with afflictions who could recover are sent to skilled nursing units (essentially nursing homes) instead of rehabilitation centers. Why? Because it’s less expensive for United Healthcare.

I am a decade from retirement and very healthy, but I will opt for Medicare.

[DeusxMac]

A post of mine on this subject from 6 years ago...

"My father had an Advantage plan, and when he needed to go into a rehabilitation facility, the number which would accept Advantage plans was a fraction of those which took the base Medicare plan.

When looking for an open bed upon release from the hospital, it severely limited his options.

The Social Worker who assisted us at the hospital told me she was going to insist that her father NOT get an Advantage plan when he went on Medicare."

[Michael]

If anybody is interested in how often Medicare Advantage programs require prior authorization and how often they deny procedures, this article might be interesting:

https://www.kff.org/medicare/issue-brief...s-in-2021/

In 2021 there were 35 million prior authorizations filed and 94% were approved. Of those that were not approved, 11% were appealed. Of those appealed, 82% were ultimately approved. With that low a percentage appealed and that high a percentage ultimately approved, I'd bet that most appeals were related to not having the appropriate information in the initial prior authorization.

It is interesting to see how different the various insurance companies are in their requirements, approvals and reversals of denials.

[Buzz]

......and that is exactly why we pay the max premiums for the Blue Shield F Extra ("F+") Medicare Supplement plan.

Sure, it's expensive, relatively speaking, but necessary for us. Before Mrs. Buzz retired from 43+ years of major airline stewardessing
during Covid, we stuck w/ her company's top HSA based plan from UHC...... All-in, it saved us between ~$800 - $2,000/year over
Medicare + Supplement, w/ most of that being from prescription meds. Since spousal unit's retirement, Rx costs have come down
(though the Supplement cost has t crept up) so it's close to a wash..... though Mrs. Buzz is *MUCH* nicer in her retirement than she
ever was while she was still working; which is a big plus.

My base annual medical expenses start at $500K+ because of my neuro crud, and go up from there w/ old guy prostate and kidney
issues, not to mention stuff like my currently broken foot. Mrs. Buzz, while generally healthy (comparatively, anyway), still has just
enough issues to justify the expensive Supplement...... especially since we get a pretty decent discount for combined enrollment and
billing to start with, and that here in So. Cali we're in the hotbed of all sorts of major medical group competition, and that way ($$Supplement),
we both see docs and get treatment from the three top groups in our area (UCLA, Providence/St. John's, and Cedars Sinai) without having
to hassle, or worry about any in, or out of, network considerations like we'd have to do w/ any of the Advantage plans (even supposed PPO's)
that are tied to a specific group of providers.

I cannot stress enough that y'all gotta plan ahead for you're Medicare era health needs. For some, an Advantage plan may work, but you
really oughta make darn sure before consigning your healthcare decisions to the beancounters rather than trained medical professionals.
There's no free lunch, so do your homework, then do more homework until you absolutely know you've got it right! It can be too difficult,
if not impossible to switch to the "right" plan once you start needing more healthcare than the "wrong" plan is willing to provide to/for you.

Good luck, and part of that homework should include consulting w/ reps from a few different care providing sources.....
being aware that some/many may only be able to offer limited solutions that (of course) they'll be pushing.


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[AllGold]

While Medicare Supplement plans are all the same (except the price), Medicare Advantage plans vary widely, both from plan to plan and from location to location.

I will say this again for emphasis: even if it's the same company, MA plans from, for example, Iowa are not the same as plans from Florida. This is because the reimbursement rate is different in different locations.

Also, usually (but not always) each company offering Medicare Advantage plans in a particular location will offer multiple plans with different levels of coverage.

And finally, Medicare Advantage has improved significantly over the last several years. What was the case for MA five years ago probably isn't the case today.

Unfortunately, Medicare insurance is kind of backwards from what it should be. Med Supp premiums are much lower when you first age into Medicare at 65 and you typically are more healthy and don't need much coverage, then continue to rise as you get older and sicker. By the time you're over 80 (although Med Supp premiums vary by location), you're often looking at north of $400/month premiums.

[Buzz]

We're not north of 80, yet (73.5), but our Supplement is ~$340 (X2)/month. Thankfully, that's all we have to pay; it covers all deductibles
and co-pays, so no surprise bills.... except when the doc's office peeps/billing dept mis-code something; then we have the hassle w/ them
to correct their billing error and get the claim resubmitted. We still call on stuff that may need a proper referral, to make sure everything gets
submitted correctly the first time around. Well worth it to have predicable medical expenses throughout the year.

When spousal unit was working (and before Baby Buzz aged out of the family plan there), the "Gold" HSA maxed out my annual out-of-pocket
w/ my first IVIG treatment each January; and we got "copay assistance" (which is common in the industry) from the maker of the IVIG, so our
costs under that scenario were predictable, too..... as long as whatever was being done was on their "OK" list, or formulary, as the case may be.
Back then, UHC required a fair bit more checking in on, than Blue Shield does now, but after all the years of dealing w/ them, we were dialed in.

If one's healthcare needs are fairly modest/routine, an Advantage PPO plan can be a real money saver if (as noted) you're in the right location,
and/or are serviced by a provider group that's a good for you. I must say, that these days, Kaiser can be an excellent choice for Medicare
coverage (compared to a couple of decades ago). Ya gotta do that homework before ya jump into the pool; it's really important.



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