MA compared to Original Medicare

[Guest]

There is definitely a place for PFFS plans but I do not think they are for all seniors.

One good use of MA is for 'underage' people on Medicare due to disability and who can't get or afford a med sup. In my area a med sup for a 58 year old was about $450 for a J plan and about $250 for an F last time I looked... and sups for underage folks have to be underwritten... and that's a non-starter for most people on disability!

Al

 

[Frank Stastny]

I agree.

Could you explain your reasoning for or behind this statement? I realize that PFFS plans have a 'risk' that the provider will refuse service or balance bill. HMOs can restrict choice. Is that what you mean or is there more?

What is the 'risk factor' that could reduce quality of care in a large, urban PPO MA where just about all the docs are part of it... like the Blue Cross MA PPO in my area? (Not arguing, just inquiring.)

Al

Yes, that is exactly what I mean regarding PFFS plans.

There are a lot more dangers being with an HMO than just restricting the choice of doctors and hospitals for seniors. The administrators of the HMO's are the ones who decide what tests and treatments will be authorized, not always the doctor.

The administrator has the last word. When I lived in the St. Louis area and was competing with HMO's I had a huge stack of documented cases where, if a patient had not been denied a particular test or treatment recommended by the doctor, the patient may have not died.

Maybe you don't because of where you live, but I have a large number of clients who spend 3 to 6 months living in another part of the country during the Winter months. If one of those clients has an HMO and gets sick when out of town they are going to have a real mess on their hands trying to get the HMO to authorize payment. Also, if they have a PFFS plan it could be a real hassle trying to find a doctor or hospital who will accept it, especially in an emergency situation.

If one can afford a Med Supp policy, there is no other health care plan that allows a senior to be in control of their health care. They can go to any doctor, any hospital in the US and the benefits are the same no matter where they are.

 

[James]

I'm of the mind that the original question, "MA Vs Original Medicare" as bogus. As Frank suggested, it is the "MA Vs Supplement", that is where it begins, I really don't run into people that are not participating in either a MA or Supplement.

If your supplement annual premium is greater than $3,000 and the MA MOOP is $3,000 then I really don't see the debate? In fact, poor or rich, rural or city dweller they are likely better off in the MA if all Dr's and Hospitals participate within the MA. They really can't do any worse dollar wise, outside of flow of money. With the supplement it is a monthly bill. With the MA it is pay as you go, if you don't have to go you don't pay!

Plus, one can easily demostrate the original medicare with the supplement has to change, we simply can not afford it any more. It isn't SS that is threatening us financially but Medicare!

Then we can always look at the Risk, if a healthy 65 yr old person can reasonably expect another 10 plus years of good health why pay the supplement premium? The savings can help in funding a LTCi policy.

 

[Cenla Agent]

Well, I can certainly think of at least one instance.

If you have a Secure Horizons Direct plan, the PFFS. You could be paying a per-diem for every day as an inpatient until you hit the policy maximum of over $3,000.

It is possible to have a 10 day hospital stay with no surgery and have physican bills of maybe $50 per day (20% of allowable). With Medicare this just cost you $500 for Part B and $992 for Part A. With SH Direct, it just cost you $2,750 (depending on plan).

Also, under Medicare the Part A deductible is paid once in 60 days. Under an MA plan, if you are re-admitted within the 60 days, you pay another charge.

Rick

Thanks, Rick. I knew about the readmission being another charge with MA but was referring to a single stay. I am not familiar with Secure Horizons since they have not really been a major player in LA up until now. If they have a per diem with no limit, I've never seen an MA like that and it looks pretty worthless unless I'm reading it wrong. Usually it is a certain amount per day and cuts off at 5 days, although some plans require the member to pay longer.

 

[Cenla Agent]

Yes, that is exactly what I mean regarding PFFS plans.

There are a lot more dangers being with an HMO than just restricting the choice of doctors and hospitals for seniors. The administrators of the HMO's are the ones who decide what tests and treatments will be authorized, not always the doctor.

The administrator has the last word. When I lived in the St. Louis area and was competing with HMO's I had a huge stack of documented cases where, if a patient had not been denied a particular test or treatment recommended by the doctor, the patient may have not died.

Maybe you don't because of where you live, but I have a large number of clients who spend 3 to 6 months living in another part of the country during the Winter months. If one of those clients has an HMO and gets sick when out of town they are going to have a real mess on their hands trying to get the HMO to authorize payment. Also, if they have a PFFS plan it could be a real hassle trying to find a doctor or hospital who will accept it, especially in an emergency situation.

If one can afford a Med Supp policy, there is no other health care plan that allows a senior to be in control of their health care. They can go to any doctor, any hospital in the US and the benefits are the same no matter where they are.

I agree with this Frank. I don't always note that I think a Supp is the best plan for those who can afford it and who can qualify, but that is my position.

You are correct that a lot of this depends on where a client lives and what their lifestyle is. I only have experience with my state. Supps are generally cheaper in rural areas whereas in most MA's are higher or have problems with acceptance in some cases. In the bigger metros, Supps can be a lot more expensive whereas there are 0 premium HMO's with good networks there. In the rural areas a Supp is generally the way to go unless they can't afford it or cannot qualify due to health conditions.

 

[retread]

I don't think it is prudent to tell a senior his Medicare card is "worthless". Some agents have even gone so far as to advise them to throw their Medicare cards away, believe it or not. Keep in mind that we are held accountable by CMS for the things we say. Seniors need that Medicare card to get either a Med Sup or MA, and even on MA plan, must have it if they wish to change during the MA period. If you think you are "conserving your client" by doing this, you are guilty of unethical conduct.

What agents need to advise their clients is: "Do Not use your Medicare card when you see your medical provider" if they are on a Medicare Advantage plan. The agent needs to understand the reason for this. If he/she doesn't, it shows they don't understand the Medicare Advantage program. (This is apparently behind the problems we experienced this year with PFFS plans.) Instead, tell them to put their Medicare card away in a safe place, because they will need it in the future if they wish to change their plan, or if their circumstances bring them in need to enroll in a Medicaid program.