Medicare Things You Don’t Know

Medicare things you don’t know (but wish you did). Questions you never asked because no one told you. And you will pay dearly if you are not prepared.

There are things about Medicare that will trip you up when you least expect it. Not so much with Original Medicare, but there are things about Advantage plans no one mentioned. Medicare things you don’t know. Stuff like access to care and prior authorization.

Medicare Stuff About Advantage Plans

You may think you understand Advantage plans but my guess is there are things in this video that will shock you.

Almost everyone LOVES their Advantage plan until they have to use it. I get calls all year long from folks who say they can’t afford their Medicare plan and want a supplement.

Most GA Medicare Advantage premiums are $0. If they can’t afford their plan there’s a good chance they are incurring hundreds or even thousands of dollars out of pocket for claims.

I have a friend that has been bragging about his plan ever since he went on Medicare. He thought I was foolish for paying “all that money” every month for a Medigap plan.

A few years ago a cancer diagnosis was a shock. His provider had grant money to pay for his treatment so his out of pocket was minimal.

Now the Cancer is Back

Gary is learning things about Medicare he did not know. Such as prior authorization.

Before he can have a test ordered by his doctor, the carrier must APPROVE the test. It’s all about the money.

His oncologist wants him to have proton therapy but his plan will only pay for a less expensive protocol. Dollars drive many medical decisions when an insurance carrier controls your benefits.

Proton Therapy – It Helps Only a Few at a Wildly Extravagant Cost MedPage Today

All he wants to do is get well but his Advantage plan is running interference. His carrier is interested in saving money. THEIR money. Not his.

It’s all about the dollars. Just another Medicare thing he did not know.

What is Prior Authorization?

According to the Kaiser Foundation “80 percent of Medicare Advantage enrollees are in plans that require prior authorization for at least one Medicare-covered service“.https://www.kff.org/medicare/issue-brief/prior-authorization-in-medicare-advantage-plans-how-often-is-it-used/

Prior authorization is more frequently imposed for HIGHER COST services.

Reading further . . .

A potentially overlooked consideration is access to covered services; specifically, how prior authorization may affect beneficiaries’ access to covered services.

Medicare Advantage plans can require enrollees to get approval from the plan prior to receiving a service, and if approval is not granted, then the plan generally does not cover the cost of the service.

On the other hand, Original Medicare does not require prior authorization for most services.

There are probably many things about Medicare Advantage plans you did not know. Limited access to care because of prior authorization requirements is probably just one of them.

#MedicarePriorAuthorization #MedicareAdvantage #GAMedicareExpert

Why Are Medicare Advantage Plans Popular?

Medicare Advantage plans seem to be popular. But why? What is the appeal? What is so attractive about these managed care plans? Are they really free? GA Medicare expert Bob Vineyard explains.

medicare advantage popular
Why are Medicare Advantage plans popular?

Why are GA Medicare Advantage Plans Popular

Are you turning 65 and confused about the Medicare process? Why is it so difficult? Why do my friends, and many agents as well, want to push me in the direction of an Advantage plan? Low premiums are attractive. So is “free”. Is there really such a thing as a free lunch?

Medicare Advantage plans are like the Hotel California. You can check in but you may never leave.

Some people turn to Advantage plans when they first go on Medicare at age 65. Low premiums, many are $0. Extra benefits like dental, vision and some have gym memberships. Drug plans are often included in the plan. “One stop shopping”.

What’s not to love?

Why do sick people leave Medicare Advantage plans?

Georgia Advantage Plan Traps

Have you ever bought something and later realized you had no idea how it works? Maybe the sales person forgot to mention key details that might have changed your decision.

If something is too good to be true it probably is.

There is nothing inherently wrong with GA Medicare Advantage plans. You just need to understand what you have signed on for. Here are a few questions you need to ask.

Preferably BEFORE you enroll.

  • Is the plan a PPO or HMO?
  • Do I need a referral to see a specialist?
  • Will my doctor take my Medicare Advantage plan?
  • Are there any out of network penalties?
  • Can I change plans at any time?
  • Can I return to original Medicare and a supplement plan if I want?
  • Does the out of pocket limit include prescription medication?
  • What will my health care really cost if I use an out-of-network doctor?
  • Will my claims be paid if I use a non-par provider?

If you ask the right questions and are satisfied with the responses, the Medicare Advantage plan could be just what you need.

When you enroll in a managed care Advantage plan, the insurance carrier, not Medicare, provides your benefits then reviews, adjudicates and pays your claims.

“No premium” plans are not free. You still have to pay for health care and prescription drugs.

There is no free lunch.

Health care is not free. SOMEBODY pays the bill. Either you or the insurance carrier.

But you knew that all along, didn’t you?

This Doesn’t Look Like Kansas Anymore

Managed care plans often have small provider networks. Fewer doctors. Fewer hospitals. The question is, how much smaller?

A Kaiser Foundation survey found that on average “Medicare Advantage plan networks included 46% of all physicians in a county.” Some plans had fewer than 5 thoracic surgeons, fewer than 5 neurosurgeons and fewer than 5 radiation oncologists.

This isn’t JUST about dollars. It is also about access to health CARE.

Each calendar year brings a new list of approved providers. Will your doctors be included or will they disappear into a dark hole?

Are you willing to change doctors to save money or pay more to keep your doctor?

Are claims submitted by non-par providers covered by your plan?

A recent government report says seniors are more likely to LEAVE managed care plans when they get sicker.

Managed care is great when you enjoy good health. But how much will your plan cost when your health changes dramatically? Can you really afford to be sick?

Medicare Advantage Final Exam

Many who enroll in a managed care plan never really understood how the plans work . . . until they had large claims. Don’t be one of them!

Do you like your current doctor(s)? Would you like to keep him or her?

Can my doctor refuse to treat me if I have a Medicare Advantage plan?

Do you want to direct your own health care, pick your own doctors and hospitals, or would you rather let an insurance carrier do that for you?

Is it easier for you to budget $120 per month to cover almost all of your health care costs or are you OK paying for your health care only as needed?

Could you budget $6,000 per year or more for your health care (not including drugs) if you had to?

How long could you afford to pay that much? One year? Two years? Longer?

Would you trade places with Marsha’s husband?

You can change your Advantage plan every year. Same is true for your drug plan. You can also enroll in original Medicare any time you want without answering health questions.

But if you want to change to a Medicare supplement plan you may need to prove you are healthy. Your best shot at getting a Medicare supplement plan is when you first enroll in Medicare Part B. If you wait until you NEED a Medigap plan you may not be able to get one. That is Catch-22.

Many will only have one chance to enroll in a Medigap plan. Will you be one of them?

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$GAMedicareExpert #MedicareAdvantagePlans #FreeMedicarePlans  #MedicareHMO  #MedicarePPO

GA Medicare Advantage

Medicare Advantage Plans in GA are privately run senior health insurance plans that replace traditional Medicare coverage. Most are either an HMO or PPO and require you to use a doctor or other medical provider that has agreed to the terms and pricing structure for the network.

Medicare Advantage Plans = Fewer Choices

Medicare Advantage Plans have more restrictions and fewer choices than original Medicare and a Medigap plan.

  • If you change to a Medicare Advantage Plan you may find that the doctor you have been seeing for years does not participate in your new plan and will only see you on a cash basis.
  • Medicare Advantage Plans typically have low premiums, in some cases $0. The trade off is higher out of pocket when you need it most.
  • Traditional Medicare and a comprehensive Medigap plan F supplement typically means you have $0 out of pocket for hospital and doctor bills when approved by Medicare.
  • When you have a Medicare Advantage Plan, private insurance carriers, not Medicare, decide which claims will be paid and which will be denied.
  • A large hospital bill that is approved by your Medicare Advantage carrier may leave you owing $3,000 or more once the dust settles.
  • When you want to see a specialist you must first have a referral by your PCP (primary care physician) and that referral must be approved by your Advantage carrier.
  • The rules for Medicare Advantage plans change every year

2014 Medicare Disenrollment Medicare Advantage

Medicare Advantage Pluses

To be fair, there are positive things about Medicare Advantage Plans.

  • Advantage plans may include “extra” benefits such as limited vision or dental coverage
  • Advantage plans require copay’s for doctor visits. Something you won’t find with most Medigap plans.
  • Many Advantage plans include prescription drug benefits. Sometimes the “package” covers the medications you need, sometimes not.
  • If you switch from original Medicare to an Advantage plan and you are not satisfied, you may disenroll during the first 12 months of your Special Enrollment Period (SEP) and return to original Medicare.

Types of Medicare Advantage Plans in GA

Most Medicare Advantage plans will fall in to one of the following categories.

  • PPO
  • HMO
  • PFFS
  • SNP

Bob Vineyard, President of Georgia Medicare Plans, has decided to specialize in GA Medigap plans. We believe the flexibility and overall VALUE of original Medicare and a Medicare supplement plan are superior to the Advantage plans currently on the market. We invite you to compare GA Medigap quotes using our instant online quote engine or ask for a free, no obligation consult.

HMO Advantage Plan

Medicare Advantage HMO plans have strict rules for Medicare beneficiaries. You must play by their rules or else your claim is not covered. This is a summary of the HMO rulebook.

  • You can only obtain care from an HMO approved doctor, hospital, lab or other participating medical provider
  • Your Advantage HMO will only pay for a specialist if you have a referral from your HMO PCP (primary care provider)
  • Some medical procedures require prior written approval from the HMO before they will be covered
  • You have limited rights of appeal if your HMO claim is denied

Bob Vineyard and Georgia Medicare Plans does not recommend Advantage HMO plans to our clients. We believe the choice and value from GA Medigap plans is superior to those offered by HMO plans.

PFFS Advantage Plan

PFFS Medicare plans allow you to see any willing provider but ONLY IF that medical provider accepts the terms and pricing structure offered by your PFFS Medicare Advantage plan.

  • For each medical service (including lab, X-ray, etc.) the provider must accept whatever limits your PFFS carrier places on the treatment plan
  • If the doctor or medical provider does not agree to the terms your medical procedure is not a covered expense and you must pay out of pocket
  • To avoid any penalty, you need to check with each provider BEFORE services are rendered, to see if they still agree to the terms and payment limits of your  Advantage plan
  • You cannot assume that a doctor or service that was covered in the past will be covered the next time
  • Some Advantage plans require you to pay a copay every time you see a doctor or receive a medical service
  • Some PFFS plans have a network just like PPO plans. If you use a non-par provider you pay a penalty.

Bob Vineyard, President of Georgia Medicare Plans, has decided to specialize in GA Medigap plans. We believe the flexibility and overall VALUE of original Medicare and a Medicare supplement plan are superior to the Advantage plans currently on the market. We invite you to compare GA Medigap quotes using our instant online quote engine or ask for a free, no obligation consult.