Health Insurance

[eyexer]

Medicare has been around since 1965, advantage and Prescription Drug plans since 2006. Being their newer perhaps and people can choose which way they want to get their Medicare. Speculation on my part except having more options. When you think of the insurance you had during your working years typically through your employer. Premium, deductible, copays and max out of pockets. Those are what advantage has. Not every plan but some do. Routine Dental hearing and vision, you could get those in your plan but once you got on Medicare you would have to purchase those separately. Now you can get those in every advantage plan. Just some offer more than others. I thinks it’s only a matter of time before supplements as we know them are gone. Don’t know if it will be in our lifetime. Just like Medica cost plans. They were started to replace some of the advantage plans because the money for advantage plans was taken and given to fund Obama care with the idea that once advantage plans gained market share over cost plans the cost plans would go away. So in Morton, burliegh, stutsman and grand forks counties that’s why medica can not offer their cost plan. They also added a couple advantage plans to replace them. So you you’re reading this, you are against advantage plans but are on a medica cost plan, you need to look at what your complaining about cause they are from the members view, the same. Only different on how they are funded or their relationship with the federal government.

So fill in the blanks for me.
1-who does the medical industry send their invoices/claims to
2-who pays the actual claims sent by hospital.
3-who determines what the premium is for someone advantage policy
4-what goes into determining that premium amount?
5-who funds the dollars for paying medical bills/claims

 

[johnr]

Medical insurance, and supplemental insurance cost are because of the government.

My oldest child, now 31 cost me $32 after insurance paid for the birth of her. My last child, 13 years later was over $4,300.

What happened in 13 years?

The government is a straight up mafia system, where they take their cut, pay themselves top notch and completely different medical coverage, then kick us in the nuts, take half our pay, and tell us how lucky we are to have them taking care of us.

 

[LBrandt]

Medical insurance, and supplemental insurance cost are because of the government.

My oldest child, now 31 cost me $32 after insurance paid for the birth of her. My last child, 13 years later was over $4,300.

What happened in 13 years?

The government is a straight up mafia system, where they take their cut, pay themselves top notch and completely different medical coverage, then kick us in the nuts, take half our pay, and tell us how lucky we are to have them taking care of us.

What tribe do you belong too and how many pony's you got. . LB

 

[Wall-eyes]

Being 60 this is a good read for me. Sounds like Jim is very knowledgeable about this, and then some so no. Have to agree visit and check all your options and each decide their own. As Jim stated he is just giving facts if he can help, and it works for some so be it. Getting old really sucks, never thought I would say that thx to damn government mostly second shitty health issues.

 

[Jim Simmers]

Advantage plans are pure garbage when you actually need coverage. They are bilking millions from seniors across this country. If you are a healthy senior are they a decent option??? Maybe. If you are ill in any way they are pure garbage and should be illegal. You are clearly in sales and NOT in healthcare.

Once you take an advantage plan in lieu of regular Medicare you may not be allowed to get on Medicare.

Thats totally wrong It is Part of Medicare. Go to Medicare.gov, everything is right there. Made into law by the same government body that brought you original Medicare. So I would like to know what information you have that debunks everything that I have stated. I have posted nothing but facts that can all be proven.

 

[Jim Simmers]

So fill in the blanks for me.
1-who does the medical industry send their invoices/claims to
2-who pays the actual claims sent by hospital.
3-who determines what the premium is for someone advantage policy
4-what goes into determining that premium amount?
5-who funds the dollars for paying medical bills/claims

So fill in the blanks for me.
1-who does the medical industry send their invoices/claims to, the insurance carrier/ member may have cost share. Some like hospice for instance go to CMS.
2-who pays the actual claims sent by hospital. the insurance carrier
3-who determines what the premium is for someone advantage policy/ The carrier with approval from CMS
4-what goes into determining that premium amount? Some of what the cost of doing business, the health and poplation and what Medicare deams as a fair amount.
5-who funds the dollars for paying medical bills/claims The money comes from Medicare which is from money you paid in during your working years and the Part B premium that the Medicare member pays in.

 

[AaronJ]

Thats totally wrong It is Part of Medicare. Go to Medicare.gov, everything is right there. Made into law by the same government body that brought you original Medicare. So I would like to know what information you have that debunks everything that I have stated. I have posted nothing but facts that can all be proven.

Work in healthcare. See the patients get denied time after time on advantage plans vs traditional Medicare. Co-pays are exponentially more costly on advantage plans as compared to traditional Medicare for the same service rendered (CTs, etc).

And, you are wrong. If you take an advantage plan you MAY not be accepted into standard Medicare should you change your mind. You actually have to apply for what would have rightfully been yours and may be denied. I see it often.

Again, you are obviously in sales. You know the lingo and are probably reporting directly off of a pamphlet provided to you by an advantage plan; but have zero clue about the real downstream effects of these shit plans on our elderly. If you are healthy and eligible for Medicare it may be a viable option until you become ill (which most in their 60s+ either are or become). Stop selling snake oil.

 

[AaronJ]

22% prior authorization denial rate for Medicare Advantage plans, compared to a 1% denial rate for traditional Medicare.Nov 16, 2023

disadvantage of Medicare Advantage is you'll have a more limited choice of doctors and medical offices than you would with Original Medicare.Nov 20, 2023


Can I drop my Medicare Advantage Plan and go back to original Medicare?


If you joined a Medicare Advantage Plan during your Initial Enrollment Period, you can change to another Medicare Advantage Plan (with or without drug coverage) or go back to Original Medicare (with or without a drug plan) within the first 3 months you have Medicare Part A & Part B.


https://www.nbcnews.com/health/rejecting-claims-medicare-advantage-rural-hospitals-rcna121012

 

[Jim Simmers]

Advantage plans are pure garbage when you actually need coverage. They are bilking millions from seniors across this country. If you are a healthy senior are they a decent option??? Maybe. If you are ill in any way they are pure garbage and should be illegal. You are clearly in sales and NOT in healthcare.

Once you take an advantage plan in lieu of regular Medicare you may not be allowed to get on Medicare.

Again, I would like to know where you get your information. They cant be that bad as they have been around for 18 years, for the almost 18 years that I have had these plans in my portfolio, I still have most of my BOB. I have seen how they perform in all settings with probably most health issues to end of lfe. Saw it first hand with my grandparents.
Bilking Millions! HAHA, you clearly know nothing. Original Medicare $164.50 mo and 80% coverage, Medigap, $200 per month average and 20%. Medicare Advantage, $0-$105 monthly can maybe have some cost sharing usually less that $4000. $4000 max because that is a few of the plans stop loss.
52% of Medicare members across this great county are on an Advantage plan. Medicare makes the rules these plans must go by. If Medicare covers it, these plans have to. If Medicare doesn't, these plans have the option. Original Medicare does not pay for observation in a hospital, Prescription drugs, yearly wellness exams, routine dental, vision and hearing. Original Medicare doesn't cover meal plans, transportation to and from Doctors appointments and to the pharmacy, the don't cover over the counter benefits or gym membership and they don't reward seniors for being active.
Medicare for many is very confusing and can be very stressful. So please, share proof of your wisdom so we can all see it . I like when guys like you come on here because this is so easy for me to debunk and I can back up 100% of what i have stated here. I get a chance to talk about something that I am passionate about because I have helped and build so many relationships over the past 18 years.
I will wait.
.

 

[Jim Simmers]

22% prior authorization denial rate for Medicare Advantage plans, compared to a 1% denial rate for traditional Medicare.Nov 16, 2023 WHY IS IT BEING DENIED? USUALLY BECAUSE OF A CODING ERROR.

disadvantage of Medicare Advantage is you'll have a more limited choice of doctors and medical offices than you would with Original Medicare.Nov 20, 2023 OK, A QUOTE, NICE, WHERE DID IT COME FROM? AARP SUPPORTS THESE PLANS


Can I drop my Medicare Advantage Plan and go back to original Medicare? YOU CAN BUT AFTER THE FIRST YEAR YOU CAN DO SO BETWEEN JANUARY 1ST THROUGH MARCH 31ST. ITS CALLED MEDICARE OPEN ENROLLMENT.


If you joined a Medicare Advantage Plan during your Initial Enrollment Period, you can change to another Medicare Advantage Plan (with or without drug coverage) or go back to Original Medicare (with or without a drug plan) within the first 3 months you have Medicare Part A & Part B. ON PAGE 76 IN YOUR MEDICARE AND YOU HANDBOOK, IT SAYS IF YOU ARE IN A PLAN FOR THE FIRST TIME, REGARDLESS OF WHAT ELECTION PERIOD YOU JOIN A PLAN IN, YOU CAN GO BACK TO ORIGINAL MEDICARE AND YOUR SUPPLIMENT IF IT IS STILL AVAILABLE OR GET ANYTHING ONE FOR ANY REASON REGARDLESS OF HEALTH.


https://www.nbcnews.com/health/rejecting-claims-medicare-advantage-rural-hospitals-rcna121012

 

[Jim Simmers]

Work in healthcare. See the patients get denied time after time on advantage plans vs traditional Medicare. Co-pays are exponentially more costly on advantage plans as compared to traditional Medicare for the same service rendered (CTs, etc).

And, you are wrong. If you take an advantage plan you MAY not be accepted into standard Medicare should you change your mind. You actually have to apply for what would have rightfully been yours and may be denied. I see it often.

Again, you are obviously in sales. You know the lingo and are probably reporting directly off of a pamphlet provided to you by an advantage plan; but have zero clue about the real downstream effects of these shit plans on our elderly. If you are healthy and eligible for Medicare it may be a viable option until you become ill (which most in their 60s+ either are or become). Stop selling snake oil.

You have your opinion and thats great. You work in healthcare? Are you in billing or a nurse or doctor? I am in sales yes, its what insurance agents do. I am more than just a salesman because of the service I provide after the sale. You talking about insurance and what good or bad is like me tying to perform a surgery just because I have had over 13 in my life.
I know you don't have many options up there and only one advantage plan and a medica cost plan, which is not an advantage plan although similar. But don't worry, you will have more within the next 5-10 years.

 

[AaronJ]

https://www.politico.com/news/2023/...icare Advantage plans,from the think tank KFF.

https://www.statnews.com/2023/03/13/medicare-advantage-plans-denial-artificial-intelligence/

https://www.aha.org/news/headline/2...edicare-advantage-coverage-denials-and-delays

https://www.aha.org/news/headline/2...iftly-correct-ma-polices-violate-cy-2024-rule

https://www.levernews.com/care-denied-the-dirty-secret-behind-medicare-advantage/


As I have stated you are obviously in sales and read like a book. I have real world experience fighting for patients that were duped by shitty advantage plans. You sell them....

Above are a variety of articles from a variety of sources. Read them yourself. Please look beyond your pamphlets. All things that are cheaper initially can end up costing you in the end (raingear, crappy outdoors equipment, and bad insurance just to name a few).

 

[db-2]

Called blue cross about the rate increase from $517 to $580/month.
They have advantage plan and our premium with that would be $140 versus the $580 per month. Big savings of $440/month.
But it would go from zero copay to as high as $3,750 each on an annual cost. Still probably a savings.
And there is question about what doctor and what hospital i would get with advantage. Nice to know one can go to Mayo if needed.
So, in end depends on how much you use to reach your max copay.

So, she said i can sign you up for advantage but when all is considered i recommend you stay with what you have.
There is no way i am able to make a decision as i do not know the whole story so will stay as is. Pay the increase cost no deductible as i go with the premium.
She did say for me with VA health care and drop my part of what i have to save $330/month is maybe something to consider but i know there are issues there also. My upcoming dentist bill would not be cover by advantage. db

 

[Jim Simmers]

https://www.politico.com/news/2023/11/24/medicare-advantage-plans-congress-00128353#:~:text=In 2021, Medicare Advantage plans,from the think tank KFF.

https://www.statnews.com/2023/03/13/medicare-advantage-plans-denial-artificial-intelligence/

https://www.aha.org/news/headline/2...edicare-advantage-coverage-denials-and-delays

https://www.aha.org/news/headline/2...iftly-correct-ma-polices-violate-cy-2024-rule

https://www.levernews.com/care-denied-the-dirty-secret-behind-medicare-advantage/


As I have stated you are obviously in sales and read like a book. I have real world experience fighting for patients that were duped by shitty advantage plans. You sell them....

Above are a variety of articles from a variety of sources. Read them yourself. Please look beyond your pamphlets. All things that are cheaper initially can end up costing you in the end (raingear, crappy outdoors equipment, and bad insurance just to name a few).

Ok, well, don't cry here, take it to CMS or congress. 52% and soon to be 54% of Medicare eligibles will argue with you. 70% of all health insurance/healthcare fraud comes from the doctors office so keep on preaching.

 

[Pheasant 54]

So if I am reading correctly Mayo Clinic in at least Phoenix is no longer going to accept advantage plans ? starting on 2024

 

[Motor Mouse]

Oh man I can’t believe I’m doing this! I said I would not so I am a dink.

Jim give it up! You are not doing your self any favors! Advantage plans are not the end all.

Why does a g or n plan or other gap plan not need a max out of pocket? Because the coverage for that 20% you refer to is covered 100%. Yes a n plan has a co pay for office visits. Might cost you a couple hundred bucks at most for most people much less. The big thing for me is the pharmacy. I am in a BCBS group plan with my former employer. I am a diabetic and have had congestive heart failure. I am on 3 diabetes drugs and 3 heart drugs. Now I.could go into drug tiers. I know them all too well. There is a major difference between tiers with gap plans and advantage plans.Will tell you my pharmaceutical coverage with my group gold plan with drug plan and monthly premium is less per year than any advantage plan. And no hassle. No denials no referrals. And more.

I will tell you from experience that max out of pocket is not the only thing to consider and what I pay for drugs and med coverage is less than most max out of pocket c plans.

What does suck is that dental is not covered. Now talk to any dentist or do the math yourself. If you need a cavity filled every few years and cleanings twice a year dental insurance does not pencil out. If you have dental issues it will make sense. I get vision screens and a discount on glasses and contacts. Not vision coverage.

I was in the hospital two times in in 2023. And with my pharmacy needs I can guarantee I’m on the right plan. Wife had cancer, will be on cancer drugs for several years. By her doctor recommendation/ approval. Not Humana. She is not at Medicare age and we are not sure if my employer plan is right for her or if we should consider an advantage plan? I am worried about approvals referrals with advantage plans? I’ve been there! Her drug costs other than the cancer drug is minimal. So advantage plan could be right for her.

Jim again you are not doing your self any favors! You are a salesman for Medicare coverage. And that’s ok! But you are biased! You can not be. This is not if gap is a better option or advantage plans are a better option! This is do your homework see what’s best for your situation! But to make claims that advantage plans are best for 99.5% of seniors is snake oil.

Just drop it. You will be doing your self a favor.

 

[eyexer]

I would still like to know his one gets an advantage plan with no premium. That’s the one I want

 

[Jim Simmers]

So if I am reading correctly Mayo Clinic in at least Phoenix is no longer going to accept advantage plans ? starting on 2024

No longer? They never did. They do not accept Medicare. Out of the 4 Mayo clinics, only Rochester accepts Medicare and most carriers are in-network.

 

[Jim Simmers]

I would still like to know his one gets an advantage plan with no premium. That’s the one I want

701-220-3251. if you live in a qualifying service area, zip code, I have 8 plans that offer a zero premium.

 

[Jim Simmers]

701-220-3251. if you live in a qualifying service area, zip code, I have 8 plans that offer a zero premium.

I am sorry, I just saw you are in Williston. I can get you a cost plan with a zero premium. pretty close to an advantage plan. Like benefits, works the same, it is just paid differently than an advantage plan.