Medicare Part C or original Medicare?

[dabomb79]

My older family member relies on me to handle anything insurance related. She has original Medicare. She also makes such a low income that Medicaid covers everything else that isn't covered my Medicare. Just got off the phone with a representative that has offered to enroll her into a Medicare advantage plan. So many benefits that my grandmother would benefit from: hearing aid coverage, denture coverage, etc. All her doctors are covered under the medicare advantage plan as well as all her drugs. All for the added cost of $0. It just sounds too good to be true. She pays $0 in Medicare and Medicaid premiums.

We have had almost 0 issues with original Medicare.

What stuck out most to me was "prior authorizations and "run by a private company" during my conversation. My relative has numerous health conditions. Companies will always choose profits over patient care in my experience. What is the company doing to offer these benefits, but still make a profit?

Just very confuse at the moment and would like yall guidance/opinions. Thank you!

 

[chelseamc]

@dabomb79 Google your local “Area Agency on Aging” and ask if they have Medicare counselors. Different states call them different things. Here in Illinois, they’re called SHIP counselors. They’re objective and unbiased and can help your mom pick the best plan for her, not their own wallet.

 

[kellic]

@dabomb79 In addition to everything else that was said, be aware that the network restrictions apply not only to doctors and hospitals but also skilled nursing facilities for rehab after hospitalizations. MA plan networks have limitations in that area also. My neighbor went to a pretty crappy rehab post hospital because the nice ones in our town weren't in network. Also, I was told that because MA plans are such a hassle for the facilities, if there's an open bed they will give it to an original Medicare patient before one with MA.

Many people are happy with MA but there are disadvantages. But I believe if your grandmother has Medicaid help, she could try out MA and return to Original Medicaid if it didn't work out and get the Medicaid assistance again.

 

[vladimirsurguy]

@dabomb79 Sounds like a Medicare Advantage D-SNP plan. My company sells them and we do indeed give tons of additional benefits like dental, vision, hearing, $0 copays on basically everything that is covered, and we even give members a pre-paid debit card that they can use for groceries, otc meds, gasoline, and to pay certain medical expenses that otherwise might not be covered.

Medicare Advantage plans take the place of traditional Medicare. The upside is the extra benefits, often for little to no premiums (sometimes they even give premium credits towards part B). The downside is that you must stay in the insurer’s network (with limited exceptions) and be subject to their medical review policies (which do at least have to be approved by Medicare). That’s how the insurers make money - basically they’re negotiating lower costs than Medicare and also getting paid based on how sick their member population is. There are also financial incentives for meeting certain quality measures - that’s where the star rating of the plan comes in. Besides the insurer’s network, that’s the other thing you should be aware of before you sign up for any MA plan. Check their star ratings. You can use the plan finder on Medicare.gov to compare plans in your area.

 

[joelelangovan]

@dabomb79 DON'T DO MEDICARE ADVANTAGE - THEY TAKE ADVANTAGE OF YOU!

I'll tell you what I tell all my patients at the PT clinic I manage and all my friends - GET MEDICARE! They'll cover practically everything (at 80% without a medigap plan) and you don't have to jump through hoops to get things approved.

For example, a post op patient with Medicare does not have a visit limit so long as it's deemed "medically necessary" which means the patient either needs an Rx for PT or their doctor needs to sign our Initial Exam/Progress Notes to continue treatment. Simple! Now let's say that same post op patient has a Med Advantage (MA) plan through Anthem BC - I submit for prior auth through another third party (Carelon), and they might get maybe 9 or 10 visits to use for 3 months. If the doctor/PT is advising 2x a week for let's say 4 months, they'll run out of those visits shortly after 1 month!! We submit again, now maybe they get 4 or 5 visits. And they typically whittle down from there. If the patient isn't post op, I'll get 4 or 5 visits tops to use for 2 months. The Medicare patient won't have this problem.

I would highly suggest to everyone to get Medicare and a secondary or better yet supplemental. Depending on the medigap plan, some still may have a doctor's visit copay, but several plans will pay the remaining 20% that Medicare doesn't cover (at the cost of a higher premium, of course).

And the best part - Medicare's annual deductible is extremely low. This year it's $226. For everything! Even better with the Medi-Medi plan your relative already has, they don't even owe the deductible! They should owe nothing!

I'll give the example of my parents. 2020 was an intense year for us - between the two them I had to coordinate 5 surgeries, 2 under emergency and 2 others I classify as urgent (including removing a very aggressive tumor). Their total billed out for surgeries came to around at least 750k. What did they owe? Just $223 each for the annual Medicare deductible! (They had a supplemental, but it was the lowest tier so they did owe $20 office visit copays but it wasn't much).

I say Medicare Advantage - they take advantage of you. Instead of you getting your earned MC benefits, the claims now go to a third party payer like Anthem BC/UHC/Aetna and THEY will determine if your procedures are a covered benefit, many times requesting pre approval even for outpatient physical therapy post op as I highlighted in the above scenario. My dad's retired and gets his insurance through work still - they are forcing all employees to an MA plan. We're calling them and he's paying to keep his Medicare. Why would they force everyone on an MA when the previous year employees could choose? Makes you think...(not really)

If they already have Medicare and Medicaid secondary, why change?? That's a Medi-Medi plan. Even providers not in network with medicaid (like us) can take it, we just agree to accept Medicare payment in full and not bill the patient the remaining 20%. You do NOT want to deal with the prior approvals. Your relative will be denied necessary care. I see it all too often!!

TL;DR Medicare all the way 1000%%%

 

[drewanew]

@joelelangovan I agree

I didn’t want anything to do with an Advantage plan. But in the state of Ohio if you are a Dual Eligible (Medicare and Medicaid) the state forces you into an Advantage plan.

I don’t have any complaints, yet. I have an upcoming hernia surgery so my opinion may change..

 

[joelelangovan]

@drewanew Wow really? My parents are originally from Ohio (Cleveland) I'm going to visit in April...anyways that's different. They don't allow a medi-medi plan there where you can keep both and the providers who aren't with Medicaid just write off the remaining 20%? That's what our office does out in CA.

Also good luck on your hernia surgery. My dad went through 3 of those as part of the medical journey I described above...are you doing laporoscopic or open? His first surgery was under emergency while his intestine went gangrene, so when they were taking care of that they put a pig's bladder in to lessen risk of infection, but they said 50/50 it would hold and yeah it didn't. Then 9 months after that he had the actual "elective" laporoscopic surgery for the bilateral inguinal hernias. That held for about a year and a half until they popped out again and I took him to the ER a few times, one time he was in so much pain they gave him morphine. Then finally I found a Hernia specialist in SoCal who all he does is these operations and travels the country giving seminars on it. Since he had so much scar tissue from past operations he did it open. That was February 2023 and it's held since. Too bad you aren't on the west coast, I will recommend this hernia doctor all day long to anyone who will listen.

Dr. Todd Harris, M.D. FACS
4501 Birch St
Newport Beach, CA 92660

He did it quick and even with him removing the scar tissue, it was a 1 hour outpatient surgery vs. The 4 hour laporoscopic in the hospital.

 

[drewanew]

@joelelangovan Wow, your poor Dad! I hope to have it laparoscopic so there’s less scarring. I just had a cat scan to find out if I’m a candidate.

 

[drewanew]

And now I’m nervous lol

 

[gchakko]

@dabomb79 It's incredibly confusing but MA plans are private insurance plans. The advantage is that they have lower premiums and out of pocket costs. The disadvantage is that treatments must be authorized by MA and the doctor network may be limited. Regular Medicare may be more costly but you don't need authorization for treatments and more doctors are available. I have heard that MA patients move back to regular Medicare when they have major health issues since treatments may not be authorized by their MA plan.