Medicare Question

[SamIam]

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.

 

[GreenSky]

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

 

[vic120]

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

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

 

[goillini52]

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

MA's have to cover everything that Medicare does...but not at the same rate.

 

[Hopes]

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

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]

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

MA's have to cover everything that Medicare does...but not at the same rate.

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.​

 

[goillini52]

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.​

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

 

[LostDollar]

Medicare pays a fixed amount for your coverage each month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out-of-pocket-costs and have different rules for how you get services ....

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

 

[LostDollar]

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

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

 

[GreenSky]

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.​

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.