Posted on 06/01/2020 7:19:42 PM PDT by George from New England
New to medicare, just turned 65 in April.
This is likely more a Florida issue, than elsewhere in the country. Florida has more HMO and Medicare Advantage providers due to more seniors down here.
History:
Two years ago I had multiple image vision in my right eye. Was 63, found eye surgeon that said cataracts, agreed to do surgery for me at no more than the price medicare allowed. Done it. A month later he wanted to do the other eye. I put it off til recently so medicare would cover it. Unfortunately this Dr doesn't not subscribe with the medicare plan I choose. Then come April and with china flu it took until just last week to get into eye Dr. This outfit right out of the gate (Perich) after my exam said I don't qualify for cataract surgery. So long story short, I wait and now I'm being screwed. Medicare covers the surgery if the Dr says I need it. Enter Optimum Medicare Advantage. It seems that their approved Dr's must get paid to NOT APPROVE surgery. That's all I can figure. Anyone else with any suggestions or similar situation, please share.
Can u go ba k to the first guy?
I used hard line feeds in my text input. My formatting was lost, sorry.
Medicare Advantage plans can be tricky. And if your Dr isn’t an approved provider under your plan, you probably have little or no recourse.
I’d get out of the advantage plan and get a supplement while you can still do so without underwriting.
Plan G is the Cadillac of supplements.
That’s mean $110 more a month that I have to pay.
Two there will be a deductible of close to $200
And I heard 80/20 paid.
So my real bitch is how two different doctors can be so apart.
This latest outfit ignored the patient history that I personally walked in the office with for that first visit.
This left eye, the one in need, had a myoptic shift since December and the Rx shows a 3 diopter change
+1.5 to -1.5
What about Medicaid? That’s how I ended up getting mine taken care of.
Isn’t medicaid welfare ?
Sounds like your advantage plan sucks. Try again next year and get a better plan.
We have Medicare and part D supplement. Not Advantage. Yes we pay more, but only $198 deductibles, pays virtually everything . Wife is scheduled for her 2 nd eye, very minor out of pocket.
Hummmmm, my Medicare Dad in Kali had the same surgery three years ago at age 89. His Dr. went overboard to have him come back for the second eye for the next two years. Sure there was some out of pocket expenses, but largely Ins. picked it up. Not sure what to make of this.
Ditto here. Had right eye done 11/19 and left eye done 1/20. I have medicare with a supplemental, not Advantage. The cost to me was around $200 bucks per eye. I have Humana as my supplemental.
We have MA and are very happy with it.
I was scheduled for cataract surgery on May 8 on Long Island. Needless to say it’s been postponed. But reason I’m posting. My doc told me I might not meet insurance standards since my corrected vision was still 20/20 left. 20/30 right. But my night vision, especially driving was dangerous. He pointed out the fact that the optometrist he works with had prescribed amber tinted lenses to filter blue light, reduce glare, and sharpen images as justifying the surgery. Emblem bought it. So though he is backed up I will get surgery in August. Best of luck to you.
Can you change your plan?
If the one you selected is giving you grief right off the bat then you might be better selecting another.
The alternate is to go to another facility. The one that did my husband's cataract surgery is well known in the area for being one of the best. They do on average about 40 a day so they know what they are doing and because of their reputation they almost never have problems with Medicare.
There was no out of pocket with Medicare, my insurance and Tricare for Life picking up what was left over.
Hey, this is Medicare. Not all doctors take it (for good reason) and the ones that do have to abide by a strict set of standards for prescribing treatment. It has nothing to do with the doctor “getting paid” to deny you treatment.
The way the Medicare HMOs work is that they get paid per patient. They then have to pay for the services provided. Anything they can avoid paying in pure profit and ends up in the hands of the execs and shareholders.
But you can fight back. Here’s a link to what you need to do to file a Federal complaint. https://www.medicare.gov/claims-appeals/how-to-file-a-complaint-grievance
And for more leverage, in Florida there AHCA - https://apps.ahca.myflorida.com/hcfc/
And, of course, you can try an appeal with the HMO itself and should probably start there. Although I don’t see your provider listed.
https://mypatientrights.org/file-a-complaint/florida/
Don’t roll over for them. Make them work. To be honest, the state makes money off the system as it is set up as well, so I don’t know how much help they will be. But you’ve got 3 shots at them.
And like others have suggested, if you can afford it, next open season go for regular medicare and a supplement.
This January I changed from regular medicare to a medicare advantage plan.
My retirement plan’s Medicare advisor advised me when I did so that for six months (IIRC) after changing to an advantage plan you can change your mind and go back to a conventional Medicare plan. That would allow you to go to any doctor who accepts Medicare.
Apparently it is not unusual for the restrictions of the advantage plans to lead to buyers remorse, so there is a trial period.
Hope this helps, good luck FRiend!
I would never have a Medicare advantage plan. And it can be expensive to switch to a supplemental plan later as they can screen you and charge more.
“The vast majority of non-pediatric primary care physicians (93 percent) say they accept Medicare—comparable to the share accepting private insurance (94 percent).”
https://www.kff.org/medicare/issue-brief/primary-care-physicians-accepting-medicare-a-snapshot/
The percentage is even higher for medical specialists.
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