Medicare Advantage Plans

Discussion in 'Fibromyalgia Main Forum' started by tgeewiz, Sep 25, 2012.

  1. tgeewiz

    tgeewiz Member

    Hello all.

    I have the regular Medicare right now and also have a supplement that costs an additional $212.00 per month plus an Rx card at $29.00 per month.

    I am trying to reduce my expenses and so I started looking at Medicare Advantage plans which don't have a monthly payment. Of course I can only go to certain doctors and I must get a referral letter from a PCP to see a specialist.

    Does anyone have any good/bad experiences with Medicare Advantage plans? I live in Texas and the name of the plan I looked at is the Texan Plus HMO. I know I need to decide in the next few months.


  2. Mikie

    Mikie Moderator

    It's the AARP Medicare Complete underwritten by United HealthCare. It's an HMO/PPO so that I can go outside the network and just pay a higher co-pay. I pay no premium per month and there is no deductible. I used to sell M/C supps and Advantage Plans.

    The most important thing to look for is the cap on maximum out-of-pocket expenses in case of a catastrophic illness. If a plan has no maximum, I don't recommend it. These plans differ from county to county in terms of premium or no premium and co-pays.

    The beauty of these plans is that you pay nothing unless you use it and most preventive services cost nothing. Also, Part D is integrated in the plan.

    Another caveat: Most of the time when you have a supp, you will always get the rate at which you too that supp. If you go to an Advantage plan and decide to go back to a supp, you will likely pay the higher rate at which you return to the supp. If your present supp co. has an Advantage plan, they may let you go back and fourth without paying more. Check it out.

    Love, Mikie
  3. mbofov

    mbofov Active Member

    I used to have a Medicare hmo, but dropped it because the HMO doctors knew nothing about CFS and it was a waste of time to see them. I have found a couple of doctors who take straight Medicare (but not HMOs), who are knowledgable. I do have to pay a copay when I see them, but it is worth it to me.

    Mikie - your plan sounds great, but I just called United HealthCare and all they have where I live (Los Angeles County, CA) are straight HMOS without any PPO component. It differs from state-to-state and even from county-to-county within a state.

    Having said that, they told me new plan info for next year will be available on October 1 so I'm going to call back and see if they have something like your plan where I live. That would be ideal of course, also depending on the co-pay for the PPO doctors (whether it's higher than the straight Medicare copay of 20%).

    And also, it's important whether or not it would require a referral to see a specialist. I would hate to depend on an HMO doctor to refer me to an integrative medicine doctor (if that's considered a specialist).

    I do have a Medicare Part D prescription plan which costs $15.10 a month - it's the cheapest plan. None of my meds (e.g., Armour thyroid) are covered by the plan. Actually, AAA (So. Calif. Auto Club) gives me a bigger discount on my prescriptions. But I keep the Medicare plan in case of something catastrophic. If you don't have a prescription plan, you pay a small penalty for each year you're without it, if you decide to sign up.

    [This Message was Edited on 09/26/2012]
    [This Message was Edited on 09/26/2012]
  4. Mikie

    Mikie Moderator

    Yes, the plans do differ from county to county. One county may have the plans and the next one doesn't. That's because the money M/C pays them depends on a complicated formula which involves the avg. cost per person in that county for straight M/C. If that cost isn't very high, the ins. co. doesn't think it's worthwhile to develop networks and contracts with hospitals. There are different models too. Kaiser used to own everything and their docs were employees of the HMO. I don't know whether that's still the case or not. Some are HMO's, which contract with providers, and some are HMO/PPO's, like mine. I usually don't need a referral to see a specialist but my docs have found that it's easier if they do one. They don't have to get the plan's permission; they just print out a form I take with me.

    Some plans pay a per-capita amount to the doc each month and he has to use that to provide care to all his patients. That gives him an incetive to keep costs down because he has to pay the specialists out of his capitation. The check to that is if he is stingy, patients will drop him for someone else. My plan is fee for service. My docs get whatever co-pay is due from me and whatever fee is in their contract from the plan. The fee-for-service is the best model, in my opinion. Still, most of these reward the docs for saving money through bonuses at year end. A doc has to disclose how his bonus works if asked by patients.

    In an HMO, the list of providers is the most important to most people if they have established docs they want to see. Almost all the docs here take my plan so I usually don't have to go outside the network except for my dentist and eye doc.

    I hope this helps cut through some of the confusion of M/C Advantage Plans.

    Love, Mikie
  5. mbofov

    mbofov Active Member

    I have heard that capitation is one of the worst physician reimbursement methods because they are paid so low per patient, doctors can only make money through volume so are rewarded for spending the least amount of time with a patient, and, as you pointed out, not referring you to specialists when you need one because they lose money if they do. I am sure these reasons are why so many doctors refuse to take HMO patients.

    I agree that fee-for-service is a better plan than an HMO, although it does have the issue of bonuses awarded for saving money. So it seems to me that straight Medicare without any insurance company intermediary would assure the best care, without any conflict of interest for doctors - they wouldn't make more money by providing less care, or get bigger bonuses for saving money, because there are no bonuses with straight Medicare.

    If a person has no health issues and just wants annual blood work and pap smear and mammogram, then an HMO would be just fine. But most of us don't fit into that category.

  6. Mikie

    Mikie Moderator

    Straight M/C is the most versatile. From a national standpoint, straight M/C has been almost a free ticket to fraud for many providers. Finally, the govt. is cracking down on fraud. Even when caught in the past, a slap on the wrist and a small fine was the usual result. Our governor here in FL was CEO of a hospital chain which was fined for fraud. The governor took The Fifth and was never charged. I'm glad to see the govt. is finally getting serious about saving M/C from fraud. They used to audit less than 1 percent of all charges and it took blatent and ongoing fraud to get their attention.

    Again, though, from the patient's standpoint, M/C and a supplement is often best. Then, the patient has to get Part D to pay for meds. I love that Part D is part of my Advantage Plan. My docs and I have never asked for expensive tests unless needed. Most of what we have done to treat my illnesses has been done empirically. For me, it has worked out well. I've never been denied surgery nor treatment I need. So, for me, the plan has worked out well and saved me a bundle but it's not for everyone. I think the best thing is for everyone to look at the different plans to find the best one, depending on needs.

    If one can afford the supplement and a Part D plan, it will be the one with the least red tape, like referrals.

    Love, Mikie
  7. lea

    lea Member

    please post your plan's phone #?

    thanks a lot

  8. Mikie

    Mikie Moderator

    Call your local AARP to ask about Medicare Complete. My plan falls under that umbrella but the plans are not even the same in one state from county to county. AARP also sells United HealthCare supplements so make sure you tell them you want info on the Advantage Plan in your area, if there is one.

    Love, Mikie