|
HC wrote to me, warning that my health provider will go out of network in 2024. They said, in part "Your plan will cover care from Sarasota Memorial Health Care System (SMH) as an out-of-network provider, if they are a Medicare-approved provider and accept the plan. Your share of the cost will be the same as if they were part of the network."
Sound comforting? Not so. The devil is in the details. SMH told me they will NOT accept UHC in 2024 - not even out-of-network. So I must change all my doctors next year, or return to an Aetna Advantage plan (which IS accepted by SMH), and lose the IBM subsidy.
I wonder if anyone knows exactly how out-of-network with same copay even works with UHC. Without a contracted rate, how much would the provider bill UHC?? Their full rate? I find it hard to believe that UHC would swallow the difference between full rate and Medicare "usual & customary" (less my copay).
|
Yeah, and those details will bite you in an uncomfortable place.
Notice UHC's caveat. "...and accept the plan." Your research shows
that SMH will not accept the UHC plan in 2024, hence you are SOL.
The IBM UHC Advantage doesn't operate in a vacuum. In this case,
SMH also gets to have a say, and they don't have an agreement with
IBM UHC as I understand from your note.
Tim
Timothy A
Johnson, Tucson, AZ ()
Member of European Train Enthusiasts ()
On 12/4/2023 7:39 AM, Michael Halliday
via groups.io wrote:
toggle quoted message
Show quoted text
HC wrote to me, warning that my health provider will go out
of network in 2024. They said, in part "Your plan will cover
care from Sarasota Memorial Health Care System (SMH) as an
out-of-network provider, if they are a Medicare-approved
provider and accept the plan. Your share of the cost will be the
same as if they were part of the network."
Sound comforting? Not so. The devil is in the details. SMH told me
they will NOT accept UHC in 2024 - not even out-of-network. So I
must change all my doctors next year, or return to an Aetna
Advantage plan (which IS accepted by SMH), and lose the IBM
subsidy.
I wonder if anyone knows exactly how out-of-network with same
copay even works with UHC. Without a contracted rate, how much
would the provider bill UHC?? Their full rate? I find it hard to
believe that UHC would swallow the difference between full rate
and Medicare "usual & customary" (less my copay).
|
And this shows the terrible truth about all Medicare Advantage plans. I know folks think they are getting something for nothing but there is no such thing as a free lunch in the Health Insurance industry.
|
Thanks for posting this. Same old story with (dis)Advantage. You get what you pay for.
|
The same thing has happened here in South Carolina.? Prisma Health is the largest health care provider in the state, but they have sent me many emails and letters since about the beginning of September that starting January 1, 2024, UHC will be out of network.? Lately, they have been upping the ante by notifying me of all the different health plans they do accept, and urging me to switch to one they accept.? They have also specified every Prisma doc, nurse practitioner, and physical therapist I’ve been to in the last 10 years, to let me know they will be out-of-network next year unless I switch to a new plan. ? This is the second time in the 10 years since I’ve lived her in SC this has happened.? Even before the IBM UHC plan was announced about a year ago, I had already been on UHC plans for many years.? Eventually a month or two into the new year, they come to an agreement and I can go back to the Prisma docs without them being out-of-network.? UHC has a history of demanding ever higher reimbursements so they can maintain their fat profit margins. ?
toggle quoted message
Show quoted text
From: [email protected] < [email protected]> On Behalf Of Michael Halliday via groups.io Sent: Monday, December 4, 2023 9:39 AM To: [email protected]Subject: [ibmpension] UHC-IBM lose large health provider in Florida ? HC wrote to me, warning that my health provider will go out of network in 2024. They said, in part "Your plan will cover care from Sarasota Memorial Health Care System (SMH) as an out-of-network provider, if they are a Medicare-approved provider and accept the plan. Your share of the cost will be the same as if they were part of the network."
Sound comforting? Not so. The devil is in the details. SMH told me they will NOT accept UHC in 2024 - not even out-of-network. So I must change all my doctors next year, or return to an Aetna Advantage plan (which IS accepted by SMH), and lose the IBM subsidy.
I wonder if anyone knows exactly how out-of-network with same copay even works with UHC. Without a contracted rate, how much would the provider bill UHC?? Their full rate? I find it hard to believe that UHC would swallow the difference between full rate and Medicare "usual & customary" (less my copay).
|
When you go out of network, UHC will pay the provider the full Medicare Allowed Amount (MAA), the same thing the provider would be paid if your were under traditional Medicare plus a supplemental plan.? The IBM/UHC plan is different from most Advantage plans in this regard, which is probably why the provider is saying they will not accept out-of-network Advantage patients - they don't understand the details of the IBM plan.
When you go out of network, the provider may agree to send the bill to UHC on your behalf. In that case, it will look little different to you from going in-network.?? You pay the co-pay and UHC pays the rest.
Some providers may refuse to send the bill to UHC and ask you to pay them instead and get reimbursed by UHC.?? That's ok, but you should be careful not to pay a bill for more than the MAA, as UHC is saying that they will not pay more than that for a Medicare Participating Provider.? If they want you to pay up front, you should check with the billing office as to whether they will accept the MAA as payment in full. They should, since the law requires that Medicare Participating Providers must accept the MAA.
There are many IBM retirees who go out of network with no problems. When a provider is in a contract dispute, many will try and scare their patients into switching to a different insurance plan as a way to gain leverage in the contract negotiations.? Refusing to treat them as an out-of-network patient is another tactic they use.
|
The IBM/UHC plan may well be wonderful. However, if it sports an Advantage label one should be cautious
and tred lightly. If it's truly NOT an Advantage plan than what is it?? Do we now have a 3rd
type of Medicare plan to choose from?? Perhaps IBM and UHC should do a better job selling it.? And of
course, always remember the fine print - we can and will change anything we want at our discretion at any time.
|
RIGHT NOW this looks like a pretty good plan for me. But that question of 'what will it be in five years' is HUGE in my mind (so I am still on original Medicare).?
dave
|
Right now my house is not on fire.
Do I still need fire insurance?
You bet I do.
I choose original Medicare!!!!!
toggle quoted message
Show quoted text
RIGHT NOW this looks like a pretty good plan for me. But that question of 'what will it be in five years' is HUGE in my mind (so I am still on original Medicare).?
dave
|
I signed up for the IBM plan for next year (first time on the plan).? Right now, all my doctors are listed as in-network. Keeping my fingers crossed that I won't regret leaving original Medicare.?
RIGHT NOW this looks like a pretty good plan for me. But that question of 'what will it be in five years' is HUGE in my mind (so I am still on original Medicare).?
dave
|
Here is the issue with Medicare Advantage - IF you are healthy and never become unhappy with being on MA then you are fine - BUT if you find MA to be less than satisfying and you move to Medicare B/D you will find that getting co-insurance (Medigap) isn't a slam dunk - you then aren't automatically coverable - you have to be vetted and that vetting is based upon your then current health. So if you start on MA at 65 and are healthy you're in great shape - but if your health declines and your MA provider doesn't want to support your medical needs then you can switch to B&D, but best of luck getting co-pay coverage.?
|
Gutsy, good luck. I am unwilling to bet cross-fingers when it comes to IBM, my health, Medicare funding and?
the sanity of our Congress.? Just getting and keeping adequate health care is a blessing. Playing roulette with?
it is out of the question. Yes, traditional cost more....as always, you get what you pay for.? When IBM is
involved, you usually get less than you pay for.
toggle quoted message
Show quoted text
I signed up for the IBM plan for next year (first time on the plan).? Right now, all my doctors are listed as in-network. Keeping my fingers crossed that I won't regret leaving original Medicare.?
Bob Young
RIGHT NOW this looks like a pretty good plan for me. But that question of 'what will it be in five years' is HUGE in my mind (so I am still on original Medicare).?
dave
|
Thank you, well said.? I would not be surprised to see Medicare(CMS) dump everyone who is on an Advantage plan and lock them out of traditional. Afterall, Medicare is technically broke. Gotta save it somehow.
toggle quoted message
Show quoted text
Here is the issue with Medicare Advantage - IF you are healthy and never become unhappy with being on MA then you are fine - BUT if you find MA to be less than satisfying and you move to Medicare B/D you will find that getting co-insurance (Medigap) isn't
a slam dunk - you then aren't automatically coverable - you have to be vetted and that vetting is based upon your then current health. So if you start on MA at 65 and are healthy you're in great shape - but if your health declines and your MA provider doesn't
want to support your medical needs then you can switch to B&D, but best of luck getting co-pay coverage.?
|
It's worth noting that Medicare Advantage was introduced with the goal of "managed care", as an alternative to the current system of "fee for service", which provides us with the most expensive health care system in the world.
I see nothing wrong with the concept of managed care, PROVIDED it's managed by medically qualified people whose goal is to cure/care for me in a cost-efficient manner.
The problem with the implementation of Medicare Advantage is that the care is being managed by people who sole objective appears to be profit. And it also doesn't help that the egos of certain medical professionals do not welcome alternative diagnosis/treatment plans proposed by others.
I would try Kaiser Permanente if I had the opportunity, as their goal seems to be managed care, without a large profit incentive. I was disappointed to learn recently, that their workforce is becoming unhappy.
|
On Tue, Dec 5, 2023 at 01:33 PM, BigAl wrote:
Thank you, well said.? I would not be surprised to see Medicare(CMS) dump everyone who is on an Advantage plan and lock them out of traditional. Afterall, Medicare is technically broke. Gotta save it somehow.
With Advantage plans, Medicare pays the insurance company the average amount they would otherwise spend on someone enrolled in traditional Medicare, plus some additional funding.? So it actually costs Medicare more for those who enroll in Advantage plans. If everyone enrolled in Advantage plans, it would bankrupt Medicare that much sooner.? So Medicare has no motivation to dump everyone.? And they could not do so without an act of Congress and the president signing off on it (short of a veto override).?
|
>>With Advantage plans, Medicare pays the insurance company
the average amount they would otherwise spend on someone enrolled
in traditional >>Medicare, plus some additional funding.? So
it actually costs Medicare more for
those who enroll in Advantage plans. If everyone enrolled in
>>Advantage plans, it would bankrupt Medicare that much
sooner.? So Medicare has no motivation to dump everyone.
This was my understanding, thats how the policy's are created.
The insures take the policy cost and compare how much it would
cost with what Medicare is paying, the difference is their
premium. The problem here for the insurance companies is how to
keep the premiums low enough for the bonus stuff they offer to be
attractive.
++Mark.
______________________
|
Suggest everyone go here and get educated:
toggle quoted message
Show quoted text
>>With Advantage plans, Medicare pays the insurance company the average amount they would otherwise spend on someone enrolled in traditional >>Medicare, plus some additional funding.? So it actually costs Medicare
more for those who enroll in Advantage plans. If everyone enrolled in >>Advantage plans, it would bankrupt Medicare that much sooner.? So Medicare has no motivation to dump everyone.
This was my understanding, thats how the policy's are created. The insures take the policy cost and compare how much it would cost with what Medicare is paying, the difference is their premium. The problem here for the insurance companies is how to keep
the premiums low enough for the bonus stuff they offer to be attractive.
++Mark.
______________________
|
Don't forget their profit margin.? ?
The insures take the policy cost and compare how much it would cost? plus their desired profit with what Medicare is paying, the difference is their premium
|
Also, don't forget insurance isn't a zero sum gain. For the minority of sick people they have to pay out for, there are almost always more people pay premiums that exceed their cost to the insurance company.
Last year, my first year on a plan with Medicaid, I personally paid out of pocket $1656 for a year of premiums, $200 deductible and the insurance company received payments from Medicaid for me.
I had a couple general Dr visits, a wellness check, one appointment with a dermatologist and a steroid injection by a pain doc. The insurance company made bank off me.... I get my medicine from a separate plan.
If you are not obese, don't smoke or have cancer and dont have heart disease.... you are supporting a fellow American who does.
++Mark.
______________________
toggle quoted message
Show quoted text
On 12/7/2023 9:09 AM, Randy Egan wrote: Don't forget their profit margin.
|
Tim Johnson
Mark C.