On the 17th day, her Medicare Advantage insurer, Security Health Plan, followed the algorithm and cut off payment for her care, concluding she was ready to return to the apartment where she lived alone. Meanwhile, medical notes in June 2019 showed Walter’s pain was maxing out the scales and that she could not dress herself, go to the bathroom, or even push a walker without help.
It would take more than a year for a federal judge to conclude the insurer’s decision was “at best, speculative” and that Walter was owed thousands of dollars for more than three weeks of treatment. While she fought the denial, she had to spend down her life savings and enroll in Medicaid just to progress to the point of putting on her shoes, her arm still in a sling.
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I have a number of family members who love to brag on how much they're saving on a MA plan vs regular Medicare. The bragging generally lasts until they actually have to make use of the Medicare Advantage plan - then they go silent about it until they're challenged - they then switch to "yeah, but..." to try to save face.
Why they can't begin to fathom that anything advertised as heavily as MA plans are right around enrollment time must be a major profit center for their owners, and they can only do that by denying/delaying care is a mystery to me.
Insurance companies are in it for the money, they aren't altruistic charitable organizations - it's the money and nothing BUT the money that counts. People get subpar care - it's not a problem as long as the next quarters profit numbers are good.
They suck. But hey! "I've got Silver-Sneakers" said the fat man who never went to a gym since high-school..
That's strange, I have been on aarp united healthcare advantage plan fir 6 years, they just got done paying over 72 thousand for my cancer treatment fir December.
Very valid concerns. Remember not all insurance companies and even for the same company not all offered plans are the same, and may be radically different. AARP Advantage is provided by United Healthcare. We just went to Medicare Part B (the medical part and what most of the care we all need except inpatient stays and surgery and some other items) and switched from my spouse's corporate plan. We didn't get a Med Supplement and go on Medicare Part B (the other major option besides Advantage plans) until she retired.
Her whole career was in insurance and in Medicare provider insurance software so we are not newbies. This insurance stuff can be too confusing for most. But even without that many of you are very smart about insurance.
On Med Supplement we went with the "Cadillac" and most expensive plan G (used to be F). $176 a month each. You can get cheaper Supplement plans. The difference usually boils down to how big your deductibles are plus some other less important items. Deductibles can eat your lunch (your money). Knowing that I have PCa we knew that a lower deductible would pay for the extra monthly cost.
Advantage plans vary all over the place. They have extra sweeteners which may sound great and sometimes they are but often are just good marketing. Drug coverage can be a good thing added but what they cover for what deductibles are all over the place. They can be part of many Advantage plans. They are not included in Med Sup and you have to get Part D separately on your own. Every state has different regulations on how these plans work.
Even though we are much savvy than most we got an advisor (free and no kickbacks from plans he recommends) to run the numbers for drug coverage and which Med Sup plan made the most sense for us.
Not trying to be too pedantic here (which I am sorry that I can be). But many get Advantage plans for the lower monthly costs and then get eaten up by what is or is not covered. And they restrict you to what hospitals and doctors you can use, or pay a big extra. One of the reasons we got Med Sup was that we could go to any state and most any hospital or clinic or doctor if they take Medicare at all. And, Medicare tells the Supplement provider what they have to cover. If Medicare B would cover it then the insurance has to cover it. Not so Advantage plans.
And, it is very difficult to change from a less advantageous plan to a better (more things covered and smaller deductibles). We went with the best Med Sup plan to avoid that. We can always go down to cheaper, worse plans but not up (except with very large premiums).
But back to the issues of Advantage plan providers and even Med Sup providers (we have Regence Blue Cross in Washington state). They often refuse to cover a given therapy so they can make as much profit as possible (what you pay less claims they pay). They can be real jerks. Borderline and many times completely over the line illegal denials of coverage. I've had to appeal a few things - depression therapy and DNA analysis were two biggies for me. We got a Foundation to cover 100% of the DNA and appalled and won on the depression therapy.
We think going with the cheapest plan, especially Advantage plan, does not make sense for anyone with potential high cost therapy, like many elderly people and certainly cancer diagnoses. The high cost of the plans can just be too high for many though and they really don't have much of a choice. They just can't pay the monthly plan costs out of Social Security or pension income they get, or out of savings. We are lucky that we can pay the higher plan monthly payments.
Do your homework and try to find the most honest and reputable insurers. Very hard to do usually. You can change to another insurer once a year though. If one is screwing you then try to find a better insurer. Our advisor was helpful in giving us hints. He could not out and out say one insurer was better than another. Your doctors and clinics might be able to help. They want to work with the insurers who will pay. They hate doing appeals or seeing patients get knocked around. Ask friends who have coverage.
I hope this makes sense and I hope I have been accurate in what I have said. Best of luck and homework to find the best insurance plan and insurer for your individual case. I can't help but believe for those with advanced cancer that going with a better, lower deductible, plan would make sense. Pay me now or pay me later.
And if you ever want to go for a 2nd opinion or treatment to a provider that is not in UnitedHealth' network what do you do then? Or if they drop a drug you need from their formulary or bump it up to tier 5 what do you do, look for a different MA insurance plan?
I can go for a second opinion at any time! They are a Medicare MA provider so I believe that unless Medicare stops covering a med then United will cover it.
"Medicare stops covering a med then United will cover it"
Probably. But the Doc in charge of Prostate cancer approvals for their regular insurance.... not a good guy if you have prostate cancer.
Dr. Myers told me that is the one health insurance company you want to avoid if you are seeking approvals for the most up to date prostate cancer treatments.
That's cause barbers don't pay attention to "number one haircuts" since they're constantly watching out for the mailman hoping this is the day he delivers the Playboy calendar....
I have a medicare supplement with BCBSM. They have discontinued enrollment to eventually cause huge premium increase to force most seniors to a MA. I can see anyone i wish no deductible no co- insurance. BCBSM will not allow you to transfer to there other supplement plan unless you can qualify. What a shameful act with thought to be a class act insurance company. Hall of shame winner.
No one should be on an advantage Medicare plan. It is not "MEDICARE", these plans are private insurance. You are at the mercy of the company. They can at will, deny coverage or cancel your plan. Under an official Medicare plan, your premium will be higher, but it is real coverage.
I turned 65 the month before diagnosis. As I was in Excellent health, I decided an Advantage plan was best., Then came my stage 4 DX. At first I looked at my total out of pocket expenses and thought having the plan wouldn't be that bad. Then as I was looking for my best care, I found out that not everyone took my MA plan - the biggest being the major cancer centers - Mayo - MD Anderson etc. As I was in my first 6 months on the plan, I was able to switch to a Supplement plan with no underwriting. It has saved me big time!
I have BCBSM (retired Mich teacher). I had a terrible fall in 2017. About $700K medical expenses (long time intensive care, top rehab place, etc). I think my cost was about $1000 as I quickly hit my OOP Maximum. I've hit that every year, between my spinal injury and PC. My plan is a PPO MA. VERY pleased so far.
There are many advantages to MA plans. ALL of the ones of value are for the benefit of the insurance companies and the brokers who sell them.
Serious illnesses require serious and expensive treatment. MA plans are designed to save costs for insurance companies. The two concepts are essentially inconsistent.
As far as I know, the Medicare INSURANCE plans also have approved procedures, treatments, etc.......eg, Medicare was paying for none or only a portion of a HIFU pprocedure. In that case, an Advantage plan would have the same right to decline or only pay a portion of the HIFU treatment. Talking to someone at Kaiser today, the rep stated that they are required to provide equal or better treatment......if a Medicare-approved treatment is not available at Kaiser, I wold be referred to an outside provider/clinic/hospital.
All who believe Medicare should be obliged to pay for everything, with no standards for effectiveness, please raise your hands?? Seeems to me the main diffference is that Advantage planslimit your selection of Docs. Some men at HU have mentioned having up to 10 separate provider opinions/consults before deciding on treatment......does Medicare have no limits on such multiple "2nd" opinions? Or , are such patients simply paying out-of -pocket for such multiple opinions?
There must be a top-notch website that clarifies the legally approved differences in coverage between traditional Medicare and Advantage plans.
There are many advantages to MA plans. ALL of the ones of value are for the benefit of the insurance companies and the brokers who sell them.
Serious illnesses require serious and expensive treatment. MA plans are designed to save costs for insurance companies. The two concepts are essentially inconsistent.
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Such sweeping generalization. "ALL..."? My OOP Max is $1700. That benefits me TREMENDOUSLY year after year. I've had many (far TOO many, sadly) medicos over the years including UCLA, Mayo, and Umich. My bills are minimal and truly ZERO once I hit my OOP max. I've had no problems seeing who I want and having txs I want including latest scans. I am pleased with my MA plan
If someone is already on an Advantage plan does the existing PCa condition disallow returning to regular Medicare with a supplement? Or does the exorbitant underwriting charges make it economically unmanageable?
That's not quite correct. You can switch back from a Medicare Advantage plan to Original Medicare during open enrollment I believe. BUT, if you want to then buy a Medicare supplement plan you are subject to the plan's underwriting. If you have PCa, or nay other major disease, you will probably be rejected. That would leave you responsible for the full 20% that Original Medicare doesn't cover.
You said "My understanding is once you are in a medicare advantage program, you can never leave." But you can leave an MA plan and go back to Original Medicare. You most likely cannot buy a supplemental plan. You might consider that splitting hairs but I think it is an important distinction.
As a fact , 6 years ago MD Anderson would not accept any MA plan. I live in Georgia and was approached by a former patient who sold MA. United Healthcare. We got on the phone and they stated they covered anything that Medicare would. I signed up and then exercising caution I called MD. ( was going for proton) they then told me they needed a letter of specific coverage, I called UH they said they would look into it. I called my agent and we dropped the UH, he then called Medicare and they accepted me back no problem. This was a non enrollment period but they understood. After completing proton and returning to Georgia I get a letter from UH telling me they are going to deny treatment at MD Anderson. I assume that once it went for review they were not notified of us cancelling coverage. I think if you stay in SOC in the area you signed up it might be fine...your choice...I personally am all over the map , ( including India.....cash only) Blue Skies
My experience with MA (UH - AARP) has been remarkable. I am receiving stellar care at UTSW in Dallas. During diagnosis process 2021-22, I explored treatment options at Mayo, MDA and TX Center for Proton Therapy - multiple therapy options - UH approved coverage for any of my choices. Settled on a clinical trial at UTSW, UH covered all non-trial supported costs ( Lupron, SBRT, PSMA, etc) - my total OOP - $1,250 - for everything. In 2022, I pay $20/visit for specialist, $0 for generic 1 (large list) so I am very pleased with my MA plan.
We have traditional medicare and great supplemental through UH and Priority. No co pay for any doctor or hospital stays. Between the two of us we see several specialist often. Everyone has different needs.
Yes, people have to be very careful. For us...there is no advantage to these plans. They are best for young healthy people. You may save some money now... but you will pay later!
I consider myself really lucky to have made the decision to select traditional medicare and a medigap plan (plan G) 5 years ago when I made the decision. My wife and I attended a couple of seminars from local MA suppliers in our area and decided that the traditional medicare would give us better coverage while traveling, knowing we could change to an inexpensive MA plan later in life if we needed to. Having the same coverage anywhere in the US while traveling was the main reason, as the MA plans do look financially attractive on the surface.
Last year when I was diagnosed with PCA, I was fortunate to have the option to research centers of excellence to deal with this disease instead of dealing with the complexities of a profit-based insurance carrier and their selections of hospitals, doctors, and treatments.
We have had problems with medical insurance carriers in the past and at this point I hope to never have to deal with one for the rest of my life. I do feel sort of stuck now with my medigap provider (Omaha Insurance Co.) since underwriters for other companies (or even a different Omaha plan) would not accept me as a client. I found that out when (before my diagnosis) I checked with a broker about selecting a different medigap plan from Omaha with a lower premium and higher deductible and found I would have to go through the underwriting process. Basically, you have one shot during open enrollment at age 65 to select a medigap plan without underwriting. Once you lock in, they can raise the rate but not get rid of you as a client or change the provisions that medicare sets for the various medigap plans.
Other than travel and some prescription costs (Orgovyx and Erleada), Medicare, Omaha, and Wellcare (a $13/month plan D) have covered everything for my diagnosis and treatment after minimal deductibles.
No, original Medicare can deny coverage. All I am saying is Medicare Advantage plans are NOT Medicare. They are private insurance policies. They accept medical bills and recover the costs from Medicare. It is a plan that is limited with more restrictions than original Medicare. Limited in coverage, treatment, and providers. Many medical facilities don't even accept medicare advantage plans.
One of the biggest arguments against MA is that if you want to go to a center of excellence they probably won't take your insurance. Here are just a couple that I looked up:
Memorial Sloan Kettering Cancer Center takes only a few plans that seem to be just for New York residents:
You couldn’t pay me to switch to MA. I did some research for my out of my state care and the MA representative told me he wouldn’t recommend MA. I would be required to seek care in my state. On another note just 3 days ago MA is using AI to decipher coverage on individuals and it favors the private insurance companies and not the patient. Yes you can file a complaint but to have a denial reversed takes on average a year. In that time you will go into incredible debt until they pay the bills. Who wants to go through that? For an extra $1200 per year it’s priceless..
I've read thru most of the replies here, and two thoughts come to mind:
1) Your insurance costs (and available plans) will vary according to what state you live in. In my case, I live in Minnesota, and have a "medicare supplement" policy (which is vastly different than Medicare Advantage). It is costly ($300 per month), but it covers every last penny of my medical costs (not drugs, which requires a separate policy). As a result in the last 7 years , my eligard shots (at $5000 per) have been covered, I've not had to pay anything for the myriad of scans I've had over that time period, and I can see any doctor I want (including podiatrists, nutritionists, etc) without a copay of any kind. It has also covered all the costs of radiation, chemotherapy, etc.
2) Given the complexities of insurance coverage, a profession of "insurance consultants)" has grown up in MN, I would strongly encourage anyone to see if this is the case in their state. I would urge you to talk among your friends (especially the smart ones in your circle) to find out what the options are in your state.
Finally, it is a shame that health insurance in the U.S is so bloody complicated ..........
In 2020 I left the full-time workforce and private work insurance as I was just turning 65 that year I talked to my financial adviser, and he recommended straight Medicare; fast forward to 2022, DX PCa G9, MRI (2), Biopsy, Colonoscopy, PSMA Pet, SBRT, Lupron, numerous visits to the Doctors office. Cost $226 (deductible), + about $200~ per month. I don't know about MA plans but thank god for Medicare
I think many of you are making a big mistake by lumping every Medicare Advantage program into the same category. Every insurance policy is not the same. In my case, I have been in Kaiser Permanente since I was 4 years old, and I have chosen to stay for 73 more years because it is, in my opinion, the very best quality of care I could wish for. As a State employee, I had the choice of literally dozens of health insurance options, and I kept my Kaiser. And when I retired, and became eligible for Medicare, I am still choosing Kaiser. It has the highest ranked hospitals in the area, I have no trouble seeing specialists and getting outside second opinions,
I have Kaiser Medicare Advantage and very happy with it. I've also had Kaiser for a long time. People often tout this advantage of being to go anywhere you want when that's not even feasible for many people. Besides that, who cares if I'm getting the same treatments at big name institution? Is Cabazitaxel chemotherapy or Pluvicto better because it's at MD Anderson? I don't feel like paying all that extra money for some advantage I'm never going to use. I had a friend with regular medicare who had and saw doctors at UCSF and OHSU that he consulted with. But at the end of day, they gave him Xtandi. the same Xtandi I was getting.
(the system cut off the last part of what I wrote) I am very happy with the state-of-the-art cancer care I am receiving, I love my personal physician AND my oncologist, and I pay $5 a month for Zytiga and nothing for YEARS of Lupron shots. I am very satisfied!
We have about six friends who crowed about how marvellous their MA plans were UNTIL they needed serious care. Every last one of them said then that they would never have signed up now that they knew how awful they were. I knew I'd made the right decision to stay with traditional medicare when I was lying in the hospital after a nasty accident discussing rehab. The social worker comes by and says "oh, you can go anywhere you like, you have GREAT insurance". I chose hospital inpatient rehab, all meals provided, able to rehab 6 hrs a day and I was discharged in a week functioning well. I then got 6 weeks of at home physio if I wanted it. A friend on an MA plan was only allowed to go to one awful nursing/rehab place in town, they did pretty much nothing except give her C diff.
Spouse and my main reason for choosing trad Medicare is that we can go anywhere in the country for covered care AND we can go to specialists without passing by gatekeepers.
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Changng Insurance (Reluctantly)
I may have prostate cancer
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