Open Forum → Re: Private Group HMO and Medicare advantage?

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I have handled my folks Medicare Advantage Plan and in so many ways it is better than many traditional Health Plans through an Employer.

I have had no problems with their medications part of the Policy and Part D. I do have to keep an eye out for the Donut Hole and have been able to schedule refills around it.

They have no yearly deductible. They have a $5.00 co-pay and a yearly Stop Gap of $1440.00 each. Once out of pocket co-pays, co-insurance and other cash outlays are met, then any future Medical Bills are paid at 100%. And we pay nothing further for any covered treatment. That amount does not include Prescriptions. And they both have met that amount in the last two years. Prior to that they just saw their Doctor for checkups and minor things. They do pay a little more Premium on top of the Medicare Premium. Plus the Policy has some extras thrown in at no additional charge. Things like hearing aids, dental, eye exams, glasses, gym membership, to name a few.

Their Insurance Company is small and is only in 9 Counties in this State. It was started by Doctors and their Dr. was one of them and I understand that he still has an ownership interest in it.

When I call their Insurance Company, the phone is usually answered by the second ring and the Employee has the power and skills to handle anything I have thrown at them. I have never been transferred to another person.

I am covered under a Medicare Advantage Policy too, and have had no problems. I did have a detached Retina in July 2013 that required surgery and later cataract surgery as a result of the Retina surgery. In the last 24 months Insurance has been billed over $60,000.00. My Surgeon is in the top 5 in his field, west of the Mississippi for that type of Surgery and I have seen him monthly after the surgery. I take a handful of maintenance medications and use their Mail Order and get 90 day supplies. Have had no problem with them and the process. I receive texts and e-mail when they are ready to be refilled, how much it is going to cost, when it is shipped and so on. I handle all the transactions online.

As to reimbursement to my Providers I have heard no complaints and none of my Drs. rush me through an appointment. Everyone I have come into contact within the medical field, treat me like any other person who has Employer provided Insurance.

And in the past I have had an employer provided policy [actually through the ex-wife] that was a Cadillac Policy through the Teamsters for about 10 years. She paid $25.00 twice a month. Coverage was great. On the Prescription side there was a stop-gap of $500.00 and on the Medical side it was $5,000.00. Though benefits changed and were tweaked over time.

But that is what I have experienced.

And I have worked in the Insurance Industry dealing with Casualty Claims and the ex has been in the Insurance Business for 23 years, first in Billing and then as a Third Party Administrator working with Taft-Hartley Trusts and Union Employers like Weyerhaeuser. So we both have known and know what goes on behind the curtain and know how to talk the lingo.

Does your Grandma have an Advantage Plan or Medigap? It does make a difference. My Cousin has both.

Grandma has original Medicare and Medigap.

That is a whole different horse of a different color.

»www.medicare.gov/supplem ··· gap.html

Wow. Just wow. I had a Medicare PPO for many years (disabled) which was excellent and then the last two years Obama betrayed his promise to Hawaii and the PPO was forced to close and we had to get Advantage instead. It was pathetic compared to the Medicare PPO and starting next year it is going to be HORRENDOUS and the ONLY other option is Kaiser which is horrible on this island. Straight Medicare (with Medigap) is out of the question here as most doctors will not take it.

My monthly premium is going from $91 to $152. My co-pay for doctor's visits goes from $15 for my primary care physician to $35 and co-pay for specialist visits goes from $25 to $50! There is a $150 deductible and as far as the drug plan it's a joke with a $315 deductible so I get my drugs from Canada. Most seniors here have concluded that we will no longer go to the doctor unless half dead. The provider (Blue Cross-Blue Shield for Hawaii) lost huge amounts of money last year on their Advantage plans hence the drastic changes for next year. Oahu residents have a much better plan than the neighbor islands and that is directly laid at Medicare's feet.

Medicare has for all intents and purposes abandoned my island and no other provider wants to deal with the neighbor islands (especially the Big Island) either. Medicare thinks medical costs are VERY CHEAP on my island yet in reality they are far higher than all other islands due to the largeness and ruralness of the Big Island. So, providers on my island are NOT fairly compensated by Medicare and more and more will not take even the Advantage Plan. Plus, we have a critical shortage of family physicians and most are closed to new patients. My family doctor is 76 and works only part time. I had to wait two months for an appointment so Medicare patients tend to go just to specialists or urgent care and now that will be $50 co-pay. When you are trying to live in Hawaii with its very high cost of living on Soc Security only it will now be just about impossible unless one just doesn't go to the doctor. No wonder why the amount and severity of chronic disease is so high on this island.

So, you are lucky. The one good thing for me is that Blue Cross/Blue Shield would be very unlikely to change doctors,etc in the middle of the year (surprised to learn United Health Care did that) and HMSA (Blue Cross/Blue Shied) has about 98% of physicians in Hawaii participating in their Advantage plans.

I'm in your boat too but I get Medicare/Medicaid (MassHealth) so my co-pay is zero. I did opt for Medicare advantage (Health New England Medicare Advantage) instead of original Medicare, much easier to deal with. But I am working with the vocational rehabilitation program here because I want to work but the wheels of that turn very slowly. I feel that the training program they sent me to wasn't adequate. Three and a half weekends to learn to drive a 40,000 lb vehicle isn't enough. I've failed two skills tests already. I'm still waiting for another test.

I'm surprised you don't qualify for Medicaid if you're on disability. Most people under 65 who SSI/SSDI (disability) is their sole source of income are dual eligible for Medicare/Medicaid or Medicaid only if they don't qualify for Medicare so their costs of going to the doctor is zero and they pay 2.55 generic and 3.65 for brand name medication.

Another advantage of Medicaid eligibility with Medicare is you lose the doughnut hole on Medicare part D. Pretty nice when one of your prescriptions costs $800 a month.

I have the original traditional Medicare. There is absolutely nothing wrong with it and no hassle at all. Why do you say it's hard to deal with?

Several reasons,
1. You can wait 30 minutes on hold when you call 1-800-Medicare. Same with dealing with Social Security, I had to call them to change grandma's direct deposit waited 30 minutes on hold Monday evening and gave up. I called Tuesday morning at 7 AM (before California wakes up) and got right through.
2. Original Medicare is like any government bureaucracy, ask two different employees the same question get two different answers. Same can be said about Social Security.
3. If your claim is denied, good luck with appeals and I mean good luck.
4. They just started this competitive bidding nonsense with durable medical equipment (I use DME) and that forces you to use specific suppliers and the cheapest equipment money can buy. With Medicare Advantage you can use any in network supplier.

Several advantages with Medicare Advantage,
1. I belong to a local plan, call them you get an actual human right here in Springfield.
2. Doctors are less hostile towards the plan as it's simplified in terms of billing (bills like private insurance).
3. Like I said above, choice of DME providers.

Mele20, Somehow all that seems unfair in Hawaii. I wonder what will happen when the next batch of boomers enter the system.

Yep, we have had many changes recently here as well, but not as drastic as yours. We have a larger population and there is a lure for Doctors to move here. The mountains for hiking and skiing is close, as is the beach. We are 125 miles from Oregon that does not have sales tax. Here it is 9.5% and in some small cities it is 10% and they keep wanting to raise it. At least their is no Income Tax. Some laws have been put on the books by initiatives to keep Property Taxes within check.

Only problem with my PCP here, is that we will cover a lot in our meetings, and he will recommend that I do things and will forget to give the orders to the referral clerk or his Nurse, so I have to track down his Nurse to get all done. Last time was a tetanus shot and a referral. Or he will forget to fax from his laptop Rx's to my local pharmacy.

Looking at last years Medicare Book that describes what is covered and what Advantage Plans are available and compared to this years Book, and I find less Companies offering Advantage Plans. So this years choices for care are limited. Also the Plan I am with raised its premium from $0.00 to $55.00 per month on top of the medicare fees this year which is at $104.90. Since I have to have some work on my right eye lens [detached retina in July 2013] and its cataract lens in 2014, I opted for the $85.00/mo premium which has a $275.00 deductible for day surgery vs 20% co-insurance. [that will mean a lot less out of my pocket] Plus the left eye has progressed faster and I need cataract surgery in that eye in 2015. Last Cataract this 2014, I paid around $700 co-insurance. At least there are no deductibles for B or D-Prescriptions.

Add to that, the two major providers here [Tacoma/Lakewood] are MultiCare and the Franciscan Systems. We are an hour South of Seattle, which has other groups available in King County, like Group Health and a few other Care Systems. I mainly go to Franciscan Doctors and the associated providers. Franciscan did not reach a compensation package agreement this year with Humana and Primera/Blue Cross. So if one has those Insurances, you will have to go to a Multicare Facility or Provider. Or pay the extra fees. So available and usable Insurance Companies have been reduced. And my past experience with MultiCare is problematic or rather horrendous.

Also I have fallen into the Donut Hole the last 2 years, so I have to be creative with the timing of my higher priced maintenance meds. And one of my meds is being moved from Tier 2 to Tier 4, with a higher copay. They gave me an alternative that is in Tier 1 or 2, but it has more side effects and I would need to be hospitalized for at least 2 weeks to titrate off the old, then have nothing for a week and then add this new one gradually, to make the change. It says that on the Rx information on the label and www.drugs.com and other sites. And I get $50.00/month too much to qualify for drug assistance.

In conclusion, we are getting more and more restrictions and choices from every angle.

But fun, fun,....we are getting a COLA of 1.7% next year. Just got my notice from SSA.

I do worry about the future costs and availability of Providers. Once I wrap up my folks' Estate, I will have a bit of money and am considering moving to another Metro Area and State that is a little more friendly regarding Medical Services and Insurance Companies. I do have 6 cousins in Minnesota that I have not seen for years. Rusty right now, but I have found the commission fees for Agents and Doctors for certain cities on the www.cms.gov site.

I too, am on SSDI and have worked in the past PT. Last I looked I could earn between $1000.00 per month to $1200.00 without jeopardize my SSDI.

With Medicare and Medicaid the state pays my $104.50 Medicare part B premium. I have to pay my $77 Medicare Advantage premium out of pocket.

Shockingly the Medicare Advantage plan I have has a Part D plan that covers all of my meds on their formulary. The standalone plans don't cover my drugs 100 percent. The drug that is hardest to find coverage on is the $800 a month Invega.

The Medicare Advantage plan also pays for heated hoses for my CPAP machine. I don't have to put up with rainout. The first CPAP that was bought by original Medicare (that was returned when I switched to Medicare Advantage) was a piece of junk. They gave me a previous version of a ResMed machine that had been discontinued. I was glad to find out that the provider was out of network on the Medcare Advantage plan.

And on that $1,200 a month you can earn on SSDI without losing it, you can subtract any impairment related work expenses. If I get stuck paying for that $800 a month medication because the employer's health plan refuses to cover it, I can deduct that and the SSA won't count it since I need the meds to work. I was told that by a disability advocate.