Regular Medicare vs Advantage.

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Dsgager

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I currently have Aetna Advantage Value PPO and they've been good at covering some things - in home PT, hospital bed 100%; trilogy, cough assist 80%. But they seem to deny smaller items and when I inquire if they will cover PWC and hoyer they refuse to say. I need to decide whether to switch to regular Medicare and a medigap policy or keep the Aetna Advantage. What are your experiences with advantage plans (especially Aetna)? Do they cover everything Medicare does or have you had problems with claims being denied that regular Medicare pays? Going to be needing expensive care next year and don't want to be holding the bag for cost of PEG tube, PWC, etc.
 

debwilson77

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My husband is a veteran so we get his equipment through the VA but for his medicare most medical people have told us to get regular medicare.
 

lgelb

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It really depends on the MA policy. Some are better than others. You can check their ratings overall and see all available plans at the Medicare site. However, if you shift to a different MA plan or switch back to traditional Medicare and then try to re-enroll in another MA plan, your pre-existing conditions may be taken into account.

But since Medicare Advantage has to go by at least the most lenient Medicare criteria for mobility devices, a power wheelchair will be reimbursed using the same medical criteria as Medicare.

As with traditional Medicare, the Hoyer will only be covered at the manual model level; you will pay the difference for power, which is why it's good to get a loaner from the ALSA or elsewhere if you can. The manual vs. power thing is also true for a hospital bed.

Plans don't like to discuss benefits without a claim on the table, and the reps are typically told not to, as it could be interpreted legally as a guarantee of coverage.
 

nona

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I have been on the advantage plan for three years and have had only two medications denied, one of which was approved after appeal. My elderly parents have regular Medicare and are always dealing with copays. This is anecdotal but I'm happy with the MAP.
 

KimT

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I have regular Medicare with the best supplement. I've not paid one penny out-of-pocket, except for the monthly premiums. Of course, I had to also get drug coverage (Part D) which does have co-pays but, for generic, the co-pays are less than $10 for a three-month supply. When I bought my PWC, Medicare paid 80% and my supplement paid the remaining 20%.

You get one chance at open enrollment to select your plan, then they can take into account pre-existing conditions. If you get Medicare before age 65, you get another chance at open enrollment where they don't take into account pre-existing conditions when you turn 65. This happened to me this year.

Medicare Advantage plans are very different from state to state. Florida has terrible Medicare Advantage plans. New York has much better ones as do some other states.

You can get an independent broker to help you go over options. I wouldn't work with agents of specific companies but independent brokers seem to be able to present options in a way that benefits you. You are under no obligation to buy from a broker.
 

lgelb

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Kim provides a good reminder -- a PALS should certainly try to have a supplement policy if you opt for traditional Medicare, as the copays for what you need will really mount up.

I also should have said, what you definitely don't want is a Medicare Advantage plan with an HMO design that requires your PCP to approve specialty referrals, not necessarily because they wouldn't approve them, but because the process is often fraught with unnecessary delays.
 

swalker

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In my case, the decision to go with a Medicare Supplement policy (Medigap) was easy. I could not find a practical Medicare Advantage policy for my area.

Most of the Medicare Advantage policies available in my area (Colorado) are HMOs with providers located in the front range (Denver, Colorado Springs, etc.). That would mean a 100 mile one-way trip for any medical care I wanted to have covered.

I have a Plan G Medicare Supplement policy, which has worked very well for me. I have had to pay a modest deductible (< $200) this year. Other than that, Medicare and the Medicare Supplement plan has paid for everything else. That includes a ventilator, cough assist, etc.

I have not tried to purchase a wheelchair under the Medicare Supplement policy, so don't know how that would work. I can say that I tried to buy one when I had Medicare without a Medicare Supplement policy. That did not go very well. My copays and deductibles would have been so high that I chose to purchase a used wheelchair instead and paid out of pocket for it.

I also needed to purchase a drug policy to go along with the Medicare Supplement policy.

Steve
 

KevinM

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Following up on Kim’s point that you get one shot at a Medicare Supplement Plan because they can’t ask about pre-existing conditions. This past January, I got a Supplement Plan F, but the cost was almost $600/month since I was under 65. Had I been 65, the cost would have been about $160/month.

Because of the very high cost, I canceled it in April, only to learn I couldn’t get another supplement plan until I turn 65 as Kim describes. I only 63 now, so I’m out of luck with supplement plans for now.

I just looked at Humana Medicare Advantage plans, but as Steve describes the ones available in my area are mostly HMO’s with a service area of about 100 miles. My neurologist is outside of that area, so I’m sticking with just Medicare A and B for now. I realize the costs without a supplement plan will really add up as I require equipment, but so be it.
 

KimT

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Kevin,

I went on SSDI when I was 60 (ouch) I paid $600 a month for nearly five years (ouch again.) I ended up taking my State of Florida pension in a lump sum because I had no idea how long I'd live. The breakeven was almost 10 years. Now, I'm spending my lump sum down but in August my premium went from $600 to $178. I guess there is one advantage of getting old.

Kevin, you'll get another shot when you turn 65. Jump back on.
 

Narrowminded

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I’m probably a bit late, but where we live, I also had Reg Medicare with Medigap G for Brian. Basically it came down to durable medical equipment. The advantage plans here would only pay 50% of that , where with medicare and Medigap, we got 100% coverage. With his vent, it was much less expensive that way. His Medigap was 125 a month at the time, vent rental was over 1000 a month so we would have Ben stuck with 500 just for the vent, not including anything else. For us it was a no brainer which way to go.
 

PrimaVera

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I am also a veteran getting most care at VA. Already have PWC, Rollator, van.

SSDI application was flubbed up; not put on Medicare immediately as was just recently diagnosed (3/2020).
Also have Natl. Assoc. of Letter Carriers-Cigna, and TriCare health insurance.

Have PEG and 99.9% food is Kate Farms formula going down tube. I’m told Medicare covers 80% formula cost after annual copay is met; passes any remaining bill to second or 3rd insurance.

Should I chose trad Medicare? Or Advantage plan?
 

lisa g

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Primavera,
Do you have Medicare now? I have Medicare and NALC-Cigna. Medicare is my primary and NALC is my secondary. I have not paid a dime out of pocket even with my Radicava infusions that comes out to just under $80,000 a month.
 

EricInLA

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In light of the comments above, I'm wondering if anyone on this forum is familiar with Advantage plans available in California, or what resources one might turn to evaluate an MA plan vs. regular Medicare for a particular area (like California!). Also, for those choosing MAs, are you doing PPO or SNPs? I am still working, but trying to gather information and plan ahead. . .
 

lgelb

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You can see/compare 2021 plans in your zip and see copays using the rx you currently take here. Of course, plans change every year. Most PALS will not qualify for a SNP and narrow networks are usually not the best idea anyway.
 
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KimT

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Eric, The good thing about the supplements (plan G or F) is that you can go anywhere and they pay what Part B doesn't. The drug part (Plan D) can be changed each year. I switched last year with no issues.

California probably has better Advantage plans than Florida and you know why. I'd still go with the supplement. It'll cost less than $200 a month.

I'll be glad when this year's open enrollment is over. I'm tired of listening to washed up Joe Namath push Advantage plans.
 
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