Original Medicare or Medicare Advantage?

[pdpatient]

This question is for the US audience.

For those of you who are on Medicare, which plan are you on and what are your experiences with regard to Parkinson's treatment?

What are the features of the plan that you are on that you have found useful?

[docjleonard55]

For Medicare I always recommend going with original instead of an advantage plan. While the advantage plans have greater coverage (dental , vision), and are cheaper, it is still an HMO where the company decides what will be covered and is limited. I have personal experience from the provider side, being a Podiatrist and then an RN, and I can't tell you how often patients could not get needed services paid for. It's corporate America.

[MarionP in reply to docjleonard55]

Absolutely! Stay away from the "Advantage" plans if you can, you will be sorry and also helpless when knot "if") the plan retroactively denies services, medications and choices, drags its feet on payments on any at home very close that would cut into its profits...unless you were independently wealthy. They are private insurance companies and this is the way they make their billions, also the way they pay for all the advertising (including compensating famous persons out there agents, which can be very expensive) that ropes you in.

[park_bear]

Why Medicare Advantage is unsuitable:

Friend of mine had Medicare Advantage from an integrated healthcare provider. She went to a regularly scheduled doctor visit at their clinic debilitated with the flu. The doctor ordered her to the ER. She went, whereupon she was given a saline IV, plus an MRI over her protests.

Subsequently the insurance arm of this provider declared the visit was "unnecessary", even though it had been mandated by one of their very own doctors. She received a bill for $19,000 - for $10 worth of saline and an unnecessary MRI. It required the state's commissioner of insurance involvement to get this reversed.

Medicare Advantage is private insurance and they will try to screw you to increase their profits. There is no penalty for this behavior - the worst that can happen is they will be forced to make it right, as they should have done in the first place. So there is every incentive to continue. Stick with Medicare.

__

Medicare Part D is supposed to limit your out of pocket in the case of really expensive medications. I have not had the opportunity to test this. For generic Parkinson's meds, I have found the best deal is to use a low-cost mail order pharmacy. I maintain an inexpensive part D policy which I do not use. Is there for backup.

[Sydney75]

My HWP is also of age to switch to Medicare. We have been advised to avoid Advantage Care plans that are so heavily pushed. Advantage Care is a cost controlled HMO, best for healthier folks. There is too much risk for us with a chronic disease of PD. His main PD meds are not covered by some Part D plans (Rytary) so we are evaluating our choices. Medicare for all plans looks back two years from date of 65 birthday at your income to determine IRMA charges, (total household income if married). He still has his employer coverage as Part B & D. through 2024. The window to apply is 3 months before or after 65 and there is a penalty if you do not pick a part B,C,D. (unless you work for a company that has 20 or more employees on medical plan).

With PD you have to think ahead. We want coverage anywhere in US not just a local system (some limited PPO and Advantage Care). I would advise getting an insurance consultant and asking your Movement Specialist staff (billing etc) which insurance offers best coverage. Some folks are lucky to live near good medical centers with excellent PD resources and example would be UPMC in Pittsburgh, the medicare plans through their system are very good but travelling out of state gets dicey if there is an emergency etc.

Good Luck

-Syd

[MarionP in reply to Sydney75]

"IRMA" means what, for all us non-experts please? And "good" medical centers may be excluded as "out of network" not allowed until you have gone through everything including much more progression into the disease and not be killed by it until they let you have services.

[bassofspades]

I have had a very positive experience with a Humana PPO Medicare Advantage Plan. Ive been on it 2 years and I just told my agent to renew it again. They give back the premiums, I get $300 a year to spend on personal care items and OTC medications, my prescriptions are all covered and not expensive, I get free visits to my primary, $45 for a specialist, labs are free, they pay 80% of most things. The list is way longer but I'll just say this beats private insurance by a landslide.

you can look it up. I guess its regional, might be different in other areas. Im pretty sure its this:

Humana Full Access Giveback H5216-393 (PPO)

Central and North Florida PPO

[MarionP in reply to bassofspades]

For most people your experience would be a fortunate, perhaps unlikely, gamble. And 300 a year is less than $30 a month, I just had one of five medications I am on, and that one medication billed at $100, my participation was $20. If I was on any advantage plan I would be excluded from the Mayo Clinic. Not happening, gambling is for Vegas and online sports betting.

[bassofspades in reply to MarionP]

just to clarify, its $75 per quarter (which is use it or lose it) for OVER THE COUNTER items, such as q tips, vitamins, toothpaste, allergy meds, ibuprophen, etc. Not prescription meds. For that, there are different tiers. For my 90 day prescriptions, I pay anywhere from $2 to $27. As for gambling, if I were to be hospitalized, the max out of pocket is actually quite low, especially compared to my wife's Blue Cross plan she gets from her job. The only thing Im not really thrilled about is the coverage for glasses.

[kgold in reply to bassofspades]

My HwP also has Humana Medicare Advantage for almost 20 years. No particular complaints. I have Anthem Medicare Advantage. Again no particular complaints. We are in KY.

[Grammy80]

My husband was a union electrician in a steel plant, and the contract supplies, at a conservative premium, BC/BS Medicare Advantage, which serves us well. It helps that I take a biologic that is $5000 per month, so my meds are 'catastrophic' and free after just a few months into the year.

I live in Indiana and recently the local hospital and most physicians practices changed ownership. Once the new board took over, they ceased accepting Aetna Health across the board....so I would just be aware of that in your area. 💞

[lch49]

I have United Heath Care Medicare Advantage plan thru AARP. I also have a prescription plan. I have several health problems and this plan has been good for me. There are many Drs in my area that accept this and I’ve not had any problems when I’ve needed a Dr out of state. I think there are many more advantages to a Medicare Advantage Plan.

[Gallowglass]

I’m on original Medicare and a supplemental plan from AARP/United Health care. Together almost everything is covered. It costs more up front but at least there are no surprises.

[MarionP in reply to Gallowglass]

Yours is what I have too, costs quite a bit up front but in the end is way more advantageous in a number of ways. If you were healthy enough to not need services, then you may be fortunate enough to skate by on a private plan. I like to leave the gambling to the poker pros on TV.

[hmm777]

I have heard the horror stories about advantage plans, but that has not been my experience. Like several others who have already responded I have a Medicare Advantage plan from United Healthcare and AARP. I have had the plan for five years and my experience has been uniformly excellent. All claims have been paid on time and without hassle, including two very expensive MRIs, a spinal steroid injection, and physical therapy with an out-of-network PT who was recommended by my doctor. They even covered my testosterone replacement therapy, which most insurers do not cover at all, especially not Medicare plans. I get vision and dental coverage, free gym memberships, free in-home consults if I want them, free quarterly over-the-counter shopping credits, and a variety of other goodies I've never even looked into.

Most of my prescriptions end up costing me $0.00. There was once a significant mix-up when my CPAP supplier submitted an erroneous bill (very long story) that could have resulted in disaster if United Healthcare had been sticklers about it, but instead they got on the phone with the provider and sorted it out between them without a paperwork war that could have left me either without my CPAP for a year or with a bill for over a thousand dollars. I ended up with my CPAP, on time, with zero hassle about the bill.

All of this for no premium (beyond the mandatory Medicare premium that everyone must pay out of their Social Security benefit). I'm sure the horror stories are true about some plans, but I really can't imagine how mine could be any better.

[Lizzy9]

We have regular Medicare with a supplemental. And very, very seldom pay for anything once our deductible is met. For me that is easier to budget. Also, we can go to any doctor anywhere and anytime. My HwP sees a fabulous neurologist who is two hours away. Recently he saw a pain management doctor for a nerve block (which is successful and he can now go for walks again!). The pain specialist is in another town and state about an hour away. I don’t know which plan is cheapest in the long run, but we go to what doctors we want and when we want and now we have an excellent “team” of doctors for his various problems.

For me that is well worth the cost!! Plus the budgeting aspect!

Good luck with your decision making!!!

Have a fabulous day!

[pdpatient]

Thanks so much for the responses here and to those still yet to be shared. I have an appointment with a SHIP counselor in a couple of weeks that should be also helpful.

What worries me more is that I am on two very expensive but very nice and effective medications that are not covered by any of the Part D plans. I called up Medicare and they said that. I could ask for a formulary exception, but I am still very apprehensive.

[threezees]

We have Original Medicare plus the AARP supplement. We never pay a co-pay and never get a bill. We can go anywhere Medicare is accepted. It is more expensive but worth it not to worry about bills. My husband with PD has the Aetna Silver Script Choice plan for RX. His use of Nourianz which is thousands of dollars gets him into the catastrophic category within months every year and then he pays $0 after that for everything! They have generally approved all of his exceptional drugs. You need good doctors to submit the proper paperwork for the RX approval. Good luck with your decision process.

[pdpatient in reply to threezees]

Thank you for sharing. Have you not tried for an exception? I am still learning...

[threezees in reply to pdpatient]

I actually spoke with a pharmacist at the Aetna once myself. They were deciding whether to approve a gut motility drug that was expensive. I gave a sob story to the first customer service agent and they connected me to the pharmacist who was making the decision. We went through all the cheaper things one by one which my husband had already tried and dismissed! So the pharmacist approved the new drug. I was pretty happy that he seemed like a reasonable person. He still has that drug approved every year - although it doesn't help anymore sadly. Mostly they get approved with very good paperwork from the doctors themselves. High cost specialty drugs are coming out so fast and furious in Parkinson's and we really need to try them all to find the ones that may help.

[mrssnappy]

My HWP and I have original Medicare with AARP United Health Care Supplement and Wellcare Part D drug plan. The supplement plan includes gym membership and dental discount plan. The drug plan has a 0 dollar monthly premium. This has worked well for my husband because he has cancer in addition to PD. If you have or might have in the future a need for care that is expensive or requires you to seek treatment out of a designated network Medicare Advantage is not a good choice. It's important to know that in most states you will have to go through medical underwriting if you want to switch from advantage to original with supplement.

If you try to switch from Medicare Advantage to Original Medicare with Medigap during Medicare open enrollment, you may find an unpleasant surprise. Because your guaranteed issue period has passed, you'll have to undergo medical underwriting to get a Medigap plan to help cover extra expenses. investopedia.com/articles/p...

[pdpatient in reply to mrssnappy]

Thank you for your warning.