Should I switch my aunt's current health insurance to an Advantage plan?

My mom n I have United Health which has been great until I got diagnosed with an aortic aneurysm n needed a certain type of heart scan. Even tho I’ve had a heart attack n 2 episodes of heart failure, I was denied this test. Im 67 today.

2months ago I would have said yes but now it’s a big NO! Harder to find drs, especially specialists. Several nursing homes & rehab centers said no as his insurance is FL BlUE HMO a advantage & they don’t take it, Recently was at appointment at Mayo- the dr was fabulous but now they’re not taking his plan as it doesn’t pay enough. He’s started to have delusions & the few that might see him are too busy. I’m a ppo so I pay more each month but for his advantage plan if he has surgery what he needs to pay is much higher than what I pay a year.

Ask to meet with representatives of her current and proposed insurance to get information.

How do you switch back if you have already done this.

(copy and paste)
https://www.aarp.org/health/medicare-insurance/info-2020/original-medicare-vs-advantage.html

Check with NH to make sure the new plan is accepted. Check with all her current drs to ensure the same. Advantage plans can be great with a few added bonuses that current insurance might not have, HOWEVER lots of folks have changed over without doing their homework (or just confused) and found their specialists/doctors/hospitals were no longer in-network or that the meds they take are not covered or cost is substantially more. (Ck with pharmacy too when inquiring)

Medicare Advantage plans have one goal, to make money for the insurance companies. I agree with Sophia54. They’re probably great when you’re relatively healthy. But God forbid anyone get a rare brain disease like my dad got, they would be s**t out of luck. There are only a few specialists in the country that deal with such things, and my dad was in and out of icu’s for months. I believe my mom would be bankrupt now if she had Medicare Advantage. What she DID have was a good secondary insurance to cover the 20% Medicare doesn’t cover.

Be very careful with this and make sure you fully understand what coverage your aunt has, how she got it, and who is authorized to make changes before any changes are made. For instance, if she has original Medicare and also a supplementary plan provided through a past employer of her or a spouse, you would probably want to leave it as it is. That is because some supplemental plans provided by past employers never let you go back once you drop them! As to your post, I never heard of an insurance company enrolling anyone in anything - it is typically not their decision. Your aunt has rights as a consumer to make her choices or have a trusted person or POA do it for her. I am NOT in favor of Medicare Advantage plans and would recommend you stay with original Medicare. Medicare Advantage plans are privately managed and limit choices in favor of cost. Nit what I want in a medical plan.

Sigh123: You'd stated "I recently received a letter from her current health insurance company that they will be enrolling my aunt in a new Advantage plan." Your aunt can't be enrolled in a Medicare Advantage plan without authorization by her or her health care proxy. Medicare Advantage plans are not what they may seem; there has been a lot of negative press regarding them.

This is my honest opinion. I once had Original Medicare and I decided to switch to Medicare Advantage and I have not regretted doing so. I love my Medicare Advantage. My husband has had a Medicare Advantage plan since the 1990s and he does not have any complaint about it.

The difference with Original Medicare is that they only pay 80% of your bill and you are responsible for the 20%.

A lot of people on this forum complain that Medicare Advantage is not a good choice. These people do not understand that the Medicare Advantage plan that they chose is a HMO plan which requires them to stay in network.

With Medicare Advantage, you have the choice between the HMO or the PPO. A PPO plan will allow you to choose ANY doctor or hospital.

HMO plan means that you have to stay in network. HMO plan needs you to get a referral from your PCP to see any in-network specialist. In my opinion, HMOs are too restrictive. I have had HMOs in the past and I found them to be too restrictive.

With a PPO plan, you DO NOT need any referral to see any specialist or to go to any hospital. Medicare Advantage accepts ALL doctors and hospitals, so it’s going to be rare that your doctor isn’t on the list. As mentioned above, I have Medicare Advantage PPO and I do not have to pay any co-pay when I visit my PCP, and I pay $25 to see any specialist. It’s a great relief for me that I don’t need a referral to see any doctor.

Also, Medicare Advantage plan comes with many, many perks that’s too many to mention here.

I did my research on Google before I decided on the current Medicare Advantage plan that I have now.

Do your research first before making your decision.

Don't move her to an Advantage plan. They are like HMOs and everything has to be approved through a primary care doctor. It is difficult to have needed services approved as the priority is to keep costs to a minimum. Keep Medicare and a supplemental plan (G is the best).

Real Medicare is a great program run by the government. Once enrolled, your doctor or PA will order tests and treatment and you will get those tests and treatments.

Insurance companies promote Medicare advantage by pretending you are still receiving Medicare but you are not. They may pay some dental bills and may even buy you hearing aids but they will not just pay for your medical treatment the way real Medicare does.

When you turn to Medicare Advantage you are trading your real Medicare for private insurance, paid for by Medicare. It is no longer really Medicare and really should not be allowed to use that name. As a private insurance program, when you need a test or treatment it has to be approved by the private insurance company and there is a good chance it will not be approved.

PLEASE meet with Elder Law Attorney.

Please stick with Standard (Original) Medicare + a Medigap policy. Using the coverage that your aunt currently has, 'Doctors" make the decisions about what the best care is for your aunt. Medicare Advantage plans (insurance companies) make the decisions about WHAT CARE will be covered. It's that simple: You want your aunt's "best practice" care to be determined by her Physician recommendations. Medicare Advantage Plans have a committee of non-Physician folks who determine "what they shall pay for" for your aunt. It's truly that simple. Go with Standard (old fashioned) Medicare, keep this good care for your aunt, or some clerk at an insurance company will make decisions based upon how much "best practice" care would cost the company.

Please take advice about NOT switching to Advantage Plan. Keep her on original Medicare with her secondary insurance to cover what Medicare does not.

You've likely already heard enough against Medicare Advantage plans, but I'll add on: A Medicare Advantage plan helped to kill my older sister.

She had a blood sugar drop in her sleep, which placed her in a coma for five weeks. After that, it was a two-year nightmare until her passing this past April at age 75. Again and again, doctors told me that if my sister had had Original Medicare, she would have received the proper treatments in a facility equipped to deal with brain-injured patients--if a doctor recommends a certain course of treatment, Original Medicare pays for it. This will seem a waste to anyone concerned with the high cost of healthcare, but when you need that care, it's very, very urgent.

After she began to wake up from her coma, her doctors recommended complex care in a long-term acute care hospital. But Anthem absolutely refused; appeals went nowhere. No skilled nursing facility would accept her because her CARE WAS TOO COMPLEX. After an additional month in the hospital (time when she could have been in the L-TACH), one SNF finally took her. There, she was treated like any other stroke or dementia patient, with no specialized care for brain injury. I struggled to patchwork together appropriate care myself, but the SNF staff said that I could not take her elsewhere for private-pay outpatient rehab, because then the insurance company would no longer pay for her 100 days in the SNF (which they stopped paying for at around 60 days anyway--we had to switch to private-pay at $400/day).

At that stage, her care was too complex for us to take on at home, so I was at the facility nearly every day to ensure she got the meager 30 minutes of physical rehab/30 minutes of speech therapy that they provided (instead of the three collective hours of guaranteed rehab that a facility specializing in brain injury would provide). If I wasn't there, many days she wouldn't receive the 30 minutes, because the injury left her oppositional to treatment--another thing a specialized facility is trained to deal with. In a SNF, if a patient says no, PTs/STs are off to the next resident in about 30 seconds.

The first few months of treatment after a brain injury are critical, and I simply could not get her the care she needed in that window. She improved a bit, but the SNF was not staffed to watch her, so 7 months in she fell and broke her hip at a time when we weren't there, leading to more hospital stays. It was a long, slow, heart-wrenching decline after that. We brought her home after rehab failed for the broken hip--by then it was too late.

Now, I realize that I should have used my sister's funds to try paying, at least for a few weeks, for the $2,000/day specialized rehab facility. But at the time, that amount just seemed so astronomical to consider--$400/day seemed awful enough. She had saved quite a bit, but at that time, I was not sure how long she would live or how much money she would need.

As my sister's court-appointed guardian, I was met with such "so-sad, too-bad" indifference from Anthem at every turn. Now, I'm left wondering "what if" every day, and I'm still reeling from the two-year ordeal in which I lost my sister slowly. It's just about unbearable.

To anyone who reads this: Medicare Advantage plans are only an "advantage" if you stay relatively healthy and require only straightforward care until you one day die of uncomplicated causes. If you ever need complex care, your chosen insurance company that oversees your Advantage Plan will refuse necessary care at every turn and simply bide its time waiting for you to die.

The irony: Between all the substandard care that Anthem DID pay for, they probably paid at least 3x more for my sister's care than they would have if they had just paid for the more effective doctor-recommended care and rehab she needed in the first place. But if other patients die more quickly, the money all balances out in their favor in the end. Yay for them.

Old Dude is right, specifically if your Aunt has a list of her own doctors she wants to keep - or thinks she can keep. I went on Original Medicare in 2021, enrolling in original Parts A & B, and then bought separate plans for Vision and Dental care. I also enrolled in a Supplemental Plan to pay what Medicare approves, but does not pay, and a Part D Plan for prescription medicine. I did all that because I have a lot of health conditions that my primary care doctor manages, and I wanted to keep my other doctors that I’ve been seeing, some for at least 20-30 years, some not that long. Back when I was working, I always kept health insurance plans that let me see “any doctor, any hospital, any lab - anytime”. Usually Blue Cross/Blue Shield. When I was initially looking at Medicare Plans, I just assumed my doctors might belong to some Medicare Advantage Plans, since they are overwhelmingly “pushed” at seniors everywhere we look. “Managed Care”. Wrong! None of them were Advantage Plan doctors. So, I enrolled in Original Medicare with a Supplemental Plan to pay what Medicare approves but does not direct pay. My doctors bill Medicare, and then balances are sent to my Supplemental Plan to pay. I seldom have any out-of-pocket medical costs to pay myself. Medicare Part D for my Prescriptions is another story. That one can be expensive, depending on what “phase of the plan” I’m in during a given year. I check with my doctors to see if a medicine is necessary, or if there is a less expensive alternative, before filling them. When he can, my PCP gives me samples. I also buy 90-day supplies of my maintenance medicines. I plan to move some of those maintenance meds (those that never vary in strength) to my plans Mail Order Pharmacy so they cost me even less. As of now, I intend to stay in my home for as long as I can, before moving to Senior Housing/Assisted Living. Perhaps at that point, I’ll consider a Medicare Advantage Plan. My Primary Care will be retiring at some point, along with a few of the others. I’m looking at stairlifts now to retrofit my split foyer house while I’m still mobil.

My daughter managed a Wound care Unit. She had a hard time getting MA to pay for A&B services. Yes, they are suppose to cover parts A & B but they try not. So then you are on the phone arguing with them that the service is covered. Not me.

Never. Other commenters have already discussed the disadvantages of Medicare Advantage plans. My husband was a private-pay long-term care resident due to frontotemporal degeneration. In the window when people can select Medicare supplements without respect for pre-existing conditions, I purchased a Plan G Medicare supplement for him. Later that year, he had a 14-day hospital stay and I could choose the hospital. We paid $0 for that hospital stay. With an Advantage plan that could have been as much as $10K. Not bad for premiums of about $140/month.

Ugh. I don't like Advantrage Plans at all. Terrible idea. They are much more likely than Regular Supplemental Plans to limit what services or care they will cover and what they do cover has to go through their specific network.

If you can afford to keep regular Medicare and a regular Medicare Suppemental plan, that is a much better and more flexible option.

From experience with BIL his POA's switched to an Advantage plan which isn't good as what he had before which he was on standard Medicare & Amerigroup thru Medicaid. The NH contacted me to have him switched back which I did but then the POA's did it again they wanted that credit card that was attached to that Advantage plan. When it was all said and done the NH took over and switched him back to standard Medicare because it pays better than you Advantage plans. With the Advantage plans if you land in the hospital the first 3 to 4 days you have to pay for then it kicks in. With the standard Medicare it kicks in right away.

With the Advantage Plan you will have to pick another doctor if her current doctor isn't in that plan. My BIL had to switch doctors. Then you have conflicting opinions on what they do for that person with medications. With my BIL they took him off of one when he was switched back they put him back on it that medication was for his seizures.

My BIL got a letter from his health insurance wanting him to switch to the Advantage Plan I threw the letter away.

And I know from my own personal experience I am on Medicare and I have a supplement I pay for every month that insurance is the best for me because I don't have to pay out for any doctors, any diagnostic procedures and if I land in the hospital/ER I don't have to pay extra for it. Yes I pay monthly for my supplement but it covers the 20% that Medicare doesn't pay.

I don't do Medicare advantage for my mom and husband. I like having the freedom to go to any doctor or hospital of my choice.

This is from a friend of mine who is a director/social worker for a Hospice/Palliative Care Organization. She posts this on her personal page almost every year during open enrollment time.

PSA: PLEASE, PLEASE, PLEASE do NOT change from traditional Medicare (your red, white, and blue card), to a Medicare Replacement Plan, i.e. Aetna, BCBS, Cigna, Humana Advantage. These plans REPLACE your Medicare benefits and offer you less benefits, which is why they cost less. Secondary supplement insurance is different, and these companies provide good coverage for that. Switching to a replacement plan means losing your Medicare benefits to a managed insurance plan where an insurance rep dictates your care and NOT your doctor.

Set up an appointment with an insurance broker. They cost nothing. The broker names their money during enrollment. Nothing should change until Jan 1 whether MA or regular. Bring a list of her meds when looking at MA plans. The broker will compare if monthly premiums are involved or if it is $0. For instance, my moms plan cost 0 ten years ago and if she stayed on the plan, her monthly costs rose to $230 per month. That is certainly a reason to change plans during open enrollment. Comparisons will be shown for ER visits and hospitalizations. The most important comparison to look at are the costs of drug co pays.
If you want to compare just the old plan to the new, then this will be do it yourself. Go to Medicare.gov and "find a plan." Plug in her zip code and register as a guest rather than doing personal info. As a guest will not save your results. You will need to plug in a pharmacy that she uses for consistency. Put in those medications. I am 90% sure you will find both plans in question. You can choose up to 3 plans at a time to see the back to back similarities.
Now medication formularies get updated closer towards the end of thebyear. As open enrollment comes out in October, what you look up today may change a little but at least you get a snapshot. Again a broker can help if you want to look at a greater number of plans.

Regarding SHIP, they are awesome for dealing with comparison marketplace insurance situations. Like for those of us posting, SHiP is helpful & works are we still can go and see docs, providers, etc at different locations, different clinics, even over to a different town if that’s where specialty outpatient place is.

But for those in a NH that is not the situation. SHIP doesn’t work well for this. And this flat is something that gets glossed over totally when families go to look at places; its like the copay requirement of basically all their income to the NH if they are Medicaid Pending / LTC Medicaid enrolled…. families are often gobsmacked that “mom doesn’t get to keep her SS $ anymore and just how are we supposed to pay on stuff to keep her home??” situation. Residents in a NH are essentially a captive audience for health care . They really have no or very limited choice. The MD who is the medical director of the NH or more accurately the DON (who I’ve found is Goddess & Ruler at a NH) determines what’s what. If they are duals aka on MediCARE and Medicaid, the State is going to want them enrolled onto something that does optimum cost containment. & Medicare is going to go along with this. For the most part, insurance companies most don’t want any part of this type of business as Medicaid reinbursement is low. This had led to a few insurers who do, and have a system to capture every possible cent, of which Molina Healthcare is probably the biggest. They probably are the leader in being the health insurance provider for anything involving Medicaid…. whether it’s “dual” elderly in a NH or kids on CHIP.

Personally I think Molina and Superior (another well run one) do a pretty decent job as health insurer for this market. ((Although I’d hate to be a vendor to Molina as I bet they beat you down big time on costs….)). If the OPs Aunt is a dual, then whatever insurance system the State uses for LTC resident is what she’s going to need to enroll in. She has to, has to, find this out. And there may be no choice as this particular NH may have contracted with specific Managed/Advantaged to provide the oversight, care, prescriptions drugs which the staff at the Nh does. NH & staff is paid for the custodial care part via LTC Medicaid program but the medical part paid via health insurance coverage. And btw the 2 they will bill such to get every cent plausible.

fwiw: When TX did the move to MCO, it was towards the end of my mom’s life. She was on hospice, so they were setting her health directives. But as her POA, I got all sorts of notices on the upcoming MCO change…., that there would be a continuum of care with no discernible impact and happen within a year or two. Yada, yada. Didn’t happen and took abt 5. A lot of the gerontologists who had been part time medical directors at NHs basically exited. They still had solid private practice & could move their time to the nonMedicaid Nh and bill Medicare. The NHs ended up with family medical docs being the medical directors. I was oh so glad mom was on hospice.

Just reinforcing the reply about talking to a SHIP counselor. They are volunteers, however, they have tools available to them that allow them to help you compare what you need, across all your options, Medicare A/B/D, Medigap and Medicare Advantage in the state (Medicare Advantage plans differ between the states). SHIP is a federal program (your tax money is paying for the training, the program materials and the software available to them).

They are NOT insurance agents and they do NOT represent specific companies.

Please talk to a SHIP counselor.
SHIP stands for Senior Health Insurance Program.
The counselors are not beholden to any company so they will review what plans are available for a person, look at medications, and other factors and will make recommendations.
Do a Search for "SHIP counselors near me"

Is your Mom on private pay or Medicaid?

If on Medicaid, do they require Mom to keep her insurance but the premium is paid from her SS money?

Is the insurance a provider thru Medicaid? Then you cannot make any changes without Medicaid being involved. Read what I replied to Old dude. We had other problems with United who only supplied his prescriptions. I was getting calls wanting us to change our coverage. I was getting letters saying they could give him better insurance. How can you give someone who has no co-payments and no deductibles better insurance. He pays nothing. I stopped answering calls and thru out the letters.

I would call Moms Medicaid caseworker if she is on it.

Igloo, thank you for your brilliant explanation!

Right now, my former employer is trying to switch all its retirees to a Medicare Advantage plan. I keep seeing videos from elderly retirees in FL and elsewhere who are in facilities; they have been told that the docs/therapists/pharmacy at their place won't accept this MA plan and that they will need to pay those charges out of pocket.

So be aware that NHs NOT accepting MA is a real thing. Call the DON tomorrow.

Oh, and if it's the NYC retiree health plan, the switch has been shut down by the courts.

I’m going to expand on Barbs post: How Medicare Advantage plans work ideally & best is for every single provider (physicians, clinics, hospitals, therapists, etc) and every single ancillary service (lab, specialty testing, etc) is 100% in their network. Again everything ever billable IN NETWORK. If not, it’s out of network and significant copay….. could be very significant like 25% of a non negotiated rate…. Serious costs

You need to - absolutely must - find out if the Advantage Plan she’s being switched to is designed to work for long term care facilities and if the NH Auntie is in specifically is in this Advantage Plans system. The DON at the NH can answer this.

If the AP knows she is in a NH, it may not actually be an traditional Advantage plan but a MCO aka Managed Care Organization that is being run through an Advantage Plan via a narrow group of insurers. That is happening in some States for how medical care is done in NH. Texas does this.

I know this is confusing so hang with me on this and some of this may be stuff you already know, if so I apologize: Advantage Plans are a spin off from Original MediCARE & was done under the guise of giving consumers more choice. But have evolved to be basically health insurance companies supported by the feds via CMS / Centers for Medicare & Medicare to run the AP’s. It’s been to the point on some Adv Plan that if federal subsidy wasn’t happening to the extent it has been that they couldn’t make the big profits. For the States, as so many are “duals” (on MediCARE & Medicaid), the States end up with higher bills as well in all this too, So what has happened to bring cost containment more in line is that the Feds & States have been pushing MCO / Managed Care Organizations to happen when feasible. And for those in NH as they are a captive audience, having them go onto a MCO makes sense to be done. The AP insurers in some areas have partnered to do MCOs and use their existing in-network for it & get their doc to be Nh medical directors w a lot of telemed. So…. Again clearly find out if the AP works for the MD, therapists, etc at her NH and that the hospital/ clinics the NH refer to out of this NH are in network for the AP as well. AP should have on-line a list of everything in network.

HOWEVER
if your Aunt is new to the NH and is still thinking she’s keeping all her old doctors, the reality of how medical care is done in a NH either wasn’t discussed with her, her POA and you OR somebody dropped the ball on discussing this with you all. If y’all are thinking she’s going to keep her old docs, that is not going to happen. She may, like may, be able to do a visit or two, but it cannot work long term as the MD who is the medical director at the Nh will be the one to determine her health care needs, write script for meds, set up schedules, determine if a run to the ER is needed, etc.. It’s really hard to have outside MD consult happening over time in a NH u less this is a pricey private pay NH. Some accommodations can be done for pre-existing but gets unwieldy. So the need for her health insurance to cover that type of care goes always and replaced by something that works for how healthcare in a long term care facility is done.
This can be hard for some elderly to accept.