Myths on this forum

Dudewho

Member
Location
NORTH CAROLINA
Reading some messages I have discovered many myths about Medicare and coverage. Here are some facts.

Medicare will not cover routine Vision or Dental.

Joe Namath was stretching the truth.

ANY doctor can see you if you have Medicare, some will charge an excess fee to do so. Some may choose not to.

Medicare Supplement and Medicare Gap insurance are the same thing and pay AFTER Medicare. So they only cover what Medicare covers.

Medicare Advantage Plans pay in leu of Medicare- If you have an Advantage plan you have made a conscious decision to get your benefits from the Insurance company. Not the Government.

You don't loose Medicare if you have an Advantage plan. You still pay your Part B. YOU MUST HAVE PART A AND PART B TO HAVE AN ADVANTAGE PLAN. Medicare will take your part B and send it to the insurance company. This is why many areas have Zero premium plans. Your bills will be going to the Insurance company. NOT Medicare.

Medicare Advantage plans have more benefits then Original Medicare. Many plans cover some dental, vision, hearing, gym memberships, over the counter drugs, meals delivered, rides to and from the doctor and much more. THERE's NOTHING NEW ABOUT THIS. Plans have been covering that for years, sorry Mr. Namath.

Many CAN change plans AFTER December, 7th.... Not a misprint.

For a free everything plan you need to have both Medicare AND Medicaid and the plan needs to be available in your area.

There are No one size fits all plans out there. Supplement or Advantage Plan, they both have strong points.

By law, Medicare Advantage plans HAVE TO cover everything Medicare covers. Period.

All Medicare Advantage plan are deemed by Medicare to be equal to or better then Original Medicare.

If your doctor is part of a hospital system they probably accepting advantage plans already.

Some companies give more benefits as an extra with Medicare Supplements, such as gym memberships or dental discount plan.
 

mathjak107

Senior Member
For those who want to know the difference between having a for profit insurer as your gate keeper vs not for profit govt Medicare I will give you an example.

A friend had an advantage plan ..she bragged all the time about how little she was paying .

Well she got pituitary gland cancer ....one side was cancerous,the other side not great shape ..her doctors wanted both haves removed ...her insurer denied both halves ...they only approved one side and she had to wait for the other side to possibly turn cancerous and spread .

Her doctors appealed and argued Medicare always pays to remove the entire gland ..

The insurer told them they can’t say what Medicare would have done in this specific case , their patient does not have Medicare ....
So the insurer administering your plan has total say because you can’t say what govt Medicare would have done , you don’t have government Medicare..with an advantage plan you have a for profit insurer deciding your course of treatment...

while on paper they say advantage plans have to cover what Medicare does , that is only true in a broad sense ... your specific treatments plan is up to your gate keeper to approve or deny .

you can never prove in your individual circumstances what govt Medicare would have approved , as you don’t have govt Medicare and the insurers know this.

nothing is ever a problem with advantage plans , that is until it’s a problem ...some people never hit issues , others do
 
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Buckeye

Senior Member
Location
Ohio
^^this^^ And there are other issues - one is that Advantage plans have "in network" providers, and if you go out of network, there can be a hefty penalty in non-emergency situations. Also, Advantage plans typically have geographical limits. So if you are a snow bird, that can be a big issue. And, lastly, once you give up medicare and go to an Advantage plan, you can not automatically switch back to medicare if you change your mind. You must medically qualify.

Disclaimer - It has been 6 or 7 years since I was an agent, so the details may have changed since then...
 

OneEyedDiva

Well-known Member
Location
New Jersey
I have Aetna Medicare Open Access HMO, an advantage plan, through the State Health Benefits Program for employees and retirees. I've had Aetna HMO even before getting on Medicare and loved it. I was seamlessly switched and told not to use the traditional Medicare card. Like the OP pointed out, I had to prove that I was on both Medicare A & B. One thing I loved about Aetna Medicare from the jump is that they didn't use my SS# as my ID#. Also co-pays started out at $5 per doctor visit then went up to $10 a few years ago. Before I got on Medicare, I had to get referrals from my PCP for certain specialist visits; now referrals are no longer needed. My hospital visits for surgeries and procedures cost me nothing and my first post op visits are free. I've had two cardiac procedures in the hospital. I've had two cutting eye surgeries and a few laser eye surgeries as an out-patient for only the co-pays. There's no paperwork for me to worry about either.

My Aetna coverage was free until I got on Medicare. I pay the basic Medicare premium but the State reimburses me $46 a month toward that cost. In 2019 Aetna started offering state workers and retirees it's Medicare PPO plan in which there is no extra charge for out of network doctors. I'm looking into switching to that plan. @Buckeye
 
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mathjak107

Senior Member
Advantage plans are great!.....until you get sick.
As long as everything fits in the box many are satisfied with their plans ...but nothing I will roll the dice with . they can end up very poor deals when things don’t fit in their box as well as you can get some pretty crappy treatments with the insurance company as your gate keeper when they have the last say .
 

J.B Books

Member
As long as everything fits in the box many are satisfied with their plans ...but nothing I will roll the dice with . they can end up very poor deals when things don’t fit in their box as well as you can get some pretty crappy treatments with the insurance company as your gate keeper when they have the last say .
I did a lot of research when I had to go to Medicare, which I just started by the way. I talked with people that had advantage plans and friends that sold supplements, and clients.
Some people loved their plans...so far. They have to stay in network and have no problem with that.
I had one client whose mother was on it and said it was a nightmare as she needed all these specialists real quick like near the end of her life. The bills she had to pay!! That's where I got the quote that advantage plans are great (cheap) until you get sick.
The other example was when a friend had a joint replacement surgery. Everything was great and covered with the advantage plan he was told. Then after the surgery he found out that the anesthesiologist was out of network and had a $7000.00 bill for that!
 

mathjak107

Senior Member
I did a lot of research when I had to go to Medicare, which I just started by the way. I talked with people that had advantage plans and friends that sold supplements, and clients.
Some people loved their plans...so far. They have to stay in network and have no problem with that.
I had one client whose mother was on it and said it was a nightmare as she needed all these specialists real quick like near the end of her life. The bills she had to pay!! That's where I got the quote that advantage plans are great (cheap) until you get sick.
The other example was when a friend had a joint replacement surgery. Everything was great and covered with the advantage plan he was told. Then after the surgery he found out that the anesthesiologist was out of network and had a $7000.00 bill for that!
There is a lot of myth as far as being billed out of network ...as long as doctors are participating Medicare doctors , network or not they may be very limited to how much more they can charge you ...there are laws in place for what is allowed as far as balance billing .

If your doctor is a participating provider with Original Medicare, balance billing is forbidden. 93 percent of non-pediatric primary care doctors in the US are participating providers with Original Medicare (if you’re in a Medicare Advantage plan and you stay in-network, balance billing will also be prohibited under the terms of your plan’s contract with the medical provider;

Medicare Advantage plans generally include far fewer physicians than Original Medicare’s participating provider system).

Some doctors aren’t participating providers with Medicare, but they also haven’t opted out of Medicare altogether.

These non-participating providers can balance bill you, but the total charge can’t be more than 15 percent more than Medicare will pay the doctor (some states further limit this amount). Medicare pays non-participating doctors 95 percent of the regular Medicare rate, and the doctor can increase that amount by up to 15 percent and charge it to the patient (in addition to the normal Medicare deductible and/or coinsurance that applies for the service). This 15 percent cap is known as the limiting charge.


Providers who have opted out of Medicare altogether cannot seek reimbursement from Medicare at all. The patient is fully responsible for paying the entire bill in that case, and there’s no limit to how much the provider can bill. It’s important for patients to understand the difference between a doctor who is non-participating versus a doctor who has opted out altogether, since the Medicare limiting charge doesn’t apply to doctors who have opted out of Medicare. Opting out is rare overall, but fairly common for some specialties. According to Becker’s Hospital Review data, only 1 percent of all doctors have opted out of Medicare, but that rises to 38 percent among psychiatrists.





https://www.medicareresources.org/glossary/balance-billing/
 
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mathjak107

Senior Member
As blue cross says about their advantage plans

When a provider in our service area sees a Medicare member from another plan, they are considered non-network. However, they are treated as a Medicare participating provider.

CMS requires Medicare Advantage (MA) plans to pay non-network providers at least the rates that they would be paid by FFS Medicare, as this is how we process all MA out-of-area claims.

CMS publishes a document which indicates how an MA plan must pay out-of-network providers.

BCBSRI pays each service based on how the provider is paid by FFS Medicare. As a provider you are required to bill BCBSRI if you were billing Medicare, and you must accept this payment as payment in full and must not balance bill the member.

so lots of myth about balance billing out of network
 

J.B Books

Member
As blue cross says about their advantage plans

When a provider in our service area sees a Medicare member from another plan, they are considered non-network. However, they are treated as a Medicare participating provider.

CMS requires Medicare Advantage (MA) plans to pay non-network providers at least the rates that they would be paid by FFS Medicare, as this is how we process all MA out-of-area claims.

CMS publishes a document which indicates how an MA plan must pay out-of-network providers.

BCBSRI pays each service based on how the provider is paid by FFS Medicare. As a provider you are required to bill BCBSRI if you were billing Medicare, and you must accept this payment as payment in full and must not balance bill the member.

so lots of myth about balance billing out of network
So when a doctor/provider does not participate in Medicare at all, how is that handled?
 

mathjak107

Senior Member
If they are not accepting Medicare at all they usually tell you that up front....very few do not accept Medicare
I ran in to it once .but they needed to make that clear up front .

hospitals tend to not let these doctors near seniors who tend to have Medicare ..it would be unethical...

I bet if you poll those here who have advantage plans you will find none that went to a doctor or were assigned a doctor out of net work who did not take Medicare at all , and did not tell them up front if they were
 

J.B Books

Member
If they are not accepting Medicare at all they usually tell you that up front....very few do not accept Medicare
I ran in to it once .but they needed to make that clear up front .

hospitals tend to not let these doctors near seniors who tend to have Medicare ..it would be unethical...

I bet if you poll those here who have advantage plans you will find none that went to a doctor or were assigned a doctor out of net work who did not take Medicare at all , and did not tell them up front if they were
I was just wondering about how that anesthesiologist thing slipped through.
He said he was out of network when maybe he didn't take Medicare at all.
 

mathjak107

Senior Member
I was just wondering about how that anesthesiologist thing slipped through.
He said he was out of network when maybe he didn't take Medicare at all.
Could be but likely more myth than anything else ..the internet is filled with these stories and odds are they are just made up or someone just did not pay attention that the doctor does not take medicare ...that is not an advantage plan problem ...the same is true for govt Medicare if the doctor does not take Medicare which is the only way that can happen
 

Jeni

Member
so lots of myth about balance billing out of network
Not always myth......the fact that the "laws or rules" say no does not mean it does not happen. i

There are many unscrupulous people out there and an alarming amount of people do not research and try paying these crooks..... i have seen it personally fought it and frankly biller said for every one like me 5 pay so they did not care that i turned them in to everyone i could BBB and FTC fraud etc......
frankly some of these folks are told to stop they reform rename themselves and continue on.
 

Ruth n Jersey

Well-known Member
We have Medicare A and B plus AARP. So far so good.
What I didn't get when we first signed up for Medicare was part D. Sometimes I feel I made the wrong choice.. At the time neither one of us took any medication and I didn't know there was a huge penalty for each month that goes by since the time we were eligible.
It isn't a one time penalty, you pay it every single month.
The hubby is on medication now and we have been able to get it for $10.00 by searching the internet and comparing prices. I also use the online coupons.
I've heard people complain about part D also. We will just keep our fingers crossed at this point.
 

mathjak107

Senior Member
Not always myth......the fact that the "laws or rules" say no does not mean it does not happen. i

There are many unscrupulous people out there and an alarming amount of people do not research and try paying these crooks..... i have seen it personally fought it and frankly biller said for every one like me 5 pay so they did not care that i turned them in to everyone i could BBB and FTC fraud etc......
frankly some of these folks are told to stop they reform rename themselves and continue on.
There is crime and fraud in every aspect of our life .but that is not normally the way it goes.

you hear these stories all the time about going out of net work ..but if a doctor is not taking Medicare he is not taking Medicare regardless what you have
 

mathjak107

Senior Member
We have Medicare A and B plus AARP. So far so good.
What I didn't get when we first signed up for Medicare was part D. Sometimes I feel I made the wrong choice.. At the time neither one of us took any medication and I didn't know there was a huge penalty for each month that goes by since the time we were eligible.
It isn't a one time penalty, you pay it every single month.
The hubby is on medication now and we have been able to get it for $10.00 by searching the internet and comparing prices. I also use the online coupons.
I've heard people complain about part D also. We will just keep our fingers crossed at this point.
My wife and I needed to be on Xarelto for covid when we left the hospital ..our part D had a 500 dollar copay on that drug or others like it ...I asked the hospital what else we can try and lo and behold they came up with coupons for us to get it free from the hospital pharmacy
 
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Aneeda72

Well-known Member
My husband still works so private insurance first, original Medicare second. His insurance costs a lot, but we have very good coverage, and with me, 😂, we need it.
 

garyt1957

Member
The other example was when a friend had a joint replacement surgery. Everything was great and covered with the advantage plan he was told. Then after the surgery he found out that the anesthesiologist was out of network and had a $7000.00 bill for that!
This may be happening to me now. But not with Medicare, just regular insurance. I had my hip replaced. The surgeon was in network, his surgery center was in network but got a bill saying the anesthesiologist was out of network and I owed $2500. I'm fighting that now. I had no idea who the anesthesiologist would be and just assumed he'd be in network if everyone else was. Actually I never gave a thought to an anesthesiologist, period. Could be a costly lesson for me I guess.
 

Don M.

Well-known Member
Location
central Missouri
Our entire Health Care System is driven more by Profits than patient care. We pay twice as much for health care than most other nations, and rank way down the list in terms of overall value for those dollars. I look forward to the day when/if our people wake up and demand a universal system similar to those available in other nations. The increase in taxes to support such a system would be a fraction of what we now pay to the various insurance companies, and providers.

If you look up the highest paying careers in the U.S., the majority of the top 25 are in the "Health Care Industry". We used to have a Medical Profession, but in recent years that has become known has the HC Industry....and the Primary Goal of Any industry is to make money.

https://www.investopedia.com/person...com/personal-finance/top-highest-paying-jobs/
 

Aneeda72

Well-known Member
Our entire Health Care System is driven more by Profits than patient care. We pay twice as much for health care than most other nations, and rank way down the list in terms of overall value for those dollars. I look forward to the day when/if our people wake up and demand a universal system similar to those available in other nations. The increase in taxes to support such a system would be a fraction of what we now pay to the various insurance companies, and providers.

If you look up the highest paying careers in the U.S., the majority of the top 25 are in the "Health Care Industry". We used to have a Medical Profession, but in recent years that has become known has the HC Industry....and the Primary Goal of Any industry is to make money.

https://www.investopedia.com/person...com/personal-finance/top-highest-paying-jobs/
But on the other side of it, if my doctor orders an MRI today, I am getting it today or tomorrow and the results are posted, on line, for me to read later that day, or the next. Unlike in the UK where you may have to wait for weeks or months to get the MRI, and weeks or months to get the results.

I guess I prefer to pay more for immediate care.
 

J.B Books

Member
Our entire Health Care System is driven more by Profits than patient care. We pay twice as much for health care than most other nations, and rank way down the list in terms of overall value for those dollars. I look forward to the day when/if our people wake up and demand a universal system similar to those available in other nations. The increase in taxes to support such a system would be a fraction of what we now pay to the various insurance companies, and providers.

If you look up the highest paying careers in the U.S., the majority of the top 25 are in the "Health Care Industry". We used to have a Medical Profession, but in recent years that has become known has the HC Industry....and the Primary Goal of Any industry is to make money.

https://www.investopedia.com/person...com/personal-finance/top-highest-paying-jobs/
I personally do not trust the government to run socialized medicine. Our current system does need improvements no doubt.
The government should not run every aspect of our lives. Too much control.
I have friends that in Canada and they have their own Government health system.
One lady drives across the boarder into upstate NY to give birth. She puts it on a credit card and goes back.
Another friend pays for a concierge doctor even though he can use the health system because he gets better care and does not have to wait for a long time to see a doctor.
If we in the U.S. go to a government run health care system you will wait six months plus to get a joint replacement.
The government can't run anything without excess waste of money, red tape, etc.
Be careful what you wish for.
 

Don M.

Well-known Member
Location
central Missouri
Millions of people in the U.S. have been "brainwashed" into believing that our health care Industry is great. However, if you explore the statistics, it quickly appears that we are victims of a massive Scam. Sure, there are examples of people in other countries having to wait for a given procedure, etc., but overall, they receive better care than we do....for half the price. Heck, there are lots of Americans who get their prescription drugs from Canada, and the border cities in Mexico do a thriving business in providing care to Americans who seek good care at a reasonable price. Medical "tourism" is a thriving business in places like Thailand, where a person can get quality surgery for a fraction of what it costs here.

The health care systems in most other countries place a priority on Preventative Care, whereas here, the system often ignores such care, because treating people who ignore their health is far more profitable.

I would encourage anyone who thinks we are getting the best care to do some research....here's an example of a good place to start.....

https://worldpopulationreview.com/country-rankings/best-healthcare-in-the-world
 

J.B Books

Member
Socialized medicine is one step closer to socialism. Let the government control everything, your health, where you live, what you eat, if you can go to church or not, take away your guns ,how and when you can travel, and what you watch on TV.
 


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