tag:blogger.com,1999:blog-8512362.post1989306334510342861..comments2024-03-10T13:59:19.230-04:00Comments on xpostfactoid: To whose advantage is Medicare Advantage? Part 1Andrew Sprunghttp://www.blogger.com/profile/17601269968798865106noreply@blogger.comBlogger10125tag:blogger.com,1999:blog-8512362.post-73526940295389395942022-10-01T19:18:36.381-04:002022-10-01T19:18:36.381-04:00Oops, I meant the Gap Plan, not Part B, and I see ...Oops, I meant the Gap Plan, not Part B, and I see this issue is addressed in the second part of this series.<br /><br />On another note, I will add that my disabled adult child has FFS Medicaid (there is also an HMO option that we turned down), and it is the best health coverage anyone in our family has had. He sees doctors in a university-affiliated system and hasn’t had a hoop (eg, prior autos, etc.) to jump through yet. No copays or deductibles needless to say. Really, the rallying cry should be Medicaid for all, not Medicare for all.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-8512362.post-69635196059589693552022-10-01T19:03:03.292-04:002022-10-01T19:03:03.292-04:00Several years ago, when I turned 65, I chose tradi...Several years ago, when I turned 65, I chose traditional FFS Medicare, in part because of an article I read that warned that once you go to MA route, you may never be able to switch to FFS. Because your pre-existing conditions would be held against you by Part B underwriters — and you really can’t go without Part B coverage. They could turn you down or charge prohibitive rates.<br /><br />The scenario where you’d want to switch to FFS is of course when you have acquired an awful medical condition and need very specialized care not available in your MA plan. Just the sort of condition a Part B underwriter might not like.<br /><br />I just hope that I’ll continue to be able to afford FFS in the fixed income years ahead.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-8512362.post-39815342030560885912022-09-28T07:02:10.733-04:002022-09-28T07:02:10.733-04:00I assume that the doctor would be requesting prior...I assume that the doctor would be requesting prior authorization, not the enrollee. The doctor would not say, "I believe you need a transplant, why don't you check with your MA insurer before I schedule it." <br />I remember a series of studies about 10-15 years ago that looked at a bone marrow procedure which several insurers denied for breast cancer sufferers. The studies concluded that the procedure really wasn't much good, although by that time the insurers were all castigated as heartless villains,Bob Hertzhttps://www.blogger.com/profile/08889826739646491269noreply@blogger.comtag:blogger.com,1999:blog-8512362.post-63804900130448601502022-09-27T12:06:06.824-04:002022-09-27T12:06:06.824-04:00P.S., didn't realize I posted the above 9/26 c...P.S., didn't realize I posted the above 9/26 comment anonymously!Ted Doolittlehttps://portal.ct.gov/ohanoreply@blogger.comtag:blogger.com,1999:blog-8512362.post-61683394544324734522022-09-27T10:13:34.252-04:002022-09-27T10:13:34.252-04:00KFF has a list of services for which MA plans are ...KFF has a list of services for which MA plans are likely to require prior auth, ranked by the percentage of plans that require the service, here https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2022-premiums-out-of-pocket-limits-cost-sharing-supplemental-benefits-prior-authorization-and-star-ratings/ Maybe the more salient question for an enrollee is how onerous the prior auth process is likely to be, rather than for which services it's required.Andrew Sprunghttps://www.blogger.com/profile/17601269968798865106noreply@blogger.comtag:blogger.com,1999:blog-8512362.post-15505928354466092952022-09-27T09:49:49.076-04:002022-09-27T09:49:49.076-04:00I mentioned that I have never had even the hint of...I mentioned that I have never had even the hint of a denial with my MN Med Ad plan.<br />Here is a summary of the conditions that do require prior approval in my plan (and thus be more vulnerable to denial)....<br /><br />Cardiology (ablation, stress test, advanced imaging, diagnostic and implantable device services)<br />Medical oncology (chemo and supportive medical specialty medications treating active cancer diagnosis)<br />Molecular lab (Breast Cancer (BRCA) gene testing, fetal chromosomal testing, molecular pathology)<br />Musculoskeletal (spinal injections for pain management; knee, hip and shoulder surgery; fusions)<br />Radiation therapy (surgical procedures such as mastectomy; radiation procedures such as 3D CRT and IMRT; surgical or radiation treatment of cancers)<br />Radiology advance imaging (MRI, MRA, PET, CT, and Nuclear Studies)<br />Sleep (sleep study, machine and supplies; apnea testing)<br />Transplant services<br />Some surgical procedures <br />Some behavioral health assessments and treatments<br />Certain medicines including injectables and intravenous therapies<br />Prosthetic supplies <br />Some medical equipment and devices including oxygen and wheelchairs<br />Some services may require a prior authorization to continue receiving the service after a set number of visits, such as acupuncture and home health visits<br /><br />Personally I have had a stress test, and not much else on this list. Thus my hassle-free experience, perhaps.<br /><br />The actual mechanics of a capitation system are probably a lot more complex than I would appreciate.Bob Hertzhttps://www.blogger.com/profile/08889826739646491269noreply@blogger.comtag:blogger.com,1999:blog-8512362.post-34038120343461982602022-09-26T17:06:21.219-04:002022-09-26T17:06:21.219-04:00Thanks -- I kept meaning to link to this series. M...Thanks -- I kept meaning to link to this series. My impression was that in their last rebuttal, Halvorson and Donald Crane punted, effectively conceding that the model they tout -- incentives to keep per-enrollee costs low -- really only works in the 18% of MA plans that in turn pay providers on a capitated basis. And that model -- in which all parties are paid to keep enrollee costs low -- sets against the opportunity to reduce low-value care the heightened risk of reducing high-value but expensive care. Finally, in this piece, the authors emptily cite support for MA and ACO reach from the House of Representatives, CMS and CMMI, as if those institutions are disinterested, not addressing the possibility of regulatory capture. https://www.healthaffairs.org/content/forefront/medicare-advantage-emperor-s-clothes-reply-berwick-and-gilfillanAndrew Sprunghttps://www.blogger.com/profile/17601269968798865106noreply@blogger.comtag:blogger.com,1999:blog-8512362.post-50858658347950763342022-09-23T21:26:07.933-04:002022-09-23T21:26:07.933-04:00George Halvorson published three longish articles ...George Halvorson published three longish articles on Med Advantage in The Health Care Blog in the spring. I have followed George since his days running health plans where I live in MN. He is very rarely wrong. I will have to re-read the articles. He is very pro-Medicare Advantage.Bob Hertzhttps://www.blogger.com/profile/08889826739646491269noreply@blogger.comtag:blogger.com,1999:blog-8512362.post-4068655862191221522022-09-21T12:10:02.097-04:002022-09-21T12:10:02.097-04:00I have been in a Blue Cross MA plan for about 9 ye...I have been in a Blue Cross MA plan for about 9 years. I have had three surgeries in that time.<br />I have never paid more than $100 out of pocket for anything. I had the choice of 98% of the drs and hospitals in MN when needed. I believe I could have accessed providers in other states with no hassle.<br />I have not had to test the drug coverage....the costs would be high for specialty drugs, but that is true for all drug plans I believe.<br />When I did have a complaint about a provider overcharging me, a Blue Cross rep got on the phone with me and solved the issue in my favor.<br />Now I am always wary of generalizing from one's own experience... so I eagerly await your next article.Bob Hertzhttps://www.blogger.com/profile/08889826739646491269noreply@blogger.comtag:blogger.com,1999:blog-8512362.post-20377113303750853332022-09-21T10:58:45.208-04:002022-09-21T10:58:45.208-04:00MA enrollees tend to have more medical debt than t...MA enrollees tend to have more medical debt than those w/ Medicare plus supplement per this recent JAMA article https://jamanetwork.com/journals/jamanetworkopen/articlepdf/2796358/himmelstein_2022_oi_220907_1662670437.46697.pdf. Anonymousnoreply@blogger.com