Medical charges

[ilene13]

I will be going on Medicare in a few years, can you share how a supplement plan is better? All of my colleagues that have already retired told me to stay away from advantage plans as they all have had issues with them.

I am a retired educator from Buffalo, NY. During my 43 year career I had a Cadillac BC/BS family health care plan ( including cosmetic surgery), that I never had to pay for. When I retired I retained that family health insurance plan for $1600 a year. When I turned 65, in order to retain my BC/BS plan I had to take Medicare as my primary health care provider. So now my BC/BS plan is my secondary. So all claims go to Medicare first, then BC/BS pays the rest, or the majority of it. For example I had a hip replacement, the total bill was $82,000. My out of pocket cost was $21.00. We recently had an accident in Cozumel, Mexico. Our charges at the hospital had to be paid upfront, they were $3500. Medicare denied them but my BC/BS plan paid all but $344. I then submitted them to our travel insurance and am awaiting their payment.
My husband is a physician and he has always said do not go on a Medicare Advantage plan. They may sound great but they are not.

 

[JudyH]

This means that your medical practitioner, or their group, has decided to "opt-out' of direct insurance payments and become "out of network" practitioner or office. They get paid in full, by you, and you get whatever the insurance will pay for "out of network" practitioners. In the in-network system, but practitioners take the "haircut" on their services fees and agrees to the amount the insurance will pay them. The out of network system means that you take the "haircut" rather than them, and what you get in reimbursement is often much lower than the cost of the copay.

The advantage of being in-network for the practitioner is a ready supply of insured patients. The disadvantage is income as the insurance companies pay a fixed and usually lower rate than the practitioner wants to get for their services.

The fix for you is to switch to an in-network practitioner or office. Getting health care from out of network offices is most often more expensive, and unless they submit the bills for you, very cumbersome.

In some specialties like psychiatry, most practitioners are out of network. Insurance companies have such low regard for mental health that their reimbursements to psychiatrists are often pitifully low so most are out of network. Lately more and dental and medical specialties have left insurance coverage which is a real shock to people as you found out.

I am a mental health practitioner. You described the insurance game quite well. I was always in-network for the convenience but the reimbursement was pitiful.

 

[Superchief]

With some insurers there is a real in-network / out of network scam. Our state has a dominant medical insurance provider, Blue Cross, and just about every doctor and facility is in their network. Others are more problematic, and you can get stung with them. An example is my wife's recent eye surgery. Her employer had switched their plan from Blue Cross to another carrier. Her eye doctor is in the new carrier's network, but when she needed a cataract surgery, we discovered that the main facility in that city where almost all outpatient surgery of all kinds is performed was not in their network, and so that would be a major expense. Working through the eye doctor, the insurancy company verbally said that would cover it as in-network and grant a waiver, but now they have billed it out of network. If we cannot get satisfaction, we are taking this to the state Insurance Commissioner.

A similar problem can occur when the surgeons and facility are in network, but anesthesiologists or lab testing aren't. The medical and insurance industry are so profit motivated that the consumer has to be very proactive to prevent problems, and willing to challenge unethical practices.

I recently had cataract surgery in both eyes. The medical practice billed me upfront and I paid all of the non-covered costs prior to my second procedure. Four months later, I received a notice from a collections company indicating I owed $45. I never received any bill, but am really pissed that they would contact a collection company for this. The anesthesia practice also charged an extra $100 for 'infant', even though I am a healthy 70 yr old.

 

[Superchief]

We had an interesting thing happen yesterday when my wife was having a procedure. When checking in, the receptionist provided my wife a statement with the proposed cost and coverage information, supposedly provided by her insurance. If we paid up front, a 10% discount was offered. However, I noticed that the information was incorrect because it showed $1000+ for remaining deductible cost and she had already met her deductible for the year. I may have considered it had the information been correct. It appears that the facilities are trying to get more money up front rather than wait for insurance payments.

 

[Glynda]

I will be going on Medicare in a few years, can you share how a supplement plan is better? All of my colleagues that have already retired told me to stay away from advantage plans as they all have had issues with them.

We have never had a problem with our AAA United Health Advantage plan. We've never had to pay more. We live in SC. My drug plan through Cigna is another story and I have to pay a lot of out of pocket costs for RXs.

 

[dago]

We have never had a problem with our AAA United Health Advantage plan. We've never had to pay more. We live in SC. My drug plan through Cigna is another story and I have to pay a lot of out of pocket costs for RXs.

The RX is a problem for most everyone.

 

[Talent312]

The RX is a problem for most everyone.

Indeed.
I am currently in the donut-hole (a/k/a coverage gap).
I found that I can save $$ for some drugs w-GoodRx
or Amazon, rather than use my drug plan.,

 

[Luanne]

The RX is a problem for most everyone.

The plan I have covers all of my usual medications. My co-pay for 3 of them is $0.00 However the Eliquis makes up for that. But the pricing, or what I pay, is all over the board. Sometimes it is $900+ for three months, last time I refilled it was $132 for three months. Hope this is a drug that the price can be brought down.

 

[Sugarcubesea]

I am a retired educator from Buffalo, NY. During my 43 year career I had a Cadillac BC/BS family health care plan ( including cosmetic surgery), that I never had to pay for. When I retired I retained that family health insurance plan for $1600 a year. When I turned 65, in order to retain my BC/BS plan I had to take Medicare as my primary health care provider. So now my BC/BS plan is my secondary. So all claims go to Medicare first, then BC/BS pays the rest, or the majority of it. For example I had a hip replacement, the total bill was $82,000. My out of pocket cost was $21.00. We recently had an accident in Cozumel, Mexico. Our charges at the hospital had to be paid upfront, they were $3500. Medicare denied them but my BC/BS plan paid all but $344. I then submitted them to our travel insurance and am awaiting their payment.
My husband is a physician and he has always said do not go on a Medicare Advantage plan. They may sound great but they are not.

My company has a medicare specialist that you can talk to before you retire to help with the transition to medicare

 

[Luanne]

My company has a medicare specialist that you can talk to before you retire to help with the transition to medicare

The company I retired from has a company that administers our retiree health benefits. I believe there is someone you can talk to, but it's on the phone. This company is heavily promoting an Advantage plan though United Healthcare starting this year. I took a quick look, but even with no premiums it still didn't appeal to me.

 

[Sugarcubesea]

The company I retired from has a company that administers our retiree health benefits. I believe there is someone you can talk to, but it's on the phone. This company is heavily promoting an Advantage plan though United Healthcare starting this year. I took a quick look, but even with no premiums it still didn't appeal to me.

@Luanne , when I talked to the Medicare lady last year, she was helping me out as my hubby was turning 65 this year, and I wanted to stay in my HSA plan and she told hubby not to sign up for Medicare as our company had creditable coverage and he was on my policy and as long as I worked to stay on my plan as it was less expensive than medicare... I pay $98 a month to ensure hubby, our daughter and myself. My company gives a $4K contribution each year to our HSA bank account so the max I would ever spend out of pocket for deductibles is $2K.

Hopefully I can stay at this company till 66 and then retire...

 

[Talent312]

@Luanne , when I talked to the Medicare lady last year, she was helping me out as my hubby was turning 65 this year, and I wanted to stay in my HSA plan and she told hubby not to sign up for Medicare as our company had creditable coverage and he was on my policy and as long as I worked to stay on my plan as it was less expensive than medicare... I pay $98 a month to ensure hubby, our daughter and myself. My company gives a $4K contribution each year to our HSA bank account so the max I would ever spend out of pocket for deductibles is $2K.

Even so, he (and you) should sign up for Part A at 65 as it has no premium,
and likely, your health-plan becomes secondary to it for hospitalizations.

Also: When you do elect Part B, you'll need to hand in a certification form
to get a Special Enrollment Period... which was a chore when I enrolled DW.
.

 

[Luanne]

@Luanne , when I talked to the Medicare lady last year, she was helping me out as my hubby was turning 65 this year, and I wanted to stay in my HSA plan and she told hubby not to sign up for Medicare as our company had creditable coverage and he was on my policy and as long as I worked to stay on my plan as it was less expensive than medicare... I pay $98 a month to ensure hubby, our daughter and myself. My company gives a $4K contribution each year to our HSA bank account so the max I would ever spend out of pocket for deductibles is $2K.

Hopefully I can stay at this company till 66 and then retire...

This was our situation when dh became Medicare eligible. He did sign up for Part A, which your husband should do. But he was covered under me for anything else. When I retired he got a Medicare Supplement Plan F. I still had a few years before becoming Medicare eligible after I retired so I continued to get coverage through my company, but my husband was dropped at my retirement.

 

[b2bailey]

My husband is a physician and he has always said do not go on a Medicare Advantage plan. They may sound great but they are not.

I'm right on the brink of switching to an Advantage Plan. (October is my birthday month, so I'm able to change).

I've had AARPUHC Supplement Plan for nearly 10 years. Did that originally because I traveled a lot. Now I'm settled in Lodi. Local healthcare is through Adventist Group. If I can identify which Advantage Plan allows me to continue with them, I'm wanting to drop the nearly $170/mo premium I now pay.

However, this comment is what makes me want to stick it out with current supplement plan.

 

[b2bailey]

Even so, he (and you) should sign up for Part A at 65 as it has no premium,
and likely, your health-plan becomes secondary to it for hospitalizations.

Also: When you do elect Part B, you'll need to hand in a certification form
to get a Special Enrollment Period... which was a chore when I enrolled DW.
.

I'm confused. I thought Part A was the amount deducted from my SS Benefit each month?

 

[easyrider]

Realize that on sept 18 they did not have this policy and on sept 23 they did. This is a post surgery visit and I am on Medicare

My wife went on Medicare last year and has a plan g that seems to work really well so far. Our friend has an advantage plan that seemed to suck when they needed hospital care.

Bill

 

[dago]

Deleted

 

[Talent312]

I'm confused. I thought Part A was the amount deducted from my SS Benefit each month?

Part A (Hospital) is the part with -0- premium.
Part B (Medical)'s premium is $164.90 for 2023.
------------------
Hence, my DW who was covered under my plan,
enrolled in Part A at 65, and then waited for 7 yrs
to enroll in Part B, when I retired.
,

 

[dago]

Part A (Hospital) is the part with -0- premium.
Part B (Medical)'s premium is $164.90 for 2023.
------------------
Hence, my DW who was covered under my plan,
enrolled in Part A at 65, and then waited for 7 yrs
to enroll in Part B, when I retired.
,

Yep . It can be confusing.

 

[susieq]

We have never had a problem with our AAA United Health Advantage plan. We've never had to pay more. We live in SC. My drug plan through Cigna is another story and I have to pay a lot of out of pocket costs for RXs.

My DH has AARP through United Healthcare also, although pricey, we've never received a bill also. It covers everything. They also have a prescription drug plan, they auto deduct that from a CC every month, (not bad - $30.). We pay a small co pay on scripts - about $2 or $3.

 

[dago]

My wife went on Medicare last year and has a plan g that seems to work really well so far. Our friend has an advantage plan that seemed to suck when they needed hospital care.

Bill

I totally understand. Plan G is the top of the line. If you can afford and accept the premium increases over time it's quite good. Both of us have been on Plan F for over 10 years. We have no regrets.

 

[Luanne]

I'm confused. I thought Part A was the amount deducted from my SS Benefit each month?

Nope, that is Part B.

 

[simpsontruckdriver]

The "problem" with Medicare Advantage (MAPD) plans is they're privatized yet regulated by the government, BUT they do not guarantee 100% coverage of everything. Doctors are not fond of either Group (employer) or MAPDs because their "pencil-pushers" make their business tough. You need a procedure done, the insurer denies it because the doctor did not go through the cheaper steps first. Same with medications, your doctor prescribes a powerful and very effective medication, but the insurer denies it because of what they call "Step Therapy", where he needs to prescribe generics first. By the way, this is not a fault of the Affordable Care Act per se, it was simply ignored and allowed to continue. But, for most Americans, an MAPD is an inexpensive option (less than $170/month including Part-B premium).

Using my late wife as an example, as she was improving and was no longer intubated in ICU (long story), her doctors at the hospital wanted her to go to a Long-Term Acute Care (LTAC) rehab at AdventHealth Daytona Beach. AETNA refused, saying she needs to go to a nursing home for rehab. They appealed twice, but AETNA stood their ground. She went to a rehab and was treated like crap until I got their administrators involved, but she was still unable to walk after a month in it (another long medical story). She got sick, most likely due to lack of care, so she went back to the hospital for a few weeks. Again, when she was ready to leave, doctors wanted her to go to the LTAC, but AETNA said no, nursing home is where she will go. She went to a different nursing home/rehab, she was treated great, but didn't get the medical care she needed, and she died on 01/20/21. n the end, we settled with #2 (where she died), because they both ignored lots of signs and they also refused to give me updates on how she was doing. Because it was during Covid19 Pandemic, I could not do surprise visits, I had to call them and make an appointment, but if someone else had visitation during the time I could go, I could not go. Under Florida law, nursing homes could not be sued for Covid19 deaths or their policies (she did not die from Covid19).

TS

 

[dago]

The "problem" with Medicare Advantage (MAPD) plans is they're privatized yet regulated by the government, BUT they do not guarantee 100% coverage of everything. Doctors are not fond of either Group (employer) or MAPDs because their "pencil-pushers" make their business tough. You need a procedure done, the insurer denies it because the doctor did not go through the cheaper steps first. Same with medications, your doctor prescribes a powerful and very effective medication, but the insurer denies it because of what they call "Step Therapy", where he needs to prescribe generics first. By the way, this is not a fault of the Affordable Care Act per se, it was simply ignored and allowed to continue. But, for most Americans, an MAPD is an inexpensive option (less than $170/month including Part-B premium).

Using my late wife as an example, as she was improving and was no longer intubated in ICU (long story), her doctors at the hospital wanted her to go to a Long-Term Acute Care (LTAC) rehab at AdventHealth Daytona Beach. AETNA refused, saying she needs to go to a nursing home for rehab. They appealed twice, but AETNA stood their ground. She went to a rehab and was treated like crap until I got their administrators involved, but she was still unable to walk after a month in it (another long medical story). She got sick, most likely due to lack of care, so she went back to the hospital for a few weeks. Again, when she was ready to leave, doctors wanted her to go to the LTAC, but AETNA said no, nursing home is where she will go. She went to a different nursing home/rehab, she was treated great, but didn't get the medical care she needed, and she died on 01/20/21. n the end, we settled with #2 (where she died), because they both ignored lots of signs and they also refused to give me updates on how she was doing. Because it was during Covid19 Pandemic, I could not do surprise visits, I had to call them and make an appointment, but if someone else had visitation during the time I could go, I could not go. Under Florida law, nursing homes could not be sued for Covid19 deaths or their policies (she did not die from Covid19).

TS

Terribly sorry about your wife. That is my main gripe with MAPD. I went through the same thing with my MIL every time she had to go to rehab.

 

[Talent312]

...
Using my late wife as an example, as she was improving and was no longer intubated in ICU (long story), her doctors at the hospital wanted her to go to a Long-Term Acute Care (LTAC) rehab at AdventHealth Daytona Beach. AETNA refused, saying she needs to go to a nursing home for rehab.,,,

Terribly sad.
The other side of the coin is that, when my DW was sent to a Rehab Hospital following surgery, neither Medicare nor her Supplement said anything about it. The premiums are costly, to be sure, but ultimately, it came thru for her.
,