Medicare Question

Aug 10, 2018

  1. SamIam
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    SamIam Guru

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    I don't sell Medicare Advantaso that is why I'm asking. While I was at breakfast this morning I heard this agent at the next table selling over Medicare this morning to his client. He told the client if the client went with a Medicare Advantage that would replace Medicare A&B which is correct. But we also said Medicare advantage com[panies decides what gets paid and what doesn't don't necessarily go by the same schedule as A&B So if Medicare would of approved a carpel tunnel it's not guaranteed that Medicare advantage would do the same in that situation.

    I was always under the assumption if Medicare would pay for a procedure Advantage would too.
     
    SamIam, Aug 10, 2018
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  2. GreenSky
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    GreenSky Guru

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    MA plans must provide at least the same benefits as Original Medicare. What the policyholder pays is set by the carrier.

    But generally it's not up to the insurance company if a procedure is warranted. It's typically determined by the medical group with whom the doctor is affiliated.

    Rick
     
    GreenSky, Aug 10, 2018
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  3. vic120
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    I have seen a kaiser article that stated, with some treatments, For instance, therapy after a stroke, Many MA plans would only approve 75% of the amount of therapy as Original Medicare would.

    There were other examples as well, It was a couple years ago, so I don't remember all the examples
     
    vic120, Aug 10, 2018
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  4. goillini52
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    goillini52 BUILD THAT WALL!!!

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    MA's have to cover everything that Medicare does...but not at the same rate.
     
  5. Hopes
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    So, can an MA plan carrier potentially charge 100% for an OM covered procedure? Or would this happen only if the doctor coded it incorrectly (to be covered)?

    I'm just trying to understand but not sure I'm wording my question in a way that make sense.
     
    Hopes, Aug 11, 2018
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  6. Hopes
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    Hopes Super Genius

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    So if MA/PDs are "as good as or better than" OM how can an MA plan not pay as much?

    Not an argument...I sell both so I legitimately want to understand.
     
    Hopes, Aug 11, 2018
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  7. goillini52
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    goillini52 BUILD THAT WALL!!!

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    MA's cover everything that Medicare does, but they don't usually cover things at the same rate that Medicare does.
     
  8. LostDollar
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    LostDollar Guru

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    P66 Medicare and You (2018)
    See pp 65-66 for a little more information.
     
  9. LostDollar
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    LostDollar Guru

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    They (the MA plans) spent the other 25% on Silver Sneakers memberships that 75% of the MA plan members never used.
     
  10. GreenSky
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    GreenSky Guru

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    At minimum they must cover the same benefits. But they are free to charge what they want.

    Here's an easy example:

    Medicare Pt A Hospital deductible is $1,340.
    MAPD hospital charge $325 each of 1st 6 days.

    The difference is the MAPD includes all services including physician charges. However it is possible the person pays more under the MA plan than Medicare.

    Rick.
     
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