🙏🙏🙏
I’m interested in any thoughts on Medicare Advantage plans vs. straight Medicare Supplement plans. Currently in the sign up process.
Just switched from Humana, but you are right. They are all pretty much the same in denying benefits..My advice is NEVER pay until you get an actual EOB. It usually takes at least two months. And when they call (and they do continuously), just tell them you won’t pay until you get your EOB.
Think that’s bad, I’m 63 so two years away from Medicare and I have to pay for Obamacare for me and my stb 56 yr old husband. We’ve tried healthsharing plans and wasn’t much better than Ocare.
Premiums are more than my mortgage payment. While I was still working my W2 job that I retired from back in Nov. 2022, (highly stressful; ran systems for 911 center of good sized county)
Had stage 1 breast cancer back in 2021 and I just told my doctor for that I will not be getting a dexta scan, etc. as every time I pay for stuff out of pocket with my HSA, before I meet the massive deductible, it never seems to clock down!
Nothing puts a dent in the deductible so I’m basically paying for catastrophic hospitalization but at a MUCH higher cost than it used to cost back before Ocare.
Prayers up for your friend.
Can’t offer help on health insurance, just my disgust and stack of bills.
As a Humana customer I can say with no reservation that Humana Advantage is excellent coverage. Nefarious complaints to the contrary, Humana ia as good as it comes.
My mother has been in an Advantage plan for years. We just moved her to a supplemental because of the crap care her Advantage offers.
I can’t speak for other places, but NYS is investigating Advantage plans and how the elderly are being scammed. They take your entire Medicare allotment and then deny services.
We called the AMAC people and got good advice when we turned 65. That might be a good place just to start gathering info.
I signed up for standard Medicare a few months ago.
I’m sort of like a fish, I like to swim in a large school.
I finally signed up for a Medicare Part D plan. I take no prescription drugs, but I entered in a few glaucoma drugs and a drug I remember from TV ads on the Medicare Part D website (which is nicely done). The prices of the drugs was shocking. If I had to take them, they’d cost from $5500 to $13000 per year. I found the Wellcare $0 premium plan had the lowest fixed cost and might only cost about $100 more annually if I needed drugs given its higher deductible.
It might be possible for her to live with a relative who no longer works.
Understand that custodial nursing care is legally considered different than rehabilitative nursing care.
In some states Medicaid might be helpful but her estate will probably have to repay Medicaid if the care is custodial.
prayers for your friend.
I think they started over with the new year - new deductible, etc.
I recently went thru the denial of claim issue with a friend who is now deceased. Hospital sorta forced him onto hospice due to a swallowing issue. (no nursing home would take him without it - 2 years ago, I could sign a waiver for him to eat regular food.) With him being on hospice, he got NO physical therapy even though he wanted it. He was condemned to a wheel chair...
on the denials - make sure of the dates and make sure the hospital updates the dates continually as long as they think your friend is improving. Humana will decide to save money....
Check the Medicare guidelines. If the proceedure is covered 100% by Medicare, then the Medicare advantage/replacement plans are also required to cover the same proceedure 100%. To do this you’ll need to obtain the proceedure code and then cross check it with the list of covered proceedures as per the Medicare guidelines.
Nursing home care
Medicare doesn’t cover custodial care, if it’s the only care you need. Most nursing home care is custodial care, which helps you with activities of daily living (like bathing, dressing, using the bathroom, and eating) or personal needs that could be done safely and reasonably without professional skills or training.
Medicare Part A (Hospital Insurance) may cover care in a certified skilled nursing facility (SNF). It must be medically necessary for you to have skilled nursing care (like changing sterile dressings).
Custodial care
Non-skilled personal care, like help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving around, and using the bathroom. It may also include the kind of health-related care that most people do themselves, like using eye drops. In most cases, Medicare doesn’t pay for custodial care.
https://www.medicare.gov/coverage/nursing-home-care
Skilled Nursing Facility (SNF) Care
Medicare pays 100% of the first 20 days of a covered SNF stay. A copayment of $204 per day (in 2024) is required for days 21-100 if Medicare approves your stay.
via Google
This is going on with a lot of plans. Cigna is a major perpetrator, exposed recently as having routinely denied claims by the thousands without even being medically reviewed. Think clearly about “health insurance.” They couldn’t care less about your health. They are not healthcare organizations. They are insurance companies, and they make money by taking your premiums and denying your claims. States have insurance commissions who are supposed to oversee this stuff but they are unreliable. The only recourse is persistence.
“The “Plan Benefits” showed FULL PAYMENT Coverage for skilled nursing through day 100.”
I would make an appeal and include a photocopy front cover and actual page of the document that says that.
Be aware that 2024 plan benefits may not be the same as 2023 plan benefits.
Make sure you have the 2024 plan benefit book.
Interesting thread considering what’s going on with us.
It is not that Humana is changing the basic terms of the policy, but that the published benefits vary upon care setting under the policy terms and conditions.
My advice is to always work with the insurance and the facility's utilization review department. The lay person does not have the expertise to navigate the system alone.
While I haven’t posted on FR in so long that I forgot my old login, I have been following some of the dialog with interest for many years, and this one really hit me close to the heart. I am in the mid-point of my seventies and make a good living during my retirement by not only selling Medicare health plans but teaching my clients about the pit falls of the various choices they can make, many of them exactly what have been mentioned in your post.
I do not like the Medicare Advantage plans in general. Not because they are intrinsically bad, but because most people coming onto Medicare have no knowledge of how it works or how the plans themselves work. The absolute best plan for those that can afford the premium is a supplement (medigap) plan “G” that really is a Cadillac plan regardless of the company selling it, and possibly the worst would be a Medicare Advantage HMO plan. The difference being the upfront cost of the supplement plan that pays everything and is network free nationwide, and the MA plan that is a nearly free option with ancillary benefits, but that is loaded with co-pays and also binds the client to a narrow network of providers in a specific location.
While we have to take courses annually on ethics and fraud among other things, there are agents that intentionally commit violations of both to sell unsuspecting prospects something that they cannot afford in the long term.
I would suggest everyone spend some time on Medicare.gov to educate themselves about Medicare, and don’t agree to purchase any plan presented by someone you don’t know.
One of the Louisville news stations ran astory about the number of advantage plans that hospitals are now rejecting because of extremely delayed payment or non-payment by the underwriters. The article noted that with some of the underwriters 90% of claims were denied initially.
They listed about eight underwriters in the story I don’t remember which ones. And if you have one of those you’re not going to get a hospital to accept it