Top 5 things your Medicare Advantage sales agent won't tell you

Top 5 things your Medicare Advantage sales agent won’t tell you.
https://retireearlyhomepage.com/medicare2022.html

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Medicare Advantage have low out of pocket expenses for the typical insured. They also have low premiums and include coverage for dental, glasses, hearing aids, etc.

Presumably they are subsidized to offer those benefits.

You might expect higher costs for treatment of major medical issues–making your lifetime costs average out.

Once again its the old “you can pay me now or pay me later” pitch. You can save money if you make the right choices and anticipate your future needs correctly. But for most of us, you may as well toss a coin. The actuaries are probably much better at it than we are. But then they don’t usually know details of our medical history.

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That is a great writeup, intercst, I appreciate it very much. In another year or so I’ll be having to make a decision on Medicare plans, I’ll definitely be going to your site to do some studying. Thanks in advance.

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Hey UpNorthJoe -

I’m not sure where you are located, but here in MA, there is a no-cost, confidential volunteer organization by the name of https://shinema.org. They help you determine what plans are the best for you considering your health, your desire to pay for insurance (more or less insurance?) and risk profile.

I found the SHINE counselor that I spoke with to be extremely knowledgeable, objective and helpful. I’d recommend them highly!

'38Packard

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38Packard writes,

I’m not sure where you are located, but here in MA, there is a no-cost, confidential volunteer organization by the name of https://shinema.org .

[/snip]

That’s called the SHIP program. (State Health Insurance Assistance Program)
https://www.shiphelp.org/

The Federal Gov’t gives each state a grant to set up the volunteer organization to help folks with their Medicare choices.

I went to a SHIP seminar in WA State 3 years ago and found it to be excellent. Two things the speaker stressed during the presentation.

#1 If you choose Medicare Advantage, you can change your mind during the first year and switch back to traditional Medicare and a guaranteed-issue Medigap Plan. But if you wait more than a year, you lose the ability to get the Medigap Plan without medical underwriting. Depending on your health, an insurer could charge you a higher premium on the Medigap Plan, or deny coverage.

#2 The SHIP counselors are not allowed to make a specific recommendation (e.g., Medicare Advantage is crap) to a client on what’s the best Medicare choice. They have to hope that the client can follow the complex arithmetic and rules in each policy form and make an informed choice. It’s easier if you have an engineering, accounting, or law degree.

intercst

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Intercst
Top 5 things your Medicare Advantage sales agent won’t tell you.

I noticed Kaiser wasn’t included in the list of companies in the link. Is that because they provide both health care and insurance?

Thanks for the link,
jg4

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Kaiser isn’t among the top 4 in Medicare Advantage market share, but their Executive Compensation is in the same range even though it’s a so-called “non-profit”.

The Current State Of Nonprofit Hospital CEO Compensation

In the world of nonprofit pay scales for executives, hospitals are outliers. A 2021 report from the Economic Research Institute (ERI) found that the average annual CEO pay in most nonprofit industries was between $100,000 and $200,000 in 2018. The two exceptions were university CEOs, who were paid an average of $350,000, and hospital CEOs, who were paid on average $600,000. But the average belies the true dimensions of executive salaries in health care systems. In 2018, Bernard Tyson, then-CEO of nonprofit health care giant Kaiser Permanente, made nearly $18 million, making him the highest-paid nonprofit CEO in the nation. The previous year, the top 10 highest paid nonprofit health system executives each made $7 million or more.

[snip]

We should all be so lucky as to run a “non-profit” operation like Kaiser Permanente. {LOL}

intercst

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I went to a ship seminar in Indiana…they laid everything out without giving any recomendations…but…after the official meeting i individually asked the presenters exactly what the personally used and how it worked…i also have followed interest’s posts and his website…no advantage plan for me…

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I have a friend who had his appointment for a colonoscopy cancelled at the last minute with seven different providers. He is on a Cigna Advantage plan and had no problems making an appointment but as the date neared the provider starting checking the particulars where they discovered that either the doctor, or the anesthesiologist, or the surgery center itself did not accept the particular Cigna Advantage Plan he was on. No way would I cnosider any Advantage Plan.

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Keep in mind, there are MA plans and then there are MA plans.

Group model HMOs such as Kaiser or Providence are structured and operate differently than Point of Service PPO style plans

Some MA plans incorporate medical services not covered by Medicare, such as hearing, vision and dental although most I’ve seen offer this as a separate coverage. Almost all MA plans incorporate a Part D plan although there are some who do not and so Part D must be carried separately. There are some plans that will also offer membership in local private gyms and exercise facilities who specialize in activities for seniors.

We have had the Kaiser Senior Advantage since 2015 and have generally been pleased with their services. They are consistently rated 5 Starts by CMS (Center for Medicare-Medicaid Services). They are big and a bit bureaucratic which can be frustrating. But in general their services are prompt, our questions/concerns answered and are proactive in making sure we get our annual medical screenings, vaccines and preventive medicine testing. To make such a large system function well requires skill of top management which means paying those positions well.

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Absolutely! Kaiser is very different from traditional Medicare.

Whistleblower case against Kaiser Permanente alleging risk-adjustment fraud

The Inspector General found $30 Billion of for-profit, Executive Compensation fueled fraud in the Medicare Advantage program. Just because Kaiser is “non-profit”, doesn’t mean it’s executives aren’t being paid like the Pharaohs.

Executive Compensation at Kaiser Health (2019)

I had Kaiser for 2 years while on Obamacare since it was the cheapest plan and I rarely need to see a doctor. Whenever I tried to get prescription filled, I asked my doctor to give me a written prescription I could take to the pharmacy with the best price. Instead Kaiser kept referring me to their inhouse pharmacy where everything was double and triple the cost. I had to threaten to file a complaint with both the State Insurance Commissioner and State Medical Board to put a stop to it. It’s illegal in Washington State for a medical provider to force you to use their captive pharmacy as a condition of receiving care.

intercst

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I agree with BruceCM’s comments about Kaiser. I have been on their Senior MA plan since 2005 and have had a similar experience. However, living on the SF Bay Peninsula and within walking distance of one of Kaisers major hospital/clinic locations is a big factor. I can walk or take a short drive to get service whenever I need it.

I have had three doctors since I began with Kaiser and all three have been excellent and you can change doctors if you don’t like the one you have. My premiums are $85/mo. I had Cataract surgery ($200 copay each eye) with them at the same facility near me. Only once did I have to go to another Kaiser location, it was for a retina scan. I have a minor spot that is not a problem. Their hearing aid center also is at my local Kaiser and they have good audiologists.

Last year, I had some chest pain and called the local Advice Nurse who listened to my symptoms and recommended the local emergency room. Err on the side of caution I suppose. I was immediately admitted to a private room in the ER and they proceeded with a barrage of tests and specialists. From the blood work they determined I did not have a heart attack, but the cardiologist had me take a treadmill test to evaluate my heart condition. He told me that I passed with better results than men half my age (80). My use of the gym over the years helped I suppose. I was at the ER for over 4 hours in a nice bed with TV and connected to wires/tubes and visited by many specialists. Copay was $75.

I use their Healthwise Handbook for any aches or pains I am suspicious of frequently and often it eliminates having to call the Advice Nurse or doctor. Their email interface is very useful for communication with your doctor and eliminates phone tagging.

Kaiser’s evacuation from abroad coverage has been of interest to me as I travel to Britain frequently. Emergency coverage there is covered by NHS and we have had to use that for minor problems in the past. Comments from anyone with experience or knowledge about a Kaiser evacuation would be welcome.

I have been lucky so far and my experience has not included major surgeries, cancer, or other major problems. So I am interested in reading about Medicare or the Advantage programs to see others experiences, but so far I have been satisfied with Kaiser’s MA plan.

jg4

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All MA plans are different from Traditional Medicare.
When one enrolls in Medicare, they have two alternatives (depending on where they live)

  1. Traditional Medicare, where Medicare is primary and a Part D plan is required. In addition, most will subscribe to a Medicare Supplement to cover what Medicare covers but does not pay for, such as deductibles, copay, coinsurance, overseas travel, etc
  2. Medicare Advantage plan. Here, with the exception of Hospice, Medicare is out of the picture for the insured. All dealings are with the plan. But unlike Medicare, MA plans are offered by region, usually by county. There tend to be more MA plan offerings in metropolitan areas and fewer to none in rural counties.

The major difference with Kaiser as a Group Model is that Kaiser owns most of the means of healthcare delivery, while PPO, Community HMO and POS MA plans typically have a for profit private insurance company contracting with disparate groups of providers to provide medical service. This allows for more flexibility of access but also puts more risk on the insured to stay within the plans coverages and contracted providers.

The older PFFS MA plans (I’m not sure they still exist today) were rife with corruption, as I recall. Their attraction was no premium and full flexibility in selecting your provider. But, as I recall, all billing discrepancies were the problem of the insured, not the insurance company or Medicare.

That there was some level of corruption with certain MA plans likely has nothing to do with Kaiser.

As I said, Kaiser can be bureaucratic and a bit inflexible in their procedures. If that’s not your cup of tea, then don’t go there. My sister would NEVER go to Kaiser where she says everything is a 'Take-a-number-and-wait-cattle call"…which it kind of is. I don’t mind…I just take my Sudoku game with me. I’ve never encountered a nurse, tech, DR or other provider who was not professional and responsive to my questions. I have 3 prescription meds that each cost me $10 for a 90 day supply. Never had a problem. Their renewal is prompt and always accurate.

The important take-away for new Medicare beneficiaries is to find a plan that fits your needs and make sure to understand the rules, coverages, cost share and the rules for changing plans at a later date.

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That’s my big worry. I don’t want a $30 million a year health insurance CEO between me and my doctor – a CEO who’s financial interest is directly opposed to mine.

intercst

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I guess Medicare itself doesn’t stand between you and your doctor…c’mon man

I assume you’re speaking of for profit insurers offering the MA plan, such as Aetna (CVS), Humana or United Health Care? If so, the CEOs show total compensation ($Millions) of $20.4, $16.4 and $12.8, respectively, with all but $1MM or so (the max deductible to the company) in the form of stock based compensation. So how is this level of stock-based compensation getting between you and your DR and how would the CEO’s interest be directly opposed to yours? Wouldn’t they be aligned? I mean, if the CEO is doing their job by putting in the time and brain power to make sure subscribers are happy and they’re getting value for their premium, then wouldn’t enrollment increase, revenues and profits increase and stock bonuses to execs increase?

And if you go with straight Medicare and so subscribe to a Medicare Supplement and a part D plan thru one of these for profit insurance companies, wouldn’t you have the same situation you’d have with a MA plan?

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I was visiting, last year, with a friend (lets call him Bob) who works in a patient services position in a large hospital in the DFW area.

I was preparing to choose the flavor of medicare I wanted. Bob didn’t know that.

In the course of listening to Bob talk to a group of us, Bob spontaneously commented that MA plans are great for HEALTHY people, or people who are on maintenence drugs/care for NON-CRITICAL issues. But when that MA covered person has a health emergency, or when that person suffers some dire health issue, MA plans ROUTINELY deny coverage.
Bob said MA plans will refuse coverage for weeks, resulting in a patient getting care too late to be an effective treatment.

Bob’s actual words were something like “MA plans deny coverage for critical care, until the patient either dies outright, or is so debiliated that the patient dies “sooner” than s/he would have.”

Since I was in the process of choosing which “plan”, this caught my attention.
Part of Bob’s job is to get the patient’s insurance to verify a procedure is covered.
Bob said Traditional Medicare routinely COVERS emergent health issues much more rapidly than MA plans. Bob said rapid approval means the patient gets care in a more timely manner.

That said. I have 6 or so other friends who have MA plans. They are a group who all follow each other. I chatted with them to suss out their opinions of their Medicare plans.
They claim to LOVE the MA.
MA has covered knee, hip, and shoulder replacements for them, as well as heart, diabetes, etc care. Often though, they had to repeatedly request and submit additional “info to prove eligibility” to get the the coverage.
Dental has been problematic for 1 person. She had to jump through hoops, her dentist also had to jump. She has the same MA plan as the others. I don’t know how the others dental care is handled.
She also got bariatric surgery… AFTER jumping through hoops, multiple times, over and over.
(I dont know anyone with Traditional Medicare who has gotten bariatric surgery.)
The majority of seniors I know, chose MA with a local regional non-profit hospital that has been subsumed into a larger regional non-profit group.

A few people I know have Traditional Medicare and have had knee, wrist, and shoulder replacements. I don’t remember any comments about having to repeatedly request the treatments.

Yes, this is anecdotal. So, take it as such.

:alien:
ralph went with Traditional Medicare. So far, I’m questioning the expenses charged to me for a covid consult back in June.
The bill was passed to “review”, the representative tells me it says “pending”. The billing department is sending “PAY IT NOW!” emails and messages on the My??Health web portal.

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Interesting assessment of MAs and serious illness.
I cannot speak to PPOs, but Kaiser routinely gets a 5 star rating from CMS who polls the MA plan enrollees, and if such mistreatment, including delayed services or disallowed services, my hunch is Kaiser’s Senior Advantage Plan would not be getting 5 star ratings. However, as I mentioned previously, the PFFS (Private Fee For Service) plans are a horse of a different color and I could definitely see something as you’ve described happening in the PFFS arena.

On a personal note, a long time friend of ours who has been healthy most of his life, went through a series of serious illnesses requiring multiple hospital admissions, lots of outpatient treatments, lots of very expensive anti-cancer drugs and finally hospice where he passed away this last weekend. We’re going to meet with her (widow) next week just for some moral support (they had been married 50 years) for a couple of days. I know her pretty well so I think I’ll ask how satisfied she is with his coverage.

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No. CMS makes all the benefit decisions for Medigap. The Medigap insurer just pays what CMS tells them to pay. CMS also does all the accounting for Medigap insurers. Since CMS is doing all the work, it’s crazy that I’m paying a 20% plus “skim rate” to my Medigap insurer, but at least the skim is being applied to a much lower premium. (21% of my $528/yr high-deductible Plan G is just $111/yr. That’s a big difference to the $2,000/yr plus skim to Executive Compensation in a Kaiser Medicare Advantage plan. i.e., 15% of $13,500/yr.)

Medicare Part D is basically a scam. I just buy the cheapest plan available in my zip code ($1.60/month premium from Aetna), and then pay cash for the 3 generic drugs I take. Currently that’s about a $600/yr savings vs. letting Aetna fill the prescriptions. If you’re taking an expensive name-brand drug there may be some value to Part D, but 90% of the prescriptions written for seniors are for generic drugs.

Also, when I put my $400/yr worth of generic drugs into the Medicare Part D search tool on the Medicare web site to check the 2023 costs, the cheapest plan was again Aetna, but they were going to charge me $2,107/yr for the $400 worth of drugs I can buy with a GoodRX coupon. My suspicion is that they’re jacking up the prices charged on generic drugs to fund the new $2,000/yr out-of-pocket limit starting in 2025. The MBAs at Aetna are betting that most people are too ignorant to price shop. I think that’s a sound assumption.

Minimizing the “skim” – the key to retiring early.

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My Mom’s cousin has Kaiser for her Medicare coverage, and just posted on FB about the fact that while Kaiser covers a life-saving drug on a regular basis for her while she’s in CA, she can’t get that same drug while she’s in NY unless she has progressed almost to death’s door. (I have no idea what the drug is, or how often she needs it to stop her progression to death’s door.) Since her life choices have resulted in her spending a lot of time in NY now, she’s trying to figure out how she needs to change her coverage in order to get that drug while she’s in NY. I advised her to contact SHIP.

Just one more anecdote to add to the pot.

AJ

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