I can speak about an apparently non-scam Medicare Advantage plan that my wife and I are on.
It is effectively a PPO (similar to the Kaiser plan someone else mentioned), so we have access to exactly the same physicians that we had already where we were paying for private insurance. Our annual premiums went from about $85k a year (on the private insurance) to around $10k out of pocket.
We are fairly healthy, though my wife is going to have some major joint surgery. What was interesting is that it was our PRIVATE insurance that stalled and stalled over approving the surgery. When she switched to the MA plan, it was approved immediately. (That stalling finally motivated my wife to make the switch out of the private insurance.)
The downside of our MA plan is that we are not going to be able to move out of the area easily. But you always have that issue regardless -- finding a whole new set of doctors and dentists when you move...
I do get these phone calls asking to schedule a "wellness" check that the article writer mentions. Oddly enough, my wife didn't get any (so far.)
>What was interesting is that it was our PRIVATE insurance that stalled and stalled over approving the surgery. When she switched to the MA plan, it was approved immediately.
At least one part of the scam seems to have worked here: you use "private" to describe your old plan, to contrast with MA. In reality, both your old and new plans are private.
No, the Affordable Care Act restricts premiums for the most costly insureds (age 64) to 3x the least costly insureds (age ~21).
So the health insurance premiums you see for ACA compliant health plans are very subsidized by younger plan members, but this subsidy ends starting age 65.
In other words, expected healthcare costs for old people are massive.
Edit: also, annual premiums for age 64 are around $20k to $25k, and that is with the subsidy from younger plan members.
That call is because Health Plans are rated by CMS on if you get certain types of services, or skip them. By skipping those checkups you are reducing your health insurance plans STARS rating, which means they lose significant monies from the government. Each .1 of a start equals around 1 million US in government funding to a health plan doing MA.
The insurance was a high end PPO with no lifetime max and $20 copay. My wife is a cancer survivor, and I take drugs to minimize my cancer risk.
Additionally, the premium growth rate accelerated considerably after 65.
We did not actually pay $85k for a year but that was going to be the price. We were told what the new premiums would be, and instead of paying the $85k (paid monthly in installments), I switched immediately to the MA plan and told my wife, let's see how this works out. She held on for six months, then ran into the stalling, and then it took her another six months before she could get on the same MA plan.
The reason our MA plan works is that it's offered by the same medical center we happened to use 100% of the time on our previous insurance. So we didn't need to switch any physicians.
Regarding predatory MA's, my wife's surgeon, who was trying to get the approval for her surgery, told her, "This isn't going anywhere, you're past the time to switch to medicare, get an MA. However, be sure you avoid these companies."
Yes, we switched to medicare late, and we are reminded of that every month when we pay the penalty.
(I should mention our current MA plan is a HMO, not a PPO -- my typo.)
I wonder if 65+ health insurance plans are allowed to price insurance based on the insured’s health, since the Affordable Care Act pricing rules only applies up to age 64.
If so, I can see someone with chronic ailments with high probability of things like heart attack, stroke, and other high cost events cause a premium that high.
49 years old, married (same age), six kids, and my ACA plan in my area is $3k/mo for bronze, and $4 to $5k/mo for gold, with $10k deductibles. We have paid cash for five of our six kids.
Thankfully, my spouse and I and kids are healthy, but that's so much money that if I'd carried insurance when building my startup, we wouldn't have a startup today.
The ACA kills the American Dream. One possible fix is that I should be able to buy any insurance I want from anywhere in the country I want; this would mean real competition; currently, I can only buy from a few providers that operate in my local part of my (large) state.
Anyway, I find $85k shocking, but not that shocking given that I'm looking at $60k/year (not including deductibles) at a much younger age. (When I first started in my career, that was more than I made in a year!)
Once I had commercial insurance from out of state. A doctor visit was covered as in-network and all was well. But they did a lab. The lab was in a hospital 100 miles away. The insurance said "ok you have to pay the deductible for this lab", which is like fine, how much can a single lab cost? Single urine sample, easy.
Well didn't you know, the hospital did NOT have a negotiated in-network rate with the insurance company. The hospital insisted that we owed them $650, because that was our deductible.
Other in-state insurance companies cut those stupid bills down by 95-97% with 'allowed amounts', but the out of state insurance didn't have that negotiated rate with them.
In the end I called the hospital and told them I knew from other insurance bills how much it should have cost, and that we can just not pay, and ignoring collectors is easy. I offered them $50 (for a $20-30 lab) and they send me a new bill "writing off" the other $600.
So, you want out of state insurance, well, be careful what you wish for, it just might come true, and you may not like it at all.
The current version of the ACA (i.e. as subsequently amended) limits your premiums to 8.2% of your household AGI were you to sign up for the 2nd most costly Silver plan in your state.
So no, you're not paying $60k a year unless you have a shockingly high AGI.
You need to look into federal subsidies. You can get them either through the relevant (federal|state) marketplace or as refunds on your federal tax bill.
The subsidies reduced my wife & I (late 50's, New Mexico) premiums by more than 50%.
The ACA is what allows small business and individuals to buy insurance in the first place. Without ACA, you would be subject to benefit maximums, pre existing coverage denials, and no requirement that insurance cover proven treatments for your ailment.
> One possible fix is that I should be able to buy any insurance I want from anywhere in the country I want; this would mean real competition; currently, I can only buy from a few providers that operate in my local part of my (large) state.
If anything I think we'd see more consolidation and fewer choices if people could buy across state lines. If enough people in state A buy from a provider in state B, state A's providers could very well close up shop.
Want to see my bills? I don't shred paperwork until 3 years go by, so they're around somewhere. We were able to afford it, though it did take a good chunk of our retirement income away. And it was less in previous years.
The goal was to protect against really bad things happening that would result in hospital bills of a million or more -- and screw up our retirement completely.
(We had private insurance because both of us retired early, and the early premiums were reasonable. Also, my wife had heard that Medicare was a bad insurance to have, and didn't want to take the risk she couldn't get the care she might need.)
Are they immediately approving the surgery so you stay on for a year and then are hooked? How long from approval until the procedure takes place? Will they deny future, follow up or other, procedures down the road?
As I mentioned elsewhere, the MA covers the same health center we've used for 40+ years as a HMO. I've had no issues with getting stuff approved. Her surgery was approved in less than a month and it's scheduled in a month. She'll need another later this year, but approval of that must wait until we see how this one turns out.
There's always the possibility the MA will stall. If it's egregious, we'll need to look into legal alternatives.
I don’t like the idea of private Medicare but this article is populist handwaving. Here is an article from real healthcare researchers with aggregates statistics: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9465897/
Notable:
> Private health insurers in Medicare Advantage must abide by all explicit Medicare coverage determinations including national coverage determinations (NCD) and local coverage determinations (LCDs). In the absence of an NCD, LCD, or other explicit Medicare coverage determination, however, Medicare Advantage insurers can apply additional coverage restrictions if they determine that a service fails to meet the “reasonable and necessary” standard.
It sounds like virtually no claims are denied even under Medicare Advantage:
> Denied services accounted for 1.40% (95% CI 1.39–1.41) of total services (paid and denied services), and denied spending accounted for 0.68% (95% CI 0.67–0.70) of total spending (paid and denied spending).
However, it sounds like MA plans will deny things that the ordinary Medicare rules by themselves wouldn’t deny.
> On average, Medicare coverage rules accounted for 85% of denied services and 64% of denied spending, with Aetna Medicare Advantage coverage rules accounting for the remainder.
It seems like an unaccounted for confouder that LCD/NCD/MUE denials are the bread and butter of a claims clearinghouse and the claims would not be sent to the payer if they failed those tests. My bias may be showing, but it doesn't seem like they accounted for that at all..
It is not a popular opinion but I always thought the tv ads that spam the airwaves in the last few months of the year were harmful to the legitimacy of institutions. In this day and age most of us are so assaulted by spammed scams that we develop a sensitive sense of scamminess and like many of the ads aimed at seniors these ones scream “get grandma away from the tv!”
Certain day parts on tv are dominated by ads for personal injury lawyers and things you can spend government benefits on and are a desert for ads for things you might spend your own money on.
One series of ads that promoted getting some free medical equipment that ran for years and I thought looked scammy turned out to really be a scam.
I’ve always thought these ads promote the idea that some chiselers somewhere are trying to rip off government benefits and they drive people, even the pensioners that these are aimed at, to vote Republican.
I've said this before but it was such a perfect moment that I share it whenever possible, my mother in law is one of these folks and once she said that she'd never support universal health care because there was a chance some immigrant might get free health care on her dime. She followed that statement up by mentioning she was going to Mexico for some dental work she couldn't afford.
There's no contradiction. Lots of insurance plans and systems, whether in the US or not, don't cover dental or don't make it "free". Let me introduce you to Mosonmagyaróvár <https://en.wikipedia.org/wiki/Mosonmagyar%C3%B3v%C3%A1r#Dent...>, a small town with no fewer than 350 dentists, because so many Austrians and other western Europeans cross the Hungarian border to visit. Dental care is so cheap that an Austrian can get work done on his teeth and take a local vacation for less than what he would pay in Vienna. Dentists even have their own small hotels <https://diamantdent.hu/en/Hotel/> to serve such patients!
If you think those are bad, try looking at the junk mail retirement-aged people get. My parents get "official" looking notices about owing money or being owed a lot of money, offers to reverse mortgage their house for a "retirement nest egg" without using the term reverse mortgage, and for different scam insurance plans that don't cover anything worth covering.
If they ever went through with the offers they get in the mail, they'd be homeless, without insurance, cashless and asset-less within a year.
They get that kind of junk mail literally everyday.
My in-laws fell victim to this. When they moved they sat us down and started to talk about this "407-B" (not the real name, but I don't remember what it was) and how it's not a reverse mortgage. Then they proceeded to describe it as exactly a reverse mortgage.
Meanwhile I was tap-tap-tapping on my phone. I called them out and said it was a reverse mortgage according this page titled "Everything you need to know about 407-B reverse mortgages". They asked what fly-by-night website it was and when I said "irs.gov" they grumbled and moved on. To this day they refuse to admit that it's a reverse mortgage.
> If they ever went through with the offers they get in the mail, they'd be homeless, without insurance, cashless and asset-less within a year.
Not that quickly, but yeah, they're on that road. They're trapped in that home until they die. They'll be needing hospice care soon, and they won't be able to get it. Nothing we can do to move them off of it now because it's basically irreversible.
In Canada we basically get no medical ads, and it’s great. We find US acceptance of direct-to-patient advertising… ethically problematic. Most developed countries are more like Canada than the US on this.
US ads is such a cultural shock when you visit USA. The biggest surprise was all the lawyer ads, "Did something happen to you? You could get rich by suing them with our help!". So ads like this:
No, this place would set you up with a knee brace or similar thing out of a catalog, the thing is they did not care if you really needed it. If it did turn out you needed something like that later you’d find that you already wasted your benefit on something you didn’t need.
I just saw a podcast about a startup that was working with Medicare/Medicaid to reduce costs by improving preventative care [1].
They look for people at risk, target them and take a cut of the overall reduced spend.
If Medicare is requiring the same outcomes and disbursing per-person based on the cost to Medicare, then the insurance company's profit would have to come from either selecting for healthier people on the input side, or keeping them healthier for longer. Selecting for healthier people might be hard if it's "all signups allowed".
My dad was on a Medicare Advantage plan offered by a traditional "insurer", and it seemed to be worthwhile - it covered some drugs better than OG Medicare, and had fixed copays rather than anything percentage based. Towards end of life (pre-hospice) they proactively sent a doctor out a few times for housecalls, with the goal of keeping him out of the hospital. And the baseline Medicare rules reigned in a lot of the usual "insurance" company shenanigans. If he had longer term health issues perhaps Medicare plus a Supplement plan would have made sense, but as it was it seemed to work out - had two years of paying the drug coverage gap (paying a few thousand dollars is essentially table stakes for health "care" in this country). I'm not a fan of "insurance" companies in general, rather just reporting my experience.
I kept his phone number (VOIP is like $1/mo), and I still get spam calls from scammers claiming to be "from Medicare" that "have a new card" for him - shamelessly pretending to be part of Medicare itself rather than a private company that's trying to steal his Medicare payments. Many times I'll ask them if their parents know they scam old people all day, or if they would want their parents getting scammed in their old age. Most of the time they just try to get me back to the script and think they'll convert me somehow ("I am not scammer").
I'm ambivalent on medicare advantage as a concept, but the scam companies are really what needs to be reigned in. Given that the benefits of medicare advantage is supposedly better coverage, I think a great way of doing reform would be to make it so people could change back to regular medicare at any time, and doing so would end up yanking back the premiums from the private company for the past year or two, unless they had actually paid them out for bona fide services. In addition to a lot more criminal enforcement against fraud, of course.
> they proactively sent a doctor out a few times for housecalls
The article talks about these housecalls:
"The home health visits are designed to look for illnesses or codings that can increase risk scores. They very much are not looking for conditions that require medical intervention. This “free home health visit” scam is so profitable that an entire industry has sprung up of companies that send nurses out on behalf of the insurance companies."
If I look at it post-hoc and cynically, maybe their motivation was to get him off the "insurance" company's books (electing hospice kicks you back onto vanilla Medicare). But it was objectively needed and they spent time to do the job, on a major holiday even.
I've no idea what the dynamic would have looked like if they came to different conclusions than me and we were at odds, but all I can say is that the quality of care always heavily depends on having an advocate.
Port request. Landline at Ma Bell with the number being in a traditional city exchange, straight to voip.ms. I forged his signature on the landline statement I sent in with the request, rather than adding complexity with POA/executor paperwork (I forget when I actually did this). It worked fine.
And it's really complex so that even if you have the money to navigate it, you might make bad choices. I have two relatives who did that. It could easily have cost them their lives, but thankfully it did not. It was close, though.
Isn't it the opposite? It's a bottomless money pit set up to ensure that everyone is motivated to work themselves to the bone throughout their productive years, since you never know how much money you'll need for healthcare in retirement.
I always thought that Medicare & Medicaid are a scam to drain the nation of their wealth, until the nation is dead AND healthcare used to be a great deal more affordable before Medicare & Medicaid got involved in it.
Now, senior folks get on Medicare until they've tapped out its lifetime benefits and then they go onto Medicaid.
This is part of what has created the upteen millions of Medicare scams.
The programs only exist because health insurance became unaffordable for seniors. Healthcare is expensive for the old! I’m not arguing against the idea that the program has fraud issues (Rick Scott made a fortune off of it), but its not going to be cheaper or better for the elderly if we let private companies exploit them individually instead of forcing them to defraud the government.
What? You're talking about two different things: Health insurance vs Long Term Care.
There are no maximum lifetime benefits for Medicare Part A & B (health insurance) that I'm aware of. When you hear about a "Medicaid spend-down", it's all about reducing an elderly persons assets so that the state sees them as poor and Medicaid will pay their Long Term Care (nursing home) expenses. Medicare has almost nothing to do with the Medicaid spend-down strategy that I know of.
Why did you always think that? Doesn’t seem true at all to me. Seems kind of wild that a country as rich and privileged as America struggles to provide healthcare to its citizens without going broke?
My father in law had Medicare advantage. They denied his claims for skilled nursing that was getting him back on his feet. The facility just downgraded him from skilled nursing and left him in an hallway. He had a cardiac arrest due to low electrolytes ended up back in the ER and never recovered. (Pop quiz, how does someone on an IV end up with low electrolytes? Only way I can think is if they don’t fill the bag)
Why did they deny him? No reason. It’s just standard procedure. They deny, get good justification and approve. They do that every 7 days. They prettied up the language but confirmed that this is exactly what they do.
They literally killed him as part of standard operating procedure.
This country is fucked. Y’all better hope you have enough money to go be old somewhere else.
Yep, this sounds like "the whole story...", doesn't it? Nothing missing here:
- FIL has MA,
- FIL (somehow, no explanation given) is in a "facility" (hospital, ER, doctor's office, bus depot, ???),
- FIL is "downgraded" and "had a cardiac arrest... and never recovered...)
...
- "They literally killed him as part of standard operating procedure."
Sounds like quite a few grounds for a lawsuit but I'm neither a lawyer nor a doctor.
Neither am I a fool: this is waaay to iffy a story/description to be useful in judging most anything mentioned in the story, be it MA, the "facility", the FIL, the writer, or the diagnosis.
As for who's fucked, the writer should worry about himself first.
When talk about Medicare they are usually talking about Part A (hospital care) and Part B (provider coverage), and sometimes Part D (prescription drug coverage). You are on your own for everything else, including dental and vision care. Adding dental coverage to Medicare continues to die in committee every year in congress.
So if you know you'll need continued care from your dentist and eye doctor then Medicare Advantage can be a good thing, since most of the highly rated plans provide that coverage as part of their benefits.
You can also get benefits for things hearing aids, and transportation to and from your provider visits, etc.
Yes, if you sign up for Medicare Advantage you'll find yourself back in the world of the In-Network and Out-of-Network care model.
At the end of the day though it's disingenuous to just label Medicare Advantage as solely the privatization of Medicare. The only way insurance companies that provide Medicare Advantage stay in business is if they provide a high standard of care for their members. The payment model set by CMS incentivizes them to do so.
Readit News
It is effectively a PPO (similar to the Kaiser plan someone else mentioned), so we have access to exactly the same physicians that we had already where we were paying for private insurance. Our annual premiums went from about $85k a year (on the private insurance) to around $10k out of pocket.
We are fairly healthy, though my wife is going to have some major joint surgery. What was interesting is that it was our PRIVATE insurance that stalled and stalled over approving the surgery. When she switched to the MA plan, it was approved immediately. (That stalling finally motivated my wife to make the switch out of the private insurance.)
The downside of our MA plan is that we are not going to be able to move out of the area easily. But you always have that issue regardless -- finding a whole new set of doctors and dentists when you move...
I do get these phone calls asking to schedule a "wellness" check that the article writer mentions. Oddly enough, my wife didn't get any (so far.)
At least one part of the scam seems to have worked here: you use "private" to describe your old plan, to contrast with MA. In reality, both your old and new plans are private.
To the article's point, the problem arises when private insurers arbitrage the services those public dollars are supposed to be going toward.
So the health insurance premiums you see for ACA compliant health plans are very subsidized by younger plan members, but this subsidy ends starting age 65.
In other words, expected healthcare costs for old people are massive.
Edit: also, annual premiums for age 64 are around $20k to $25k, and that is with the subsidy from younger plan members.
Deleted Comment
Yes, both of us are over 65.
The insurance was a high end PPO with no lifetime max and $20 copay. My wife is a cancer survivor, and I take drugs to minimize my cancer risk.
Additionally, the premium growth rate accelerated considerably after 65.
We did not actually pay $85k for a year but that was going to be the price. We were told what the new premiums would be, and instead of paying the $85k (paid monthly in installments), I switched immediately to the MA plan and told my wife, let's see how this works out. She held on for six months, then ran into the stalling, and then it took her another six months before she could get on the same MA plan.
The reason our MA plan works is that it's offered by the same medical center we happened to use 100% of the time on our previous insurance. So we didn't need to switch any physicians.
Regarding predatory MA's, my wife's surgeon, who was trying to get the approval for her surgery, told her, "This isn't going anywhere, you're past the time to switch to medicare, get an MA. However, be sure you avoid these companies."
Yes, we switched to medicare late, and we are reminded of that every month when we pay the penalty.
(I should mention our current MA plan is a HMO, not a PPO -- my typo.)
If so, I can see someone with chronic ailments with high probability of things like heart attack, stroke, and other high cost events cause a premium that high.
A gold plated plan where I live for a 65 year old couple who smoke and have a child is about US$10k for a year.
https://join.southerncross.co.nz/quote/step2
Thankfully, my spouse and I and kids are healthy, but that's so much money that if I'd carried insurance when building my startup, we wouldn't have a startup today.
The ACA kills the American Dream. One possible fix is that I should be able to buy any insurance I want from anywhere in the country I want; this would mean real competition; currently, I can only buy from a few providers that operate in my local part of my (large) state.
Anyway, I find $85k shocking, but not that shocking given that I'm looking at $60k/year (not including deductibles) at a much younger age. (When I first started in my career, that was more than I made in a year!)
Well didn't you know, the hospital did NOT have a negotiated in-network rate with the insurance company. The hospital insisted that we owed them $650, because that was our deductible.
Other in-state insurance companies cut those stupid bills down by 95-97% with 'allowed amounts', but the out of state insurance didn't have that negotiated rate with them.
In the end I called the hospital and told them I knew from other insurance bills how much it should have cost, and that we can just not pay, and ignoring collectors is easy. I offered them $50 (for a $20-30 lab) and they send me a new bill "writing off" the other $600.
So, you want out of state insurance, well, be careful what you wish for, it just might come true, and you may not like it at all.
So no, you're not paying $60k a year unless you have a shockingly high AGI.
You need to look into federal subsidies. You can get them either through the relevant (federal|state) marketplace or as refunds on your federal tax bill.
The subsidies reduced my wife & I (late 50's, New Mexico) premiums by more than 50%.
If anything I think we'd see more consolidation and fewer choices if people could buy across state lines. If enough people in state A buy from a provider in state B, state A's providers could very well close up shop.
Deleted Comment
The goal was to protect against really bad things happening that would result in hospital bills of a million or more -- and screw up our retirement completely.
(We had private insurance because both of us retired early, and the early premiums were reasonable. Also, my wife had heard that Medicare was a bad insurance to have, and didn't want to take the risk she couldn't get the care she might need.)
There's always the possibility the MA will stall. If it's egregious, we'll need to look into legal alternatives.
They would have known that you had the option of going elsewhere. The stalling looks strategic and, unfortunately, successful.
Deleted Comment
Notable:
> Private health insurers in Medicare Advantage must abide by all explicit Medicare coverage determinations including national coverage determinations (NCD) and local coverage determinations (LCDs). In the absence of an NCD, LCD, or other explicit Medicare coverage determination, however, Medicare Advantage insurers can apply additional coverage restrictions if they determine that a service fails to meet the “reasonable and necessary” standard.
It sounds like virtually no claims are denied even under Medicare Advantage:
> Denied services accounted for 1.40% (95% CI 1.39–1.41) of total services (paid and denied services), and denied spending accounted for 0.68% (95% CI 0.67–0.70) of total spending (paid and denied spending).
However, it sounds like MA plans will deny things that the ordinary Medicare rules by themselves wouldn’t deny.
> On average, Medicare coverage rules accounted for 85% of denied services and 64% of denied spending, with Aetna Medicare Advantage coverage rules accounting for the remainder.
Certain day parts on tv are dominated by ads for personal injury lawyers and things you can spend government benefits on and are a desert for ads for things you might spend your own money on.
One series of ads that promoted getting some free medical equipment that ran for years and I thought looked scammy turned out to really be a scam.
I’ve always thought these ads promote the idea that some chiselers somewhere are trying to rip off government benefits and they drive people, even the pensioners that these are aimed at, to vote Republican.
Deleted Comment
If they ever went through with the offers they get in the mail, they'd be homeless, without insurance, cashless and asset-less within a year.
They get that kind of junk mail literally everyday.
Meanwhile I was tap-tap-tapping on my phone. I called them out and said it was a reverse mortgage according this page titled "Everything you need to know about 407-B reverse mortgages". They asked what fly-by-night website it was and when I said "irs.gov" they grumbled and moved on. To this day they refuse to admit that it's a reverse mortgage.
> If they ever went through with the offers they get in the mail, they'd be homeless, without insurance, cashless and asset-less within a year.
Not that quickly, but yeah, they're on that road. They're trapped in that home until they die. They'll be needing hospice care soon, and they won't be able to get it. Nothing we can do to move them off of it now because it's basically irreversible.
I couldn't imagine living there, deprived of carnival barkers yelling at me about erectile dysfunction, cybercriminals, and investing in gold.
That’s always a good idea, not only because of the ads, and not only grandma.
https://www.youtube.com/watch?v=Q3wX5pOUIMw
Do you mean Hoveround¹, or was it something else?
¹https://oig.hhs.gov/oas/reports/region5/51200057.asp
They look for people at risk, target them and take a cut of the overall reduced spend.
If Medicare is requiring the same outcomes and disbursing per-person based on the cost to Medicare, then the insurance company's profit would have to come from either selecting for healthier people on the input side, or keeping them healthier for longer. Selecting for healthier people might be hard if it's "all signups allowed".
That sounds like a good thing.
[1] https://www.pushkin.fm/podcasts/whats-your-problem/how-to-sa...
I kept his phone number (VOIP is like $1/mo), and I still get spam calls from scammers claiming to be "from Medicare" that "have a new card" for him - shamelessly pretending to be part of Medicare itself rather than a private company that's trying to steal his Medicare payments. Many times I'll ask them if their parents know they scam old people all day, or if they would want their parents getting scammed in their old age. Most of the time they just try to get me back to the script and think they'll convert me somehow ("I am not scammer").
I'm ambivalent on medicare advantage as a concept, but the scam companies are really what needs to be reigned in. Given that the benefits of medicare advantage is supposedly better coverage, I think a great way of doing reform would be to make it so people could change back to regular medicare at any time, and doing so would end up yanking back the premiums from the private company for the past year or two, unless they had actually paid them out for bona fide services. In addition to a lot more criminal enforcement against fraud, of course.
The article talks about these housecalls:
"The home health visits are designed to look for illnesses or codings that can increase risk scores. They very much are not looking for conditions that require medical intervention. This “free home health visit” scam is so profitable that an entire industry has sprung up of companies that send nurses out on behalf of the insurance companies."
I've no idea what the dynamic would have looked like if they came to different conclusions than me and we were at odds, but all I can say is that the quality of care always heavily depends on having an advocate.
How did you do that? Just through a normal carrier or something different?
Dead Comment
Now, senior folks get on Medicare until they've tapped out its lifetime benefits and then they go onto Medicaid.
This is part of what has created the upteen millions of Medicare scams.
There are no maximum lifetime benefits for Medicare Part A & B (health insurance) that I'm aware of. When you hear about a "Medicaid spend-down", it's all about reducing an elderly persons assets so that the state sees them as poor and Medicaid will pay their Long Term Care (nursing home) expenses. Medicare has almost nothing to do with the Medicaid spend-down strategy that I know of.
Deleted Comment
Why did they deny him? No reason. It’s just standard procedure. They deny, get good justification and approve. They do that every 7 days. They prettied up the language but confirmed that this is exactly what they do.
They literally killed him as part of standard operating procedure.
This country is fucked. Y’all better hope you have enough money to go be old somewhere else.
- FIL has MA,
- FIL (somehow, no explanation given) is in a "facility" (hospital, ER, doctor's office, bus depot, ???),
- FIL is "downgraded" and "had a cardiac arrest... and never recovered...)
...
- "They literally killed him as part of standard operating procedure."
Sounds like quite a few grounds for a lawsuit but I'm neither a lawyer nor a doctor.
Neither am I a fool: this is waaay to iffy a story/description to be useful in judging most anything mentioned in the story, be it MA, the "facility", the FIL, the writer, or the diagnosis.
As for who's fucked, the writer should worry about himself first.
So if you know you'll need continued care from your dentist and eye doctor then Medicare Advantage can be a good thing, since most of the highly rated plans provide that coverage as part of their benefits.
You can also get benefits for things hearing aids, and transportation to and from your provider visits, etc.
Yes, if you sign up for Medicare Advantage you'll find yourself back in the world of the In-Network and Out-of-Network care model.
At the end of the day though it's disingenuous to just label Medicare Advantage as solely the privatization of Medicare. The only way insurance companies that provide Medicare Advantage stay in business is if they provide a high standard of care for their members. The payment model set by CMS incentivizes them to do so.