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lucillle

Do you have Medicare Advantage?

lucillle
last month

Just a reminder that for many, July marks the quarterly OTC allowance. I got $60, I realize it's not a lot but I got a bunch of OTC supplies from the online catalog and the shipping is free.

Comments (70)

  • JoanMN
    last month

    Not an alternative, if you don't have Medicare, you cannot get a Medicare Advantage program. Whichever company you choose gets a payment from Medicare monthly, and have conditions they have to meet. Medicare tells them which are mandatory. the company can add benefits, but they can't take away the mandated ones.

    Our advantage plan which is Humana, does have the OTC benefits. My husband, who does not have Part D get way more a month than I do. But we have to cover any prescriptions he may have in the future. At 87, the only prescription he has is Simvastatin, which is very reasonably priced.

  • Zalco/bring back Sophie!
    last month
    last modified: last month

    I guess not dealing with this is one advantage to having a husband who refuses to consider retiring. This is way too complicated for me. Yes, I know his health could one day demand it. It's just not Plan A for him. He says the lack of stress would kill him ;-)

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  • Joan Soles
    last month

    I came back to add that diffferent states have some different rules regarding Med Supps. And also, don't take all your insurance advice from strangers on the internet, including me. Try to find a local agent and establish xome trust. Good luck! We made a living selling iMedicare supplements for a long time, when Part D came along, we quit, because it was so confusing. So imagine trying to figure it out for the average lay-person.

  • Mystical Manns
    last month

    Benefit from my late husband, is Tricare for Life. I pay no monthly premiums and everything I've encountered so far is covered by the combination of Medicare and Tricare. No co-pays, either.


    I say "so far" because I'm in good health currently and don't have experience on how this combination will work if my health changes for the worse.

  • DLM2000-GW
    last month

    "I say "so far" because I'm in good health currently and don't have experience on how this combination will work if my health changes for the worse."

    And that's the 'trick' with all insurance, health care and otherwise. You make your best educated guess based on your history and throw in a little for the unknown, while the insurance companies are placing bets on far more widespread statistics knowing you are likely to fall into one of their known statistics. Can anyone begin to read, comprehend and make decisions about which coverage they want based on the fine print in evidence of coverage, which in most/all? cases you don't see till AFTER you are signed on anyway? Maybe 'you' (that's the grand general you, not anyone specific) have that ability but most do not. I certainly don't.

  • Zalco/bring back Sophie!
    last month
    last modified: last month

    Just buying regular insurance as a healthy middle aged couple is frustrating as all get out. Add to that you are buying a product which obfuscates every single aspect of what it may or may not provide when the time comes you need it. Then factor in the added risks as we age is much too hard to contemplate. There must be a better way if doing this.

  • greenshoekitty
    last month

    I do not have one of the plans. I dislike all the ads on tv that say check your zip code you can get stuff. Well in my county you must pay big bucks to get any of them , and would have me paying for stuff I get covered by filing for senior (income discounts) if my county was like so many others, I would get one.

  • sushipup2
    last month

    Two points: Someone mentioned Tricare For Life. That is retired military benefits and is considered the Gold Standard, But it's unavailable to those who are not retired military,

    And check with your local county Office of Aging (may be called something else) for free Medicare counseling. An "agent" is selling something. The consultation is just to help you look at the available plans, regardless of who's selling what.

  • woodrose
    last month

    I've had a Medicare Advantage Plan for many years. As Elmer and others have said, it covers everything Medicare covers, plus has additional benefits like vision, dental, and a quarterly allowance for OTC items. I am not limited to a geographical area when it comes to doctors, hospitals and pharmacies. Why would national insurance companies limit someone to only doctors, hospitals, etc. in one area? I think some people don't realize that "in-network" covers a lot of doctors, hospitals and pharmacies. Also, I don't have to get a referral from my PCP and can see any specialist I need.

    If you can afford Medicare premiums, supplement premiums, etc. then by all means go that route. I can't afford all that, plus I like to keep my health care as uncomplicated as possible, so an advantage plan works for me.

  • lucillle
    Original Author
    last month

    I think Medicare Advantage plans differ, as I am limited to a geographical area. It did not matter what I said, my Medicare Advantage plan refuses to let me use my previous person/office 100 miles away after I moved.

  • raee_gw zone 5b-6a Ohio
    last month

    I have $105/quarter OTC allowance, the catch being (since it is Aetna's Advantage plan) that it has to be used at CVS only. I typically wouldn't buy OTC items there, since IMO they are overpriced - i see some generics that I could pay 2-4 times less at Meijer or Kroger, but since to me it is free, I shrug my shoulders and order it from the CVS catalogue. I would think that it is a practice to price gouge the government, but the prices are the same in the brick&mortar store for non-MA customers.

    I do not need a referral to see a specialist; the co-pay was $45 for the in-network dermatologist. However, they declined a substantial amount of the charges for the in-network podiatrist, so I need to follow up on that . This plan also includes basic coverage for eye exams, glasses (a small allowance), and dental care - but here the network of dentists is very limited.

    I think that so far, the coverage is fairly equivalent to the insurance from my large hospital system, which was self-insured, and Advantage has a few additional benefits. The eye plan was better but at extra cost; the dental had a larger network, but there was a waiting period for coverage for things like crowns, endodonture, & periodonture. No waiting period with the Advantage plan.

    Yes, health insurance really should be much simpler to understand. Instead of hav.ing to keep coming up with patches (like legislation addressing the problems like that of the facility being in-network, but individual providers employed by the facility not being in-network without warning to the patient) and having a patchwork of both state and federal programs to fill gaps, perhaps we should start focusing on designing a really good single payer system for essential health care for all ages



  • Elmer J Fudd
    last month

    "There are serious problems with Medicare Advantage plans--both to the consumer and to original Medicare itself, which pays them-- and I won't go into discussing all of them. However, you can find detailed, correct information about Medicare and MA here"


    What is it about this particular site you've linked that makes its comments "correct"? Why do you consider the information there to be objective and without any subjective bias or intent? Personally, I doubt that any such privately run effort unlikely to be so.

  • Elmer J Fudd
    last month
    last modified: last month

    There's no question that Medicare is complicated. Why? It's a political Christmas tree on which generations of politicians and interest groups have hung their favored provisions and wrinkles of all kinds, some that match and some that don't. To use another dumb cliche, it's also a sacred cow. Just like Social Security, it's a radioactive topic that active politicians stay clear of.

    Layer on top of that Medicare supplemental insurance or Advantage policies. Insurance is also complicated. Policies come in all colors of the rainbow and then some. To say that one type of policy is this or is that requires making broad generalizations that aren't necessarily valid and often aren't.

    Experiences vary, by policy and perhaps also by location. I'll add mine. My Medicare Advantage coverage is part of an "employer" retirement benefit. It could also be a retail policy underwritten by an insurance company. The program overall is administered by an insurance company that gets reimbursed by Medicare for services it covers and by my employer for additional, supplementary coverage. That includes a variety of things like prescription drugs, coverage in some areas that's broader or more generous than Medicare, etc.

    My experience is that most providers in my area, other than those in a pricey concierge-type practices, accept Medicare. As long as a provider accepts Medicare, it doesn't matter for my coverage. We have two major medical schools in the area and both accept Medicare and are out of network. It happens I called in advance of an eye surgery my wife wanted to schedule and spoke to someone in their finance department insurance section. I was told they don't believe it necessary to negotiate fees for Medicare Advantage plans because since they accept Medicare, that sets the rates. My wife had the procedure there and everything was covered, with copays for office visits. She also needed a joint replacement and had it done by one of two highly recognized joint replacement practices in the area that do only such procedures. Both accept Medicare. As do a broad spectrum of physical therapists, medical equipment companies, yada yada. I believe the veracity of the Mayo story but suspect there's more to know about it.

  • phoggie
    last month

    Be sure the doctor and hospital accept MA! My pain management doctor does not! I have a friend who used to brag about MA...but was taken to a hospital for an emergency surgery that was not in the MA network and she had to pay for it out of pocket...needless to say, she went back to Medicare with BS/BS suppliment.

  • Lindsey_CA
    last month

    "Medicare Advantage is a term for health insurance that compliments and suppliments [sic] Medicare."

    No. Medicare Advantage is health insurance instead of Medicare. It's quite similar to Medicare, but it's different. It does not supplement Medicare, it replaces it.

    Hubs and I have Original Medicare as well as an Anthem Blue Cross supplement. The supplement policy pays all of the Medicare deductibles and we also do not have the "donut hole" in prescription coverage that some folks run into, depending on what meds they take. We are not limited geographically at all. Medicare only covers folks while they are in the USA, so if we travel out of the country, our supplement policy becomes primary and covers us anywhere in the world.

  • Elmer J Fudd
    last month
    last modified: last month

    "Medicare Advantage is health insurance instead of Medicare. I"

    Sorry, no. Not in all cases and not for everyone. We're all sharing experiences concerning a complicated area. I'll revert back to mine. I have "employer" health insurance that's integrated with Medicare for covered individuals once they reach Medicare age. To be eligible for coverage, I need to be a participant in Original Medicare. Monthly premiums for Medicare are deducted from my Social Security checks. My supplemental coverage through my employer, which is administered by a large insurance company but the expense footed by the employer, is cost shared and the employer deducts my percentage of the total from my monthly check.

    My insurance card says Medicare Advantage.and the insurance company administrator's name. Providers submit fee claims to one place, the insurance company.

    A couple of times, providers have submitted bills to Medicare and the claims are rejected with a note saying to send them to the insurance company. I know because this happened to a couple of local, miscellaneous providers I've used.

  • chisue
    last month

    JoanMN -- Curious about your statement that your DH does not have Part D coverage. I'd thought that Medicare *requires* everyone to buy Part D insurance.


    My DH and I didn't realize that because it became a requirement after both of us had first been enrolled in Medicare. By the time he bought Part D he was already penalized for the years he'd gone without. Now he must pay a penalty on top of the Part D premium every year.


    Is it because your DH has a Medicare Advantage plan that he can skip Part D coverage?

  • sheesh
    last month

    Chisue, i wonder the same thing. I also pay a life-long monthly penalty because i did not get Part D when I enrolled in medicare. I have medicare and a Medicare Advantage plan.


    Having read this thread with its conflicting information, it is obvious that threads like this are virtually useless, except to prove that we must each navigate this ridiculous system in our own neighborhoods to suit our individual needs. Good luck to everyone.

  • jill302
    last month

    Thank you all for sharing. It appears that there may be more Medicare options than I knew of about. Primarily the different supplements and Medicare Advantage benefits such as the drug donut benefits and out-of-country coverage. Not 65 for a few more years, but this thread has enlightened me that I will definitley need to research all my options a few months before becoming eligible. Definitely more complicated than one might expect.

  • sheesh
    last month

    Jill, I hope that this absurd system is fixed before you turn 65.

  • terezosa / terriks
    last month

    ^^^ There's a better chance that it will become more absurd than be fixed. 😕

  • Elmer J Fudd
    last month

    The system is a mess as I commented earlier and for many of the reasons I mentioned. Don't expect any significant changes in the existing muddle anytime soon.


    As for individuals who will be new to Medicare coverage, I remember reading in this forum some years ago that there are advisory agencies that provide free information and assistance to help. I just looked it up and in my state the program is called HICAP. These are not insurance brokers in disguise but rather disinterested third parties. As it's an area those concerned need to get up to speed with before decisions with lasting consequences need be made.

  • bpath
    last month

    Chisue, I don’t know if it was a typo or a sly dig, but I am going to call the insurer BsBs from now on. It is our private insurer, and now my supplemental, and while the people on the phone are as nice as can be, they don’t always get it right, hold times are long, and the website sucks.

    As I was signing ip, I learned about the penalty for not signing up for Part D at 65. My brother, who signed up for original Medicare only, two years ago, kind of gulped when I told him that. I hope he signs up soon, as the penalty will only grow the longer he waits.

  • sushipup2
    last month

    HICAP is the name of the program in California, and it is known by other names in other states. It is a federal program, administered on the local level by the local office of aging/health department. It was originally part of the Older Americans Act.


    https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/BeneficiaryCounselingandOmbudsmanPrograms

  • terezosa / terriks
    last month

    Also, Medicare.gov explains the differences between original Medicare and Advantage plans.


    https://www.medicare.gov/basics/get-started-with-medicare/medicare-basics/parts-of-medicare

  • woodrose
    last month

    Lindsey_CA Medicare Advantage Plans are not insurance that replaces Medicare. Please read the last sentence in the first paragraph on this page. https://www.medicare.gov/types-of-medicare-health-plans/medicare-advantage-plans/how-do-medicare-advantage-plans-work

  • JoanMN
    last month

    Chisue, my DH (and also my brother-inlaw and a neighbor) had Medicare before Part D was around (they are in their 80’s). They all opted not to get Part D. My BIL gets his prescriptions through the Vets’ Administration. My 87-year old DH pays out-of-pocket.

  • blubird
    last month

    As a retired NYC municipal employee, I had a crash course in Medicare Advantage Plans. NYC attempted to throw all of its retired employees on Medicare into a MAP to replace our Traditional Medicare with a supplement., so a large group of us filed a lawsuit and now have a stay in implementation among winning some other concessions. Too long to detail here.

    While not all MAPs operate the same way, many of them require pre-authorizations for many common procedures. The NYC MAP had 87 procedures which required pre-auths for such ordinary procedures such as regular lab testing. While traditional Medicare does have pre-auths, they are mostly for rarer procedures, and approvals are usually quick and seamless. The issue with MAPs is that they are known for delaying or even denying approvals, which can delay treatment to the detriment of your health. There are many documented instances where this process has harmed people. While denials can be appealed, many people don’t have the knowledge or health to challenge the denials. Of course the MAPs are known that the more procedures which get denied keeps more money in their insurers pockets.

    Be aware that while any dr. who takes Medicare will take traditional Medicare, many drs. will not take MAP, because the pre-auth process forces them to hire additional personnel to handle the submissions and denials, as well as notoriously slow payment from the MAPs. In addition, while the drs. may be within a large insurance network such as Empire/Anthem/Blue Cross/Blue Shield, they still may not necessarily take the MAP within the network.

    And frankly, if I am Ill enough to need medical care, I really am not swayed by a free Silver Sneakers gym membership, a fitness smart watch (if I qualify), free meals after a hospitalization (if I qualify), free transport to dr offices (limited to certain urban areas and again, only if I qualify), or a small allowance for some OTC items.

    I want quality medical care with doctors who decide what medical care I need to get and stay healthy. I don’t want the insurance company, with people with unknown qualifications to deny or approve my medical treatment.

    Despite all the ads screaming FREE, FREE, FREE, nothing is really free.

  • Elmer J Fudd
    last month
    last modified: last month

    "While not all MAPs operate the same way, many of them require pre-authorizations for many common procedures."

    Generalizing about Medicare Advantage plans isn't necessarily useful. Most, as you say, are different. Some are or operate like HMOs, some are or operate like PPOs. Or, a combination.

    We have yet to encounter anything with ours requiring preauthorization. We can see any specialist as and when we choose, no referrals are necessary,

    Again, a different experience from yours, one which is mine and mine only. My Medicare Advantage program is like a PPO and has a broad and generous range of benefits. I had no choice in the matter other than take it or leave it. It was cheaper to take it since my participation is subsidized.

    Everyone's experience is likely different. Different from state to state, different if a plan that involves or doesn't involve a former employer. These of the latter sort can (outside of Medicare's specific requirements) offer everything under the sun or nothing extra at all. Can be very generous or very restrictive.

  • chisue
    last month

    JoanMN -- Thank you for your reply. I guess the government must not check to see if everyone using Medicare complies with the requirement that they buy Part D coverage. It would be easy to look at Social Security records, since many of us have the premiums paid from those benefits. Maybe they only know if and when someone does require expensive meds that are only 'affordable' through a Part D plan, but at that point the Senior will get socked with a penalty on top of the cost of the plan.


    Because my DH didn't sign up for a Part D for seven years after it was mandated, he now pays about $100 in penalties on top of his annual premium.


    I try not to think about the way the US health care 'system' abuses its Seniors to make insurance and pharmaceutical industries profitable. Why, they are so profitable that they can afford to buy members of Congress!



  • JoanMN
    last month
    last modified: last month

    He is in compliance. It was not mandatory when he started on Medicare. He neither pays for nor receives Part D. It was because of the age he was. He had to fill out paperwork to opt out. somehow, I feel like you think he did something illegal. He could have paid the penalty or paid for his own prescriptions. I, my sister and my friend all got Part D, because we were not born in the 1930’s.

  • joann_fl
    last month

    I have it but I only get $30 OTC : ^ (

  • JoanMN
    last month

    I get $25.

  • salonva
    last month

    My head is spinning , reading this thread.

    I would say in general that those posting and perusing on here are relatively comfortable using a computer, doing research, are quite literate. Obviously there are all levels but imy point is that this is a pretty savvy - educated- able group.

    If we can't get a clear grip on Medicare then that speaks volumes.

  • Kswl
    last month

    Elmer said, ”To a healthcare provider, for Medicare covered services, two identical patients receiving identical services, A with conventional Medicare and B with a Medicare Advantage plan, reimbursements are the same. For A, they come from the federal Medicare agency. For B, they come from the insurance company.”


    Absolutely untrue. Many advantage plans pay only 80% of what Medicare pays and that is the reason some doctors do not accept advantage patients.

  • Elmer J Fudd
    last month
    last modified: last month

    I don't work in healthcare administration and consistent with my knowing I don't personally have experience working with the many complexities of this area, I'll accept what you say kswl. Although it disagrees with what I was told in the conversation I mentioned above that I had with a manager in the insurance billing department of a major medical school's faculty group practice services we use. Who told me they don't negotiate rates with insurance companies for patients having Medicare Advantage care because Medicare rules and rates prevail. I confirmed with my insurance carrier that the entire system at this medical school is "out of network" but that that was of no consequence because they cover in and out of network providers the same, so long as the out of network provider accepts Medicare. And, I have had bills for out of network, Medicare opt-out providers covered by my policy all the same. I have no further explanation for that, perhaps it's a feature of the specific coverage I have.

  • Kswl
    last month

    Medicare advantage is a huge moneymaker for insirance companies precisely because they pay less than medicare rates, Elmer. How did you think they could turn a profit if there was no spread between the costs and their reimbursements? Some MAP’s pay 80% for some services, 90% for others, and even up to 95% in some areas for some procedures and treatments. It depends on what the plan negotiates with the doctor, hospital or group. It is all based on Medicare rates, that much is true, but only as a percentage of those rates.

  • terezosa / terriks
    last month
    last modified: last month

    Medicare Advantage is a way for insurance companies to profit off of our taxes that we paid into Social Security.


    IMHO

  • Elmer J Fudd
    last month

    There are lots of twists and turns. I accept there are major differences from one to another. My primary coverage is Medicare as administered by a major insurance company but my plan is also self-insured by my employer. My guidance is that I must see providers that accept Medicare but even others seem to someone be covered from time to time.

    As I've said before, we're all sharing personal experiences and I understand there are important differences from here to there, plan to plan, place to place.

  • Kswl
    last month
    last modified: last month

    When you turn 65 and are employed, the usual route to health care is that you go on Medicare as your primary coverage with the company paying your premium, and the company’s insurance becomes your secondary coverage for the twenty percent Medicare does not cover.

    Most people do not understand how their insurance works, whether it’s Medicare or commercial insurance. It is a glaring fault of our system that it is so opaque and not understood by the people who need it, use it, and pay for it.

  • heritagehd07
    last month

    I‘ll be turning 65 in a few months and plan to continue working. I’ve signed up for Medicare Part A since there is no premium, but will keep my employer plan. This has been confirmed and reconfirmed with my employer HR and their insurance. My employer plan will pay first and Medicare pays second. The Medicare rules in that situation are at https://www.medicare.gov/basics/get-started-with-medicare/medicare-basics/working-past-65 

  • Trapped
    last month

    I have regular medicare plus a supplement. People I contacted were really pushing the advantage plans until------ I told them I had RA. Suddenly they were no longer interested in selling me an advantage plan. That was a bit of a red flag for me.

  • Elmer J Fudd
    last month
    last modified: last month

    "When you turn 65 and are employed, the usual route to health care is that you go on Medicare as yournprimary coverage with the company paying your premium, and the company’s insirance becomes tour secondary coverage for the twenty percent Medicare does not cover."

    I retired in my mid-50s and my coverage has been continuous through my former firm as a retirement benefit. Some aspects of it changed when I turned 65 and the coverage was integrated with Medicare but the only perceivable differences for me was the instruction to see providers that accept Medicare and to get health insurance when travelling outside the US. I pay the Medicare premium, as a deduction from my Social Security payments. I don't need to reiterate what I was told by my insurance company and by Stanford. If you have a disagreement with them, give them a call.

    You can repeat your thoughts over and over but it changes nothing - what you're describing may be common for some, and may be accurate as to what you have, but it's not what I have or have experienced.

  • Kswl
    last month

    Jesus, Elmer.

  • maifleur03
    last month

    Kswl my insurance was the exact opposite of what you wrote. When still employed my employer's insurance was primary. When I retired only then did it become secondary.


    I had my husband on my plan and one of his doctor's offices decided that because of his age Medicare was primary to bill them when I was still working. It was only after receiving a bill after it was rejected by Medicare marked past due was their error found out.

  • maifleur03
    last month

    I will add that for most insurance companies, be they medical or property, where they make their money is the number of people/companies that do not have claims. Simplistic but their profit is the difference between premiums, costs of doing business and any claims they must pay. Most people pay premiums but can be like me and go to the doctor once a year or only for minor things.

  • raee_gw zone 5b-6a Ohio
    last month

    When I was assessing which direction to go with Medicare enrollment, I consulted with both a firm that specializes in advising on plans, and with the Senior Options volunteer.

    The firm's representative made it quite clear to me that his recommendation of an Advantage plan was based on the fact that I was free of significant chronic health issues. We discussed what my move would be if I developed anything later. He clearly felt that MA would not be the best choice if I had a chronic issue requiring more than basic/ occasional care.

  • terezosa / terriks
    last month

    I have heard that it can be very difficult to move out of a Medicare Advantage plan to traditional Medicare with a supplement, especially if you have health problems as you lose your guaranteed issue right to be able to purchase any plan sold in your state, and that you won’t be charged higher premiums based on your health status.


    https://www.kff.org/faqs/medicare-open-enrollment-faqs/ive-been-enrolled-in-a-medicare-advantage-plan-for-several-years-but-i-want-to-switch-to-traditional-medicare-can-i-make-that-change-during-the-medicare-open-enrollment-period/

  • chisue
    last month

    JoanMN -- I'm very sorry if my post sounded accusatory. No, no, no! I was trying to learn if there was an 'out' available for my DH, who did have to buy Part D, despite also being born in the 1930's. I guess that your DH will never have to buy Part D, nor pay a penalty, as long as he never needs prescription meds that are only affordable if you have a Part D policy.


    As for Medicare Advantage plans, it appears they can save you money -- as long as you don't have any serious/chronic medical issues, and your favored medical services accept your plan.


    I've found my best medical insurance assistance advice from my state's unaffiliated SHIP group and the worst from 'licensed agents', who are as unbiased as your average car salesman.





  • maifleur03
    last month

    chisue with all of the announcements I was sent or saw elsewhere including at the grocery store where I shopped at the time about everyone needing to enroll in Part D unless you were covered elsewhere was apparently just ignored by your husband. I remember it being discussed on here.


    I am still covered by my employer based insurance if for any reason I wish to switch unless something changes all I have to do is tell the insurance company. There is no penalty for me if I do switch to any of the parts of Medicare nor would there be for JoanM. I do keep a copy of the yearly statement that I am covered in case I would decide to switch. The one time I was thinking about switching I had the person call his company because he too was not aware that I could do it with no penalty.