MORE other-than-DS-surgery MEDICARE ADVANTAGE PPO (not HMO) BS

[Spiky Bugger]

I think my about-to-be-former ophthalmologist might be an asshole.

I had my eye surgery under traditional Medicare and a secondary (not supplemental) policy that covered most everything. But MrSue’s former employer now has ONLY Medicare Advantage PPO policies.

Time for an annual exam, plus 1-yr-post-sx exam (delayed via COVID-19) plus I’m doing dry-eye right now. So, it’s time. SOMETIMES, they get confused and think “Advantage” means “HMO.” And they say they don’t accept HMO coverage. Not this time. This time it’s “we are out of network for United Health Care.” I say, ‘Yes, but you accept regular Medicare, so if you bill UHC, they are required to pay you whatever Medicare would pay.“ And they said, “We won’t bill them.”

I call MrSue’s retirement medical insurance office, they call UHC, UHC calls me, confirms details, calls the doctor’s office and tells me that the doctor doesn’t have to bill UHC, I can pay cash and then UHC will reimburse me…the Medicare amount. I ask if they are required to accept Medicare approved amount. UHC says, “If they accept regular Medicare, and you are Medicare-eligible (which I obviously am), then they are required to charge me the Medicare amount. (I neglected to ask if I would be reimbursed all of what I paid or only 80%, but I don’t think it will matter in the long run.)

I wanted the doctor who performed my last eye surgery to revisit his work. So I called again (and yet, she persisted) and this time I was told that, no, I would be billed the uninsured patient all cash amount. LOTZA money.

This is frustrating. He’s a good surgeon, very experienced, Yale grad (we know how THEY are, don’t we DianaCox ?) and I think that before I take my dog and pony show to the group on the FIRST floor (he’s on the sixth floor), I think he should determine if HE is satisfied with the surgery outcome. THEN I can move to the first floor guy.

I called the UHC rep back and left a message.

For you young’ens, this is an example of how we spend our Golden Years.

 

[DianaCox]

Here is a link to a page on Medicare.gov where a person with the government can be contacted and you can be given more guidance.

Preferred Provider Organization (PPO) | Medicare

A PPO is a Medicare Advantage Plan in which you can go out of network for care, but in-network providers cost less.

www.medicare.gov

Is this guy a preferred provider in your PPO? Even if not, this MIGHT qualify as continuity of care.

My superficial understanding of Medicare (I assume it will take me into my 90s to get a firmer grasp of all the problems and nuances) is that if a provider takes Medicare at all, he must take any Medicare patient at Medicare mandated rates (albeit possibly with a different deductible). I could be wrong.

Not billing for you is I think OK. But he can’t bill for more than the Medicare rate, possibly plus 15%. See this:

What to Do When Your Doctor Doesn't Take Medicare

Not all doctors accept Medicare for the patients they see. Here are five options to consider if you find out your doctor doesn’t take it.

www.investopedia.com

 

[southernlady]

My superficial understanding of Medicare (I assume it will take me into my 90s to get a firmer grasp of all the problems and nuances) is that if a provider takes Medicare at all, he must take any Medicare patient at Medicare mandated rates (albeit possibly with a different deductible). I could be wrong.

You’re not wrong. And if you have a Med Sup plan (the alphabet ones), they have to accept even if the Company who offers that plan is not one if the ones in the area.

I had my eye surgery under traditional Medicare and a secondary (not supplemental) policy that covered most everything. But MrSue’s former employer now has ONLY Medicare Advantage PPO policies.

He can go out if the employers “network” and go straight to the Medicare ones.

I ask if they are required to accept Medicare approved amount. UHC says, “If they accept regular Medicare, and you are Medicare-eligible (which I obviously am), then they are required to charge me the Medicare amount. (I neglected to ask if I would be reimbursed all of what I paid or only 80%, but I don’t think it will matter in the long run.)

Medicare only pays 80% which is why most of us get an Advantage plan or a Med Sup plan.
The thing with a Med Sup plan, if Medicare says it’s a covered procedure even if the EOB from Medicare says you “MAY” be billed, it said it was covered, the Med Sup plan has to pay the difference based on your plan.

I’ve been meaning to ask you, Spiky, are y’all members of USAA? If not, you should be.

 

[Georgepds]

Re "with a Med Sup plan, if Medicare says it’s a covered procedure even if the EOB from Medicare says you “MAY” be billed, it said it was covered, the Med Sup plan has to pay the difference based on your plan."


That's been my experience with BCBS supplemental ln MA.... Spiky's type of experience drives me nuts. I just want to get treated, not obsess about billing

Life without co-pays and post treatment surprises has been calm, even if I probably pay more in the end for supplemental

BTW no letters on supplemental here, I think it's because Universal old age heath care in MA was implemented while Mitt Romney was governor, before Medicare... the details elude me

 

[Spiky Bugger]

Preferred Provider Organization (PPO) | Medicare

A PPO is a Medicare Advantage Plan in which you can go out of network for care, but in-network providers cost less.

www.medicare.gov

Is this guy a preferred provider in your PPO? Even if not, this MIGHT qualify as continuity of care.

My superficial understanding of Medicare (I assume it will take me into my 90s to get a firmer grasp of all the problems and nuances) is that if a provider takes Medicare at all, he must take any Medicare patient at Medicare mandated rates (albeit possibly with a different deductible). I could be wrong.

Not billing for you is I think OK. But he can’t bill for more than the Medicare rate, possibly plus 15%. See this:

What to Do When Your Doctor Doesn't Take Medicare

Not all doctors accept Medicare for the patients they see. Here are five options to consider if you find out your doctor doesn’t take it.

www.investopedia.com

His website does not list United Health Care at all. So, he’s not a preferred provider.

I’ll go read up on those links. Thanks.

 

[Spiky Bugger]

Re "with a Med Sup plan, if Medicare says it’s a covered procedure even if the EOB from Medicare says you “MAY” be billed, it said it was covered, the Med Sup plan has to pay the difference based on your plan."


That's been my experience with BCBS supplemental ln MA.... Spiky's type of experience drives me nuts. I just want to get treated, not obsess about billing

Life without co-pays and post treatment surprises has been calm, even if I probably pay more in the end for supplemental

BTW no letters on supplemental here, I think it's because Universal old age heath care in MA was implemented while Mitt Romney was governor, before Medicare... the details elude me

We’ve never had supplemental. Ours WAS a regular old like your-spouse’s-insurance-picks-up-most-of-what-your-insurance-doesn’t-cover type that “backed up” our regular old Medicare. For nine years now (I’m 74), we’ve had no copays, almost no out of pocket costs, except on Rxs…and even that coverage was better than most have. Niw, it’s confusing at best.

 

[Spiky Bugger]

You’re not wrong. And if you have a Med Sup plan (the alphabet ones), they have to accept even if the Company who offers that plan is not one if the ones in the area.


He can go out if the employers “network” and go straight to the Medicare ones.

Medicare only pays 80% which is why most of us get an Advantage plan or a Med Sup plan.
The thing with a Med Sup plan, if Medicare says it’s a covered procedure even if the EOB from Medicare says you “MAY” be billed, it said it was covered, the Med Sup plan has to pay the difference based on your plan.

I’ve been meaning to ask you, Spiky, are y’all members of USAA? If not, you should be.

He can go out if the employers “network” and go straight to the Medicare ones.
If I understand what you’re saying here…not likely…I think I disagree with you. So, ‘splain, please.

And, on the USAA question, I seem to remember that a hundred years ago, at discharge from service, you had to be E-6 or higher to join and neither of us was. So we joined NCOAA or something.

What do I need from USAA?

 

[southernlady]

And, on the USAA question, I seem to remember that a hundred years ago, at discharge from service, you had to be E-6 or higher to join and neither of us was. So we joined NCOAA or something.

What do I need from USAA?

As of about 15-20 years ago that changed (I think it was because of Geico who originally was for the enlisted) , but now anyone who is a veteran may join.

Only you can answer if USAA is for you.
We use it for banking, truck insurance, our Med Sup plans, when we had a house, our mortgage and house insurance, we have an umbrella policy. And I know when agents of other auto insurance companies ask who we are with and we mention USAA, they stop annoying us. Most know that USAA can’t be beat. Plus it’s a member owned company who returns money to its “stockholders” yearly. I’m coming up on 40 years and my dividend will increase dramatically.

Go and explore. You might find it suits you.

 

[southernlady]

He can go out if the employers “network” and go straight to the Medicare ones.
If I understand what you’re saying here…not likely…I think I disagree with you. So, ‘splain, please.

Unless it is a requirement for him to continue to receive his pension, they can’t stop him for going somewhere else. The sup plans don’t change, an a is an a a g is a g. But the prices from the companies offering them do change.

 

[Spiky Bugger]

Unless it is a requirement for him to continue to receive his pension, they can’t stop him for going somewhere else. The sup plans don’t change, an a is an a a g is a g. But the prices from the companies offering them do change.

I think we're too spoiled.

His medical coverage is an optional part of his retirement package. They take what was our original Medicare and roll it over into their stupid Advantage plan. Not only does this cost us $ ZERO, they pay his Medicare directly (because he hasn’t started collecting his SS yet) and, quarterly, they reimburse me for the Medicare premiums that were deducted from my SS checks.

I am (maybe not OBVIOUSLY) not complaining about actual costs (because even if we paid out of pocket, we’d get reimbursed), but rather the cluster fuck that this Advantage plan causes.

Anyway, he COULD decline insurance, and we would still have Medicare, but then we’d have to have one of those alphabet supplemental policies or another stupid Advantage plan that we’d have to pay for.

Life should be easier, for EVERYONE.

 

[Spiky Bugger]

As of about 15-20 years ago that changed (I think it was because of Geico who originally was for the enlisted) , but now anyone who is a veteran may join.

Only you can answer if USAA is for you.
We use it for banking, truck insurance, our Med Sup plans, when we had a house, our mortgage and house insurance, we have an umbrella policy. And I know when agents of other auto insurance companies ask who we are with and we mention USAA, they stop annoying us. Most know that USAA can’t be beat. Plus it’s a member owned company who returns money to its “stockholders” yearly. I’m coming up on 40 years and my dividend will increase dramatically.

Go and explore. You might find it suits you.

I guess we are simply WEIRD.

I just got off the Phone with USAA. We did the auto insurance quote first…what we now get for $427/6 months, they can pretty much match for $840+/6 months. So, I guess we're staying with Mercury for now.

But we ARE finally USAA members! LOL

I’ll look at banking, etc.

 

[southernlady]

I guess we are simply WEIRD.

I just got off the Phone with USAA. We did the auto insurance quote first…what we now get for $427/6 months, they can pretty much match for $840+/6 months. So, I guess we're staying with Mercury for now.

But we ARE finally USAA members! LOL

I’ll look at banking, etc.

Good!

Does Mercury require all 6 months in one payment. We have the option of paying monthly.

 

[southernlady]

But we ARE finally USAA members! LOL

Now that y’all are members, MsSue can become an associate member. I passed down my membership to our daughters, the the younger one’s hubby joined the Air Force Reserve. So she transferred her membership to spouse. I earned my own but my other sisters got theirs thru my daddy. When he passed away, one of my first calls was to them to lock down his account until the executor took over. They also sent me a sympathy card.

 

[Spiky Bugger]

Good!

Does Mercury require all 6 months in one payment. We have the option of paying monthly.

Not all six months are required, but it’s cheaper that way:
monthly auto pymt from checking…+$2/pymt…adds $12
divided into two or three pymts…+$6/pymt…adds $12-18
so we went with all six months up front…adds nothing.

I compared Mercury to AAA last year, and it, too, was way higher. Now it could be that we are paying through the nose for homeowners/earthquake/umbrella. But I‘d need an energy boost to engage! LOL

 

[southernlady]

Now it could be that we are paying through the nose for homeowners/earthquake/umbrella. But I‘d need an energy boost to engage! LOL

Understand. I go thru this every time we move. Not only the change of address but redo the auto policy/etc (this move saved us about $300 a month between where we domiciled in SD and here in WV).