Medicare Advantage Plans -- Is There A Huge Hidden Flaw?

R

Ryan

New Member
This is a huge concern for me and I am trying to get some experienced and expert response to address it.

I have heard rumors about what seems to be a potentially huge flaw in Medicare Advantage plans, especially HMO type plans since they have no out of network coverage. I would appreciate any information that will help me understand this.

Here is one possible scenario that I am talking about. Suppose you are in a hospital. While you are there, you are attended to by doctors without your advanced knowledge and sometimes without your knowledge at all until you get their bills later. I know this is not an unusual scenario because I have been assisting my father for 10 years while he has been in and out of hospitals regularly. There are often charges from doctors we never even heard of... sometimes major charges depending on the reason you are there. Take your anesthesiologist, for example. Does any patient ever have a relationship with them before they go in for a procedure? Under many common scenarios you have no idea who they are either before or after you have a procedure.

I have heard that such charges may not be covered by an HMO since the doctors involved may not be in network doctors. And there may be other things not covered as well particularly related to hospital treatment. I've heard horror stories of five and even six figure bills due for patients who had hospital stays even though they had a Medicare Advantage HMO plan.

The same unexpected cost may be involved with a PPO plan as well I assume although in the scenario I described above I assume the PPO would pick up at least some of the out-of-network doctor's charges. Still, such additional costs would probably be a surprise to most people with Advantage plans. And the primary purpose a consumer buys insurance is to avoid such surprises.

If this is true, it is frightening and would be a major factor in making a decision about what plan to get. Can anyone shed any expert light on this? I am particularly interested in hearing from insurance professionals who have knowledge of how significant this problem is in practice or people who have actually had experience with this.

Thank you.
 

I have a PPO advantage plan and I insist on seeing only in network providers. My pcp knows this and my family does too. I have been known to question doctors who pop in for a consult before they see me. If you are not an in network provider, get out..Works for me!
 
This is how we have been advised to handle these situations in a Medicare overview symposium. I suppose though it will depend on how diligent one spouse is in caring for the other.
terry123 said:
I have a PPO advantage plan and I insist on seeing only in network providers. My pcp knows this and my family does too. I have been known to question doctors who pop in for a consult before they see me. If you are not an in network provider, get out..Works for me!
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I currently am inrolled on a HMO but am switching to PPO as of January. My health problems are, fortunately, minor thus far but the HMO Primary Care Physician and I don't communicate well.
 
The big flaw in HMO plans is a restrictive network. The big flaw in PPO plans is a restrictive network (although if you have LOTS of money you can go out of network).

If you can afford it there is nothing better than Original Medicare with a supplement. Go with the high F if money is tight and add a hospital indemnity plan if you must. In fact, the best scenario is a HDF for about $35-40 per month, $10,000 of cancer coverage for another $30, and maybe a hospital plan for about the same. It's likely cheaper than Plan F with (in my opinion) better coverage.

Some will argue how wonderful their HMO is and I won't dispute that. My hope is that they never have an illness better treated by a non-network doctor. My question about HMO plans is addressed to the beneficiary - "If your granddaughter has a brain tumor who do you want to do the surgery?" Generally the answer is "The best doctor." I then ask "What if that best doctor is at Stanford, UCLA, etc but they are not in your granddaughter's network. How much would you then pay to save her life?"

That's my issue with HMOs. You reliquish control of your health to others. And that means the medical group generally controlled by an accountant.

Rick
 
My PPO Humana Advantage plan works for me as it has a built in drug plan that gives me my meds free. My situation is a lot different than most as I have late effect stroke problems. After a massive stroke from a brain aneurysm rupture, I was affected in many ways. I was blessed to have recovered as much as I have but it takes a toll on the body organs. When I complain that I cannot do what others my age do, my doctor reminds me that I have had 3 brain attacks and survived each one and am blessed to be alive. I wish I would have known that I had an aneurysm before it ruptured, but it is what it is. My plan is not offered everywhere but it works for me and I do not have to have a supplement.
 
GreenSky said:
The big flaw in HMO plans is a restrictive network. The big flaw in PPO plans is a restrictive network (although if you have LOTS of money you can go out of network).

If you can afford it there is nothing better than Original Medicare with a supplement. Go with the high F if money is tight and add a hospital indemnity plan if you must. In fact, the best scenario is a HDF for about $35-40 per month, $10,000 of cancer coverage for another $30, and maybe a hospital plan for about the same. It's likely cheaper than Plan F with (in my opinion) better coverage.

Some will argue how wonderful their HMO is and I won't dispute that. My hope is that they never have an illness better treated by a non-network doctor. My question about HMO plans is addressed to the beneficiary - "If your granddaughter has a brain tumor who do you want to do the surgery?" Generally the answer is "The best doctor." I then ask "What if that best doctor is at Stanford, UCLA, etc but they are not in your granddaughter's network. How much would you then pay to save her life?"

That's my issue with HMOs. You reliquish control of your health to others. And that means the medical group generally controlled by an accountant.

Rick
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It isn’t only going out of network that can be a problem . It is the fact you have a for profit insurer as your gate keeper . They can approve or deny procedures and treatments that fall in to gray areas like those I discussed in other threads . Medicare is not for profit and is far more liberal in approving procedures .

while they both claim to cover the same things that is only in a broad sense ,like the police protect the public at large not you personally . When those advantage plans deny your procedure or modify it you have no recourse to show Medicare would have covered it since you don’t have govt Medicare
 
When you have an HMO or PPO and you are making elective doctor's visits, of course you can decide not to go to an out-of-network doctor.

What my question is about though is what happens when you have an HMO or PPO and you go to a hospital.

I'll give you a specific real example.

When my father was 88 years old, he had a heart attack. He went to the hospital emergency room. During the time he was in the emergency room I think he was seen by maybe three doctors or more.

Then he was taken for an angiogram. Three additional doctors were involved in that process.

Then he had a double bypass surgery. There was a heart surgeon and yet several more doctors involved in that process.

Then he stayed in the hospital for recovery. Various problems from digestion issues, for which he was treated by a gastroenterologist, to problems with other organs, for which he was seen and treated by several other specialists, occurred during that time.

He had no idea who any of these doctors were. And he was of course in no condition to even think about whether they were in network doctors or not. And even if he wasn't in a condition like that it would be impossible or foolish to insist on something like that at a time like that and possibly cause delay in your life-saving treatment or complications getting that treatment. For the same reason I wouldn't have been able to do it for him even though I was there with him. It just wouldn't be practical or maybe even possible to be sure that the doctors who saw him were going to be covered by the plan in that situation. If I insisted on in network doctors chances are the hospital wouldn't or couldn't treat him at all. You just can't arrange something like that in a situation like that.

And I think the same thing would apply to virtually all hospital stays weather emergency room or admitted to the hospital or possibly even outpatient treatment. You simply cannot control weather in network or out-of-network doctors are going to treat you under those conditions... It's neither practical nor wise if even possible. You often have to accept whatever doctors are available at the hospital.

Needless to say this hospital stay and the follow-up visits -- including required follow up visits with the heart surgeon who my father did not choose and may well have not been an in network doctor -- were enormously expensive. My father had supplemental Plan G. So in his case he had no out-of-pocket cost at all for the entire process. But I wonder what would have happened if he had a Medicare HMO or PPO plan.

I don't think this is an unusual scenario, as a matter of fact I think this is typical of any hospital experience these days.

So my question is not about elective visits when you make an appointment with a doctor to visit his office. My question is about whether or not, if you have an HMO or a PPO, you could find yourself in a catastrophically expensive situation when you need to use a hospital. And if so, are you really protected?
 
I think it depends on the plan. I have Aetna Open Access Medicare, which is an HMO, as part of my retiree benefits (group plan). I love Aetna! Almost 3 years ago I went to the hospital for a cardiac procedure, stayed over night and didn't pay a dime. I didn't get any bill from the anesthesiologist nor the doctor who did the procedure, who is in network. Members can use out of network doctors, it just costs more. With If a plan holder is admitted to a non-network hospital, lets say in another state, there's no payment due except for the $75 E.R. co-pay (which I believe is waived if admitted).My husband has Clover. He just had hernia surgery by a doctor who does not take his plan. He was told by his PCP, who brought that doctor in on his case, that since he was admitted through the E.R., any treatment and procedure done during that admission would be covered by his plan. We'll see!
 
Thanks for that info OneEyedDiva. Yes, no question, I think with all HMO or PPO plans, the rules for emergency room visits are different. And there are additional things covered if you go to an emergency room and then are admitted. I think that generally, if you are admitted that way (from an emergency room), more things are covered. Also if you are not in your home area and have emergency care, I think it is generally covered even if it is out of network. Trying to sort this all out is like trying to invent an atomic reconstituter. You are a good example of an insurance customer who has a claim and still doesn't even know if you are covered. That should never happen. You shouldn't have to rely on your fingers being crossed to find out if you are financially wiped out or not.

But my basic question is still unaddressed. What I am looking for is what happens if you have an HMO and you are admitted to a hospital for non-emergency reasons. For example, what if you were admitted to a hospital for non-emergency hernia surgery. Suppose you go to a hospital that is in your network. Could you still be exposed to additional costs if something happens in that hospital such as your being treated by doctors who are non-network? This is turning out to be a very difficult question to get an answer to. I have heard rumors of horror stories, and I am sure that brokers in the Medicare insurance industry know the answer, but it's not in their interest to discuss this topic since they don't want to point out flaws in the products they make their living selling.

Very tough to find out information about this so anyone who can shed any light on this is welcome. What I'd really like is for a broker who has experience with this explain the pitfalls related to this question, or, alternatively explain that there aren't any pitfalls and reassure that if you are admitted to an in-network hospital, then everything that happens there is covered. I think this really takes someone in the Medicare insurance industry, who deals with many many cases, to explain.
 
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Ryan said:
Thanks for that info OneEyedDiva. Yes, no question, I think with all HMO or PPO plans, the rules for emergency room visits are different. And there are additional things covered if you go to an emergency room and then are admitted. I think that generally, if you are admitted that way (from an emergency room), more things are covered. Also if you are not in your home area and have emergency care, I think it is generally covered even if it is out of network. Trying to sort this all out is like trying to invent an atomic reconstituter. You are a good example of an insurance customer who has a claim and still doesn't even know if you are covered. That should never happen. You shouldn't have to rely on your fingers being crossed to find out if you are financially wiped out or not.

But my basic question is still unaddressed. What I am looking for is what happens if you have an HMO and you are admitted to a hospital for non-emergency reasons. For example, what if you were admitted to a hospital for non-emergency hernia surgery. Suppose you go to a hospital that is in your network. Could you still be exposed to additional costs if something happens in that hospital such as your being treated by doctors who are non-network? This is turning out to be a very difficult question to get an answer to. I have heard rumors of horror stories, and I am sure that brokers in the Medicare insurance industry know the answer, but it's not in their interest to discuss this topic since they don't want to point out flaws in the products they make their living selling.

Very tough to find out information about this so anyone who can shed any light on this is welcome. What I'd really like is for a broker who has experience with this explain the pitfalls related to this question, or, alternatively explain that there aren't any pitfalls and reassure that if you are admitted to an in-network hospital, then everything that happens there is covered. I think this really takes someone in the Medicare insurance industry, who deals with many many cases, to explain.
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My plan says that this will never happen under its Advantage coverage -- and it hasn't happened to either me or my sister or anyone else we know who is covered under our plan. If you admitted to an in-network hospital then everything done there falls under the plan. (It DID, however, happen to my sister when she was covered under another plan 3 years ago and some ER doc wasn't in network.)

When I had my hips replaced, I asked this specific question of the insurance carrier and also at the hospital billing office before the surgeries. They affirmed that indeed everything happening under their roof (and by whatever provider) was covered. It was, and the same thing was true at my sister's hip surgery after she was under the same plan as me. The same is true at the in-network's ERs. My sister has had several ER visits (she has multiple health problems) and a buncha diagnostic tests.

I think your best shot is to talk directly to whatever carrier you are considering and get an answer from them, preferably in writing. I have a deep and abiding distrust of insurance companies in general, and when I was dealing with my sister's out-of-network charge I got a lot of yeah buts and weird explanations -- i.e., this only happens if your last name begins with U and is it a Tuesday and snowing outside. Get an answer directly from the carrier and carefully check their information booklets, etc. Doesn't hurt to have a conversation with your hospital's billing/admitting office, too.

No disrespect to brokers, but sometimes even they are not given straight poop from the carriers, or don't have all the yeah buts.
 
There is a lot of good info here, but a lot of misinformation here also. You have to check into the Advantage plan that you have. Not all are offered by insurance companies, and many have 4.5 to 5 star ratings. We have an advantage plan that is offered by the large hospital network in our state; not by an insurance company like Blue Cross or Humana. It offers out of network coverage, lower coverage than in-network but hey. It has proven itself to be an absolute gem; perfect healthcare for zero dollars/month. This month, we have had a first ER visit and hospitalization, and no surprises except that the care was far better, and far lower cost than we expected. Do your research on the plan you are interested in, and read the reviews from people that actually have the plan; don't rely on strangers on a forum that simply regurgitate 'experiences from someone they read about'.
 
NewRetire18 said:
There is a lot of good info here, but a lot of misinformation here also. You have to check into the Advantage plan that you have. Not all are offered by insurance companies, and many have 4.5 to 5 star ratings. We have an advantage plan that is offered by the large hospital network in our state; not by an insurance company like Blue Cross or Humana. It offers out of network coverage, lower coverage than in-network but hey. It has proven itself to be an absolute gem; perfect healthcare for zero dollars/month. This month, we have had a first ER visit and hospitalization, and no surprises except that the care was far better, and far lower cost than we expected. Do your research on the plan you are interested in, and read the reviews from people that actually have the plan; don't rely on strangers on a forum that simply regurgitate 'experiences from someone they read about'.
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ABSOLUTELY! My plan is also offered by a large hospital network in our state, not by one of the big insurance carriers. It works flawlessly and has great coverage as we and people we know have experienced. I've had it for 7 years now and have had absolutely no surprises or complaints.

You must do the research on whatever plan you are considering; they are all NOT alike. I would not trade my plan for anything out there.
 
the problem with advantage plans is far to often they are just not a problem -until they are a problem .

like finding a good financial adviser . they are few nd hard to find and you don't really know good from bad until you have an issue .overall gov't medicare and a supplement tend to have far less issues and you don't have to 2nd guess your choice
 
mathjak107 said:
the problem with advantage plans is far to often they are just not a problem -until they are a problem .

like finding a good financial adviser . they are few nd hard to find and you don't really know good from bad until you have an issue .overall gov't medicare and a supplement tend to have far less issues and you don't have to 2nd guess your choice
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No question in my mind about this. A supplement plan is almost certain to be more comprehensive and less likely to have any leaks. As I mentioned somewhere in this forum, both of my parents have had supplement plan G for many years and many serious medical issues with hospitalizations, and I can't ever remember them paying a dime out of pocket for anything other than the premiums. So while over the years they have paid much more than they would have paid for an advantage plan, the cost is very predictable. That is the whole point of insurance. You incur a relatively small and predictable cost to protect you from an unpredictable large loss. Unfortunately, health insurance today has become a kind of hybrid between real insurance and subsidizing a pool of certain losses (as in covering preconditions). If you buy "insurance" that covers preconditions it's not really "insurance" since insurance is for covering unanticipated losses, not expenses that you already know are going to happen. This complicates the economics of health care delivery a lot. My personal view is that there is no good solution to provide quality healthcare to everyone for an affordable cost since there simply are not enough resources to go around. No matter how much you slice and dice it, it cannot happen. So I think healthcare will always have to be rationed as it is now for at least the foreseeable future.

But I digress. :D

In any event, supplement plans are relatively expensive. So the challenge here is to see if you can come up with an advantage plan that is sound and predictable. Not an easy task. As you said, your plan can be fantastic... until it gets the stress test... and then it can be a disaster. The problem is that it is extremely difficult to know what will happen until there is a crisis.

Good point was raised that there are other groups besides insurance companies that offer advantage plans. I am not certain if there is something like that in my area, but it's possible. I will contact some of the hospitals and larger medical groups and see if I can get information.

Is this the way to find out about these plans, or is there some other resource where you can find out what non-insurance company advantage plans are available? The only lists of plans I have seen are all from insurance companies.
 
Just heard on TV that there is some discussion in the US of going full out for medicare type medication for all, young and old alike, and no other options allowed. If so it makes all this threads discussion a waste. It seems that some think our European ways, and Canda's way are superior to the US and we should just go their ways and forget our individual selection ways.

If you do not mind waiting a long time for an appointment and not having choice on doctors or procedures, just do what the government says. It sounds as if we are rapidly falling into the international poverty of all around this world.

Nothing wrong with our original ways of want more, work harder and manage your money better. Socialism and communism are good examples of how not to go.
 
My family in Austria have had no problems with medicare for all type health coverage. When my aunt (in her early eighties) had a fall at home, she had a doctor's visit to her home that very day. Another aunt who is a hypochondriac has been admitted to multiple hospital stays without a problem. A cousin is in a free program to help her lose weight and exercise after she was diagnosed with a heart problem. I have zero complaints from my family there.

There are dentists there, but it's cheaper to get major dental work in Hungary.

I think it's better to consider all, than to have the all or nothing approach. And, by the way, how quickly can one get an appointment with one's doctor here, other than with an emergency, and even then your doctor will tell you to visit the ER instead of going to them, even with non-life threatening problems.

Just want to add, that it all sounds really good to go the private way only in the U.S. until you have a major illness that bankrupts you. My mom's stay in the hospital with pulmonary fibrosis cost a total of $700,000! And she died anyway. If my dad didn't have three insurance company coverages, guess what would have happened?
 
There have been times when Canada had to send folks to the US for service not offered in the Canadian health plan. Similar from a few other countries in this world also.

For me and my wife, we have done very well with the US medical system. We use the 911 health services efforts. Both the wife and I have needed to use it with rapid response. I had a problem with balance and she took me to the local hospital. This in a small rural town in Colorado. They ran some tests and I was released to a surgeon in New Mexico and a brain surgeon took over my situation. He removed a tumor from the rear of my brain.

In Arizona, my wife had a heart attack and I used the 911 number to alert medical services. In a few minutes a fire truck arrived and they started working with the wife. Then an ambulance arrived and helped the fire dept medical folks with the wife and put her into the ambulance for a ride to the local hospital.

In Ohio I had a seizure and the bank I was in called 911. Again it was but moments till the medical folks arrived and took me to the hospital. This was in a smaller city of about 20,000. I was held for a while then sent to Toledo for closer following.

I see no reason for single payer type stuff forced on all the US population. We don't all have the same needs nor the same abilities to pay. Some folks live in mega size cities and others live in wide open country areas. Needs are totally different and services must also be different. Single payer means the richest pay for most of it through their taxes. I am not rich but through our personal selective system my insurances have done well for us.
 
I see no reason for single payer type stuff forced on all the US population.
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Far as I know we still live in a representative democracy. So who you vote for would agree with what you want.

We don't all have the same needs nor the same abilities to pay.
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Can't argue with that.
 
Well, I, for one, think that we all have the same need for decent health care when we are ill or injured, and I strongly think our ability to pay should not determine whether or not we receive life-saving health care when the need arises.
 
And I am glad that we have an elective type of coverage so I am part of the decision. Prefer this over the 'one size fits all' coverage being suggested. That our congress has brought us the ability to set up our own medical wants and needs that we can afford makes sense. Limiting our medical to what ever the congress feels the nation can afford so that in itself says health care itself must also include some cash from the potential patients, insurance from all, to help pay for the cost of health care. I see no real solution for the situation but full participation from all. And there will be limits for all.
 

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