Stop the Medicare “Advantage” Scam Before Medicare Is Dead

I can speak about an apparently non-scam Medicare Advantage plan that my wife and I are on.

It is effectively a PPO (similar to the Kaiser plan someone else mentioned), so we have access to exactly the same physicians that we had already where we were paying for private insurance. Our annual premiums went from about $85k a year (on the private insurance) to around $10k out of pocket.

We are fairly healthy, though my wife is going to have some major joint surgery. What was interesting is that it was our PRIVATE insurance that stalled and stalled over approving the surgery. When she switched to the MA plan, it was approved immediately. (That stalling finally motivated my wife to make the switch out of the private insurance.)

The downside of our MA plan is that we are not going to be able to move out of the area easily. But you always have that issue regardless -- finding a whole new set of doctors and dentists when you move...

I do get these phone calls asking to schedule a "wellness" check that the article writer mentions. Oddly enough, my wife didn't get any (so far.)

I don’t like the idea of private Medicare but this article is populist handwaving. Here is an article from real healthcare researchers with aggregates statistics: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9465897/

Notable:

> Private health insurers in Medicare Advantage must abide by all explicit Medicare coverage determinations including national coverage determinations (NCD) and local coverage determinations (LCDs). In the absence of an NCD, LCD, or other explicit Medicare coverage determination, however, Medicare Advantage insurers can apply additional coverage restrictions if they determine that a service fails to meet the “reasonable and necessary” standard.

It sounds like virtually no claims are denied even under Medicare Advantage:

> Denied services accounted for 1.40% (95% CI 1.39–1.41) of total services (paid and denied services), and denied spending accounted for 0.68% (95% CI 0.67–0.70) of total spending (paid and denied spending).

However, it sounds like MA plans will deny things that the ordinary Medicare rules by themselves wouldn’t deny.

> On average, Medicare coverage rules accounted for 85% of denied services and 64% of denied spending, with Aetna Medicare Advantage coverage rules accounting for the remainder.

It is not a popular opinion but I always thought the tv ads that spam the airwaves in the last few months of the year were harmful to the legitimacy of institutions. In this day and age most of us are so assaulted by spammed scams that we develop a sensitive sense of scamminess and like many of the ads aimed at seniors these ones scream “get grandma away from the tv!”

Certain day parts on tv are dominated by ads for personal injury lawyers and things you can spend government benefits on and are a desert for ads for things you might spend your own money on.

One series of ads that promoted getting some free medical equipment that ran for years and I thought looked scammy turned out to really be a scam.

I’ve always thought these ads promote the idea that some chiselers somewhere are trying to rip off government benefits and they drive people, even the pensioners that these are aimed at, to vote Republican.

I just saw a podcast about a startup that was working with Medicare/Medicaid to reduce costs by improving preventative care [1].

They look for people at risk, target them and take a cut of the overall reduced spend.

If Medicare is requiring the same outcomes and disbursing per-person based on the cost to Medicare, then the insurance company's profit would have to come from either selecting for healthier people on the input side, or keeping them healthier for longer. Selecting for healthier people might be hard if it's "all signups allowed".

That sounds like a good thing.

[1] https://www.pushkin.fm/podcasts/whats-your-problem/how-to-sa...

My dad was on a Medicare Advantage plan offered by a traditional "insurer", and it seemed to be worthwhile - it covered some drugs better than OG Medicare, and had fixed copays rather than anything percentage based. Towards end of life (pre-hospice) they proactively sent a doctor out a few times for housecalls, with the goal of keeping him out of the hospital. And the baseline Medicare rules reigned in a lot of the usual "insurance" company shenanigans. If he had longer term health issues perhaps Medicare plus a Supplement plan would have made sense, but as it was it seemed to work out - had two years of paying the drug coverage gap (paying a few thousand dollars is essentially table stakes for health "care" in this country). I'm not a fan of "insurance" companies in general, rather just reporting my experience.

I kept his phone number (VOIP is like $1/mo), and I still get spam calls from scammers claiming to be "from Medicare" that "have a new card" for him - shamelessly pretending to be part of Medicare itself rather than a private company that's trying to steal his Medicare payments. Many times I'll ask them if their parents know they scam old people all day, or if they would want their parents getting scammed in their old age. Most of the time they just try to get me back to the script and think they'll convert me somehow ("I am not scammer").

I'm ambivalent on medicare advantage as a concept, but the scam companies are really what needs to be reigned in. Given that the benefits of medicare advantage is supposedly better coverage, I think a great way of doing reform would be to make it so people could change back to regular medicare at any time, and doing so would end up yanking back the premiums from the private company for the past year or two, unless they had actually paid them out for bona fide services. In addition to a lot more criminal enforcement against fraud, of course.

The entire health care system for seniors is a scam to drain them of their wealth and/or government benefits until they are broke or dead.

My father in law had Medicare advantage. They denied his claims for skilled nursing that was getting him back on his feet. The facility just downgraded him from skilled nursing and left him in an hallway. He had a cardiac arrest due to low electrolytes ended up back in the ER and never recovered. (Pop quiz, how does someone on an IV end up with low electrolytes? Only way I can think is if they don’t fill the bag)

Why did they deny him? No reason. It’s just standard procedure. They deny, get good justification and approve. They do that every 7 days. They prettied up the language but confirmed that this is exactly what they do.

They literally killed him as part of standard operating procedure.

This country is fucked. Y’all better hope you have enough money to go be old somewhere else.

When talk about Medicare they are usually talking about Part A (hospital care) and Part B (provider coverage), and sometimes Part D (prescription drug coverage). You are on your own for everything else, including dental and vision care. Adding dental coverage to Medicare continues to die in committee every year in congress.

So if you know you'll need continued care from your dentist and eye doctor then Medicare Advantage can be a good thing, since most of the highly rated plans provide that coverage as part of their benefits.

You can also get benefits for things hearing aids, and transportation to and from your provider visits, etc.

Yes, if you sign up for Medicare Advantage you'll find yourself back in the world of the In-Network and Out-of-Network care model.

At the end of the day though it's disingenuous to just label Medicare Advantage as solely the privatization of Medicare. The only way insurance companies that provide Medicare Advantage stay in business is if they provide a high standard of care for their members. The payment model set by CMS incentivizes them to do so.

When you sign up for Medicare Advantage, and you shouldn't, you will still have to apply for and qualify for Medicare (65, 40 quarters of work, ...). You will generally pay the Medicare Part B premium ($164.90/mo this year) and any Medicare Advantage premium.

But roughly, the coverage will be the same, anything medically necessary. The difference is that with Medicare Advantage you'll have an insurance company sitting at the table between you and your doctor. Then there are restricted doctor networks, copays, coinsurance, deductibles. But when you get expensive, you become a cost center, and they can delay and deny coverage.

With Medicare Advantage, you get to spend the rest of your life fighting health insurance companies. And for the most part, you're stuck on Medicare Advantage. Guaranteed enrollment is only in your first year. BTW, brokers are incentivized to sign you up for Medicare Advantage. Their commission is much higher for Medicare Advantage than for a Medigap plan. Medicare Advantage is vulture capitalism.

Traditional Medicare generally pays 80% and you get a Medigap plan for the other 20%. My UHC Plan G costs $139.28/mo with a $226/yr deductible, no copays, no coinsurance, no restricted network. And you'll need a Part D drug plan. My SilverScript SmartRX PDP costs $4.50/mo.

Bernie is right. Medicare for all would be awesome.

The root of the problem is pre-insurance costs. If an average person was able to pay for their and their kids health care out of pocket, the problems of being sicker than average or poorer than average would be solved without much controversy. And to address costs, we need transparency, freedom, competition and more healthy attitudes towards personal health. No payment system will get us out of this problem, it will be high out of pocket expenses, or high taxes, or limited care or some combination of the three.

I agree with the author, but for far different reasons. Anytime taxpayer money is up for grabs by private companies, there is almost no oversight and things get out of hand quickly. This is the wrong way to go about things and it never works.

I don't think the US government is capable of running large programs efficiently. They're universally understaffed, the staff that does work there is under-qualified, and they don't have to answer to anyone because they can't be fired for missing budgets, goals, or deadlines.

I don't know what the right answer is honestly, so I do enjoy ready other people's views in this thread.. but I'm certain its not what we're doing now.

This is an odd rant.

Medicare Advantage is simple - instead of getting regular Medicare (Part A,B and D) through the government (though Part D is always private), you elect for your Medicare dollars to be used as premiums for a private Medicare Advantage Plan that offers similar coverage.

Thats it.

It’s nice because it offers options. For some people with chronic conditions a MA plan might offer better coverage than regular Medicare for your treatment in exchange for less coverage in another area.

And it’s entirely the patient’s choice.

Don't like Medicare Advantage? Good, don't choose it.

Medicare for All would be great, at the prices being quoted by folks on here. But I bet your premiums and deductibles aren't covering your costs, especially at your age. Over 65 spending is around $18K per year.

Average in the US is $7-12K across age groups and genders (depending on how it's counted).

The problem with traditional fee-for-service Medicare is that there is no mechanism to reign in those costs - doctors get paid pretty much no matter what they order. So they order a lot.

For Medicare Advantage, it's more a capitation model where the insurance co is paid per patient, and their incentive is supposed to be to keep the patient healthy and thus less costly. That's the theory.

Incentives matter, and getting them right in healthcare is a messy task.

This is how most of Medicare works. 10 or so choices of co-insurance or unified Advantage, outsourced to private insurance. Private health insurance should be illegal just as it is in other countries.

As someone who will be medicare age in a few years, I was following the article until it hit the [drat those darn republicans] comment and my attention quickly waned, and not because of age.

I live in a country with socialised medicine and wanted to give some counterpoints to "the grass is always greener in socialist utopia".

1 yes they scam boomers. An actual funded pension system means boomers are the richest people in the country. Everyone wants a slice.

2 healthcare is expensive as fuck so the government is only providing the bare minimum they can get away with. Think "when was the last time my 80 year old mother had a shower".

3 commercials aimed at boomers for private healthcare services: you can get your own private nurse (because the one provided to you by the government only shows up for an hour a week). Obviously most people can't afford such luxuries.

4 community care. Please volunteer in your local nursing home because they are chronically understaffed. They have an entire propaganda campaign on this. The Philippine nurses did not work out.

To say we already live in Idiocracy would be too banal. I'll only say these ads infurate me even though I don't live in US.

I’m so glad I don’t live in America and get forced to watch ads like that

So, before the 2028 solvency crisis?