I have no experience, but I noticed one day when I was with DH at his internist’s office, there was a large sign in the lobby saying they did not take Medicare Advantage plans.

I have no direct experience either but have several friends with Advantage plans who seem happy with them. I just got through my Medicare research to make a decision on what to get for DH and opted for a supplement rather than an Advantage plan. I have a healthcare background and a lot of experience as a consumer of healthcare and decided I wanted as much freedom as possible - who to see, where and when I want. I’m willing to pay more for that freedom.

We opted for an Advantage Plan after meeting with an insurance broker (VIA - no cost to you) and discussing plans with the office managers of our primary doctors. So far, we have had no problems with our preferred specialists or procedures. We are both pretty healthy but realize that a major hospitalization may cost us more out of pocket but we have personal savings that would cover the max charged us. The cost worked out less then what we would be spending on premiums.

This is a totally unscientific opinion- It just makes me wonder why on earth do the Medicare Advantage Plans have to hawk themselves on television. It brings out the skeptic in me - just like Alex Trebeck's ads for Colonial Penn.

DH and I opted for regular Medicare and a supplement for the same reasons as 2 katz - we wanted the freedom to choose our providers and not be limited by the Plan. Additionally DH spoke with his billing department and they recommended traditional Medicare over the Advantage plans.

It's not an easy decision - I wish you luck deciphering it.

DH and I each have Medicare Advantage plans- we have different ones because we have different needs.. Each year when we have the chance to change, we look at the various plans and have still come back to Medicare Advantage. I have even stayed with the same carrier ( in my case, Aetna).

The plans really vary by county within each state. My sister, who was a NYC teacher has been sharing some of this. I think she is going to try the advantage plan this year and see how it works.

I agree with Maddie in that I have a great selection of doctors and hospitals. I have no real medical issues. DH on the other hand sees tons of specialists regularly and has had no complications with approvals or referrals and authorizations. It has been working qell for us.

• “Additionally DH spoke with his billing department and they recommended Medicare over the Advantage plans.”

? Ours is Medicare with the Advantage Plan.

Maddielee- I should have specified traditional Medicare. I'll correct my post. And as Salonva pointed out the plans vary. My neighbor is happy with her Advantage Plan and she was the Health Benefits Coordinator for a large regional transportation agency under the State - they negotiated their own plan and had political clout to back them.

“Maddielee- I should have specified traditional Medicare. I'll correct my post.”

I confess to not fully understanding everything about health insurance. we still have traditional Medicare, the advantage plan is what supplements it.

My understanding is that you have one year to "try" an Advantage plan and still go back to a Medigap supplement without having your preexisting conditions evaluated. After that it's possible you cannot go to a Medigap plan depending on your health.

There is a federal free program to help people understand Medicare ins and outs. It has a different name in every state unfortunately, but just call your local county's health Dept/office of senior services for a contact.

Personally, I'll say to keep regular Medicare and your supplement, even if it costs a bit more. Not having that 'gatekeeper' on referrals is a blessing should something go wrong and you need more care.

Several of you have mentioned one of the reasons we hesitate to participate in this pla….we prefer that we have the freedom to choose what providers to see and to follow their advice if we need special tests, without a gatekeeper with questionable credentials to determine what we are eligible for.

@salonva, like like your sister, i'm a retired NYC teacher. This change to a MA plan would apply to all NYC municpal employees. I would guess your sister has filled you in as to how badly this rollover is being implemented. conflicting information, delayed timetables, lack of transparency, etc.

@maddielee, my understanding that in a MA plan, Medicare is no longer administered by the federal government; instead, Medicare is administered by the MA plan, a for profit corporation, supposedly following federal medicare guidelines. i also understand that the MA plan makes money as the fed govt pays a “bounty“to the MA plan for each signup. The MA plan also makes money by not authorizing some procedures which saves them more money. Now if i've made any misstatements, i'd happily be willing to be proven incorrect.

“@maddielee, my understanding that in a MA plan, Medicare is no longer administered by the federal government; instead, Medicare is administered by the MA plan, a for profit corporation, supposedly following federal medicare guidelines. i also understand that the MA plan makes money as the fed govt pays a “bounty“to the MA plan for each signup. The MA plan also makes money by not authorizing some procedures which saves them more money. Now if i've made any misstatements, i'd happily be willing to be proven incorrect.”

This has not been our experience. We’ve also have never run onto gatekeepers or any plan control over who we choose to see for medical care.

Maddielee, your experience can vary wildly depending in locale. You are fortunate.

Remember that providers can opt out of the plan, leaving you to change doctors when you don't expect to.

"? Ours is Medicare with the Advantage Plan."

"I confess to not fully understanding everything about health insurance. we still have traditional Medicare, the advantage plan is what supplements it."

@maddielee, it sounds like you have traditional Medicare with a Medigap supplement. Advantage plans do not supplement traditional Medicare, Medigap plans do. If you have an advantage plan, you do not have traditional Medicare. If you have traditional Medicare and a supplement, you have a Medigap plan rather than an Advantage plan.

According to our current cards, we have Advantage Plans and Medicare.

I promise.

“Remember that providers can opt out of the plan, leaving you to change doctors when you don't expect to.”

I once had a doctor who stopped accepting our health insurance (BC/BS) before my retirement.

Maddielee. That is not the same thing as Medicare plus Medigap or Supplement plan.

‘Supplement’ was not the correct word for me to use.

We have Medicare and an Advantage Plan that work well for us.

maddielee, who do your EOB's come from? Medicare or the other insurance?

^^^our advantage plan

I think if you still had Medicare and a supplemental insurance, your EOB would come from Medicare. We have Medicare Advantage and no longer get EOB's from Medicare. If we have any questions the number we call or the people we contact are the ones at the Advantage company. Our insurance is self funded by the company we worked for, but administered by UHC. We have had no problem and are not limited on which physicians we can see. I had a knee replacement with an out of network orthopedic surgeon that was paid as if they were in network. As someone above said, I think the policies can vary a lot, depending on the company you are insured through.

When I retired I still had 5 years before I qualified for Medicare - I stayed on my Cobra insurance as long as possible ($$$) then had to find other insurance. In my community, through my work, I knew seniors sometimes had a terrible time finding primary care doctors (and others) who would see new Medicare patients. I didn't want to be in that position when I finally got Medicare, so I decided to join Group Health, which is a managed care local coop (that has since become Kaiser). I believed that if I was a regular member pre-Medicare, that they would keep me as a member even when I went on Medicare and I wouldn't have to worry about finding doctors when needed. I believe it is an Advantage plan, but I am limited to seeking care through Kaiser.

I was never a fan of Group Health and had heard some less than great things about Kaiser, but figured either was better than NO doctor. I've been very pleasantly surprised with the high level of care I've received. I love all the docs I've seen over the years. My only complaint is generic drugs, when I know that some name brands work better for me. Oh, and they are a little conservative about treatment (I believe as cost saving measures) but I think if I ever felt I needed more than what was offered, I could get it by advocating for myself and being assertive about it. I am pleased with the low cost copays and other things available through them (glasses, etc.)

My (our) experience with the Advantage plans has been similar to Maddie's. The EOB's come from our carriers. (Aetna and Cigna.) I mention the names because they are obviously very large and even within them, they have numerous advantage plans so again, it's not a one size black and white question. As I have mentioned, DH has lots of health issues, among them, diabetes. His plan is actually geared for people with diabetes. It does vary a lot by location, but as far as selecting doctors I have not come across any that did not take my plan. In addition, my plan includes dental. ( up to $3000 per year). My premium (and for DH) is the basic Medicare amount which I can't recall but I think is $144 per month.

They are all in very well regarded groups, and when I search for care, I do also check out reviews and credentials. FWIW, one of the things I look for (since we are fairly new to the area and don't have years of accumulating info here) is for Board Certification. I know that's not the be all and end all, but it's one filter. All the doctors I use are board certified.

DH has had numerous tests and procedures and has had no problems with having them done (ha beyond normal scheduling).

We are very pleased with the advantage plans.

I think we had this same discussion a short while ago, and the upshot is that people who retire from various governmental/educational/union/etc careers often have medical insurance plans that are not available to the general public.

@sushipup1 that is our situation, although we have a few years before we are eligible for medicare. We have had great insurance through my former employer, which is why I worked the required number of years to get the best insurance benefits. We will stay on the retiree plan until I reach medicare age and then we will move to my company's supplemental plan. I did not realize until recently that due to my years of service, we also get a nice discount (over $200) on our monthly premiums.

Just to clarify the gatekeeper aspect, there are no referrals to specialists in this particular plan; the network is a Blue Cross Blue Shield provider network, so there is a pretty wide assortment of doctors on the list, (better in NYC, less so in other states).

The gatekeeper here refers to the requirement that the dr. is required to get pre-authorization for many tests such as CAT scans and MRIs, which can lead to delays in medical treatment. If the test is denied, which i inderstand happens frequently in MA plans, you can appeal. but there is evidence that very few people appeal, and thus don't continue with their treatment plan.

“The gatekeeper here refers to the requirement that the dr. is required to get pre-authorization for many tests such as CAT scans and MRIs, which can lead to delays in medical treatment.”

@blubird Here’s what is posted on a health insurance (not Medicare, not an Advantage Plan) site about certain procedures. Note that Prior Authorization is required for certain services. Even for those still under ’regular’ health insurance plans.

https://www.floridablue.com/members/tools-resources/prior-authorization-for-medical-services

“Ahead of some services, we ask your doctor to consult with our medical and pharmacy teams to discuss and agree on the course of treatment. This helps be sure you’re getting the right care and to know that your procedure or medication will be covered. Be sure your doctor gets the following services approved in advance (also called prior authorization). You may be responsible to pay for the services that are not approved.

• Advanced Imaging - Prior Authorization
• Select Medical Pharmacy Drugs - Prior Authorization
• Cardiology Services - Prior Authorization
• Sleep Studies - Prior Authorization
• Hip & Knee Surgeries
• Spine Care - Prior Authorization
• Radiation Oncology ”

So with pre-authorizations, your insurance company decides what medical treatment you receive, not your doctor. That may be a good plan when you are healthy. The less medical care you receive, the more money the insurance company keeps.

"with pre-authorizations, your insurance company decides what medical treatment you receive."

It's a yes and no situation and unfortunately the insurance company wields most of the power. If the insurance company approves the test that your physician prescribed then you're getting the treatment that your doctor recommended. If they deny it, yes it can be appealed but that's not a guarantee that it will be approved.

I have an Advantage PPO plan. It provides all of the benefits of traditional Medicare - all Advantage plans are required to do so. There is no extra cost to me - I pay my regular Medicare part B premium to Medicare directly each quarter.

I am pretty healthy. My plan, so far, has paid for me to visit a couple of specialists along with my PCP (everyone I wanted to see has been part of the PPO) with a small co-pay ($25-40). My medication is free, and I have an OTC benefit as well that pays for a certain $ amount of things like cold remedies, allergy meds, oral care, pain relievers, skin care. There are also basic dental and eye care benefits - which basic Medicare doesn't offer- but I do pay for a different vision insurance because have some issues..

However, there are some things in which they only follow the Medicare benefits - like, a pap only every 2 years, and my GYN does have to request approval. If my GYN exams were provided by my PCP, I think it would be included in the yearly preventive exam benefit without pre-approval.

All of the above is really not much different from my employer provided plan (from a hospital system that self-insured).

There are many MDs who don't accept traditional Medicare either, because the reimbursement rates are so low.

Medicare only pays 80% of a hospital bill, period - my Advantage plan, I believe, is slightly better, up to a maximum, but does cap OOP.

A health insurance broker is a good person to sit down with to discuss the pros and cons of all the options. Medicare also has information on its website. Which plan is right for you really depends upon your health, your anticipated health care needs, and your finances.

I don't think there's much of any kind of health insurance coverage these days that doesn't have contracts with facilities and providers from which they can opt out if they find some other option more palatable - Medicare included. As far as brokers are concerned, they are insurance sales people and you never know what kind of incentives they get to promote particular products. I sat in on one of their educational webinars which was helpful as a start but I got a lot of info from other sources online. I also queried various friends to see what choices they made and why.

In order to to get a Medicare Advantage plan you have to have Medicare first, of course. I've had a Medicare Advantage Plan for many years and with different insurers. The one I have now is an HMO (which I said I'd never have) and I've never had a problem getting any procedure approved. Even Medicare won't approve every procedure requested. Most doctors in my area accept it, perhaps because it's a large, well-known company. I don't have to have a referral for a specialist, they just have to be in my network, which most are. My plan also has vision and dental coverage, which I like and need. One of the reasons I have it is because there is a set, daily charge for the first seven days I'm in the hospital and after seven days I pay nothing.

If you can afford to pay a large monthly fee for supplemental insurance, plus all of your own dental and vision costs, then I'm sure Original Medicare would be fine. .

@maddielee my pre-medicare health insurance required pre approvals for those items you mentioned; however, government medicare does not. The MA plan does require those pre approvals. There has been some rumor circulating that regular medicare may require pre approvals, but that seems to be limited to certain doctors who have a track record of over requesting some procedures. those drs would have to get pre authorization approval.

@Zalco/bring back Sophie!, ”So with pre-authorizations, your insurance company decides what medical treatment you receive, not your doctor. That may be a good plan when you are healthy. The less medical care you receive, the more money the insurance company keeps.” …..You pretty much summed up my gut feeling about being shoved into this MA plan.

We already have dental and some vision coverage through our union benefits, so this MA plan does not add any of those. This whole rollout has been loaded with scant information, incorrect information and obfuscations. The city is touting the Silver Sneakers membership, the meals after hospitalization, (if one qualifies) and some mention of a few rides to and from dr appointments as the best thing since sliced bread. None of those is a big help when youre ill and need medical attention.

Yours sounds similar to what we have. I'm a retired teacher from the state of Michigan. Our Medicare Advantage plan is administered by BC/BS, and I carry my husband on it, since it was better than what his company offered. So I have Medicare premiums taken from my retirement pay (amount depends on your income), pay a very small amount (less than $100. for both of us) for additional coverage from state of MI. It includes vision, dental, and hearing. We have been happy with it and have never had them refuse to cover tests, although the yearly deductible has gone up quite a bit over time. They have a list of "preferred doctors," but we live out of state and so can choose whomever we wish. Every year they offer us the "opportunity" to choose something else, but this has an annual

max out of pocket and works well for us, since my husband has a number of health issues. Hope that helps.

I looked into one Advantage plan fairly closely because a couple friends have it and are very happy with it. I did find that the network of dentists was quite small and didn’t include mine. It included the very large local groups that I consider to be revenue generating machines. There was also an additional $25 per month premium and $75 deductible if you wanted $2500 of coverage instead of $250 per year. What was covered seemed good but again only covered in the limited network. I won’t go to any old dentist or doc so decided the dental coverage was of no value to me. I never looked into the vision coverage after I determned the dental didn’t work for me.

I use a health insurance broker, and I am very happy with him. I might decide to change my supplementary insurance at the end of this year because I have a SCAN program and requires me to use UCLA doctors, which is great while I am in Los Angeles (no shortage of UCLA doctors, clinics, etc here), but this provides me no coverage at all in Palm Springs, and I might need to go to a doctor there when I am in the desert.

If I switch to Blue Shield, I will still be able to see the UCLA doctors, but I will also get coverage in Palm Springs, and so it might be worth it to change. Or I might delay it for another year and only go to doctors while I am in L.A. I have switched my dentist to one in Desert Hot Springs, but I have no dental coverage anyway, and so I always pay cash for dental work.

I received a Medicare book in the mail today, and it is very confusing to me. This is why I would want my insurance broker to explain my options to me, and his service is free.

Lars, I don't think his service is free. You don't pay him directly. Insurance companies pay him via commission, and some companies may pay additional bonuses or higher commissions to push their products.

Lars, I would be concerned waiting a year to change if you have no coveraage in Palm Springs. While we never think things are going to happen to us, they do. If you have a medical emergency (stroke, heart attack, bad car accident, fall, broken bone, etc) and no coverage that could be a very steep bill.

Emergency coverage is included in every advantage plan, but must be deemed an emergency after the fact by your insirance company’s review. This determination includes factors such as your diagnosis, type and duration of treatment, and the distance you were from an in-network provider when the emergency—- illness or accident— occurred. If Lars has a fall in Palm Springs he is covered, but not necessarily for a sore throat unless accompanied by a fever.

We ran into an unanticipated situation with my husband’s insurance situation. Because he is completely disabled as a result of his illness and subsequent procedures in 2019 (we are at 20 surgeries now) he qualified for medicare 20 months after the date of his disability. We had Cobra insurance from his previous employer that covered us both (at great cost) until he reached that medicare eligibility. Coincidentally, I also became eligible for medicare in the same month as I was turning 65; I am two and a half years older than he is. Our plan was to choose regular medicare and the most extensive coverage supplement, as you can downgrade your supplemental coverage but never increase it. I obtained this coverage without problems, but my husband was rejected for supplemental coverage because he is 62, not 65. We were told that when he turns 65 he will be newly eligible for supplemental coverage at the medicare group rate as if he were just obtaining medicare for the first time. We were told this by three insurance companies and brokers, but it sounded so bizarre I called Medicare and spoke directly yo two people there. They confirmed it; a person who gets medicare for disability instead of age is not eligible for the medigap policy group rates. My husband was instead offered similar supplemental coverage for $1300 per month in addition to his near $500 per month medicare cost.

As an alternative we looked at Advantage plans. They are medicare SUBSTITUTES, NOT SUPPLEMENTS. Most have restrictive panels of physicians and hospitals, imaging clinics, and other service providers, and most of those are restricted geographically determined by what is available AND by cost, in or near one’s county of residence. We still hope to be able to travel at some point so I looked for Advantage plans that were not restrictive. Those higher end Advantage plans were available in our area at an additional monthy subscription ranging from $50 to $200 per month. There is still an out of pocket for DH’s plan but no deductible for most of the services he will use, and no out of network additional charges and no out of network deductibles or decreased coverage. For the two months he has had it we’ve had no issues. Financially it works out, if we end up paying the out of pocket in a year, on a par with my traditional medicare plus my highest coverage supplement cost. If he doesn’t have to pay even half the out of pocket costs in a year’s time then his plan costs less than mine for that year.

We will reevaluate both plans annually and revisit the supplement vs advantage issue when he turns 65. Plans and costs change yearly so its a good idea to do that regardless. Most people select “free” Medicare Advantage plans as a lower cost inclusive coverage than the Medicare-plus-gap model, but there are also overlooked paid Advantage plans for whom some here may be good candidates. Ironically, we are now paying only a few hundred dollars less for our “affordable” medicare coverage than we did for our “expensive“ Cobra insurance.

Thanks to the Covid impact on DH’s S-corp his medicare plus supplement and part D are half what we paid for an individual plan and we now have no deductible or copays vs $1400 deductible, 20% copay and $4000 out of pocket per person in network. We also now have no network other then whoever accepts Medicare.

I played golf with a friend today who worked in the insurance business his whole career. He’s a big proponent of a local Advantage plan which he told me would save us $300 per month per person with some copays and a local network. I let him know I’m okay with paying the additional $300 to have complete freedom and flexibility to go wherever I want including to an out of state expert should the need arise.

Well, a new situation arose where the whole implementation of the MA plan might be stalled. Aetna, who was in contention with Empire/BC/Emblem(Alliance is the name of the newly created partnership) for the coveted NYC business, just sued NYC and the Municial Labor Relations board claiming the process of choosing was done illegally and that Empire et. al. did not meet the qualifying requirements, yet somehow they were awarded the administration of the MA plan. getting my popcorn ready.

While I'm glad to hear that many of you who responded are happy with your MA plans, one of my particular concerns is that I no longer live in NYC, where many of the drs. are in the BC/Bs etc. network. Pre-medicare we had to travel significant distances to locate drs. in network. This new Alliance MA plan would draw from that same network, so I'd be traveling again if I wanted to be in that network, and most likely having to give up my current drs. Which leads me to think that opting out of this MA plan and paying that monthly surcharge is the way to go for now, if the MA plan does survive the legal challenge.

My DH manages care for one of his older siblings and has run into an issue recently with his Medicare Advantage plan. His brother is 66, has a serious mental illness and lives in an assisted living facility. He lives about 5 hours away from us, so we are not able to check on him on a regular basis. He takes his medication regularly, so that is not an issue.

DH tried to set up home therapy for him (two agencies in his city offer a behavioral health component). However, neither accepts Medicare Advantage (or private pay for that matter). They only accept Medicare. I don't know if this is the case with other types of home care services, but it is something to consider. My mom has regular Medicare and receiving home health services has never been an issue for her. I know there is a limit on the number of visits, but that has also not been an issue.

Blubir, the advantage plan we purchased for DH (because of issues stated above) has a network but no out of network penalty or lowered reimbursement. The additional cost MA plans have a surprising range of features.

Texanjana, I had a specialist whose business office people tried to tell me they couldn't take my MA plan. I called my insurance and they did a three way conference call and got it straightened out. Your situation is probably different, but it might be worth a call to your BIL's MA plan. That seems really strange that they won't accept private pay.

lizbeth-gardener I will take your advice and make sure to change my supplemental insurance this year. I think I will have to switch from SCAN to Blue Shield, but I will discuss it with my insurance agent, as he has given me good advice in the past. I realize that he works on commissions, but he still has a better understanding of my needs and how to service them than I do.

Lars, I didn't read what you had written correctly. I didn't realize you were on Medicare and were talking about a supplemental or Medigap. I thought you were talking about just having SCAN as your only insurance, so Kswl is probably correct about emergencies being covered whether you are in LA or the desert. But do check to be sure; better safe than sorry.

Did Alex change last names in the last year?

Since this thread resurfaced, and I am aware that things got delayed with the NYC situation, I figured I will take the opportunity to ask @blubird (and any others) if you've decided which way to go. My sister has been following along on several zoom sessions explaining it all and seems very confused.

NYC retirees had a brief respite when the retirees group filed lawsuits which challenged several aspects of the implementation of the original MA plan with Anthem, a for profit division of BS/BS and due to judgements against NYC, the original plan was dropped.

However, in recent weeks, the new mayor, Eric Adams, who had claimed he was against the idea of MAPs, suddenly sided with several of the unions who were pushing for the MAP. Although the concept of unions not siding with their retirees is abhorrent to most of us, that is the current situation. . (There seem to be some funny money financial issues which are pitting the unions against the retirees; if anyone is really interested in how this all developed, I,d be happy to fill you in)

Another company, Aetna, has come up with a new MAP proposal. Supposedly this one has fewer pre auths required (for now) and it's supposed to be what they call an extended service area to expand use outside of the NYC area, However, many of the out of state retirees are finding out their current medical facilities and doctors do not accept this plan.

And, to make this new situation even worse, is that with the earlier proposal, a retiree had the option of remaining with original medicare and their current supplement, for an additional fee. The current proposal is sort of ’my way or the highway’ in that there is no option for staying with our original Medicare and city provided supplement, one would have to opt out of city coverage completely and find their own supplement, at not group rates. Since Mayor Adams just signed the MAP contract this past week, a new retirees group lawsuit has been filed. Wish us luck.

I've actually seen the results of an unwanted switch to a MAP personally, My cousin, a retired teacher from Maryland with some recent serious medical issues, currently living in NYC, was recently switched to a Maryland MAP. She was injured last week and found that 2 of her doctors would no longer accept her MAP, and she needed a hand doctor for her injury. she had to call over 10 hand doctors to find one to take her MAP.

Unfortunately, this seems to be where many mucipalities are heading for Medicare retirees, but a change is in the air for active workers as well as to the type of plans offered.