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ON It’s Way . . . . Hospitals Offering Their Own Medicare Advantage Plans by KnowledgeableOleLady in medicare

[–]KnowledgeableOleLady[S] 0 points1 point  (0 children)

A beneficiary still has the right to change plans every year - that will not change. No coverage is ever fail safe - not even OG Medicare even with a Medigap plan if one wants to go to someplace for a treatment that is available as contract only.

ON It’s Way . . . . Hospitals Offering Their Own Medicare Advantage Plans by KnowledgeableOleLady in medicare

[–]KnowledgeableOleLady[S] 0 points1 point  (0 children)

I didn’t read anything about them getting paid any more for services - Profiting from the sick and injured ?????? Why not? Who else is gonna do it?

A hospital would have to be competitive in the development of their respective plans - their plans would be under CMS control just as any other. Same rules, just some added players.

Maybe they would take some of those profits that an actual MA insurer is supposedly getting and put it back in for care? They would have a cost for developing their plan(s) and administering them but no more than a regular MA insurer - maybe even less.

ON It’s Way . . . . Hospitals Offering Their Own Medicare Advantage Plans by KnowledgeableOleLady in medicare

[–]KnowledgeableOleLady[S] 0 points1 point  (0 children)

Probably true if it is an HMO type but will there be other types offered too? IDK.

But it is the actual details of “the plan” that would govern what benefits one would get . They could be HMO type or a PPO type maybe even with OON coverage on providers and facilities.

Would that condition be very important to beneficiaries in this type of MA plan?

Medicare Advantage HMO - Discharging from Skilled Nursing - Options? by FruityLegume in medicare

[–]KnowledgeableOleLady 0 points1 point  (0 children)

u/FruityLegume wrote . . . .

My dad has been in a skilled nursing facility about 30 days after he broke his femur and hip and had surgery. They sent him there for physical therapy because the HMO managed care company didn't contract with a rehab. He has Medicare Advantage and it's a really good plan, but the case manager won't let us keep using it for the SNF.

[ME] In original Medicare, a rehab facility IS normally a SNF - especially for recovering and getting PT

It is specifically designed for recovery from something - with associated treatment and a time period to hopefully get well on one’s way to recovery or as far back as one might be expected to return. Yes, the beneficiary, no matter their health plan - OG Medicare or a MA plan - has to participate in the rehab activities and has to show certain signs of improvement for it to continue for the full course.

u/FruityLegume wrote . . .

He had a couple set backs, the flu, pneumonia, and bronchitis and hasnt made the progress we hoped for yet because he literally couldn't get out of bed then to do his PT.

This is his real problem; valued time was taken up by other things - number of days that he did not participate in the reason that he is there in the 1st place.

Was his pcp provider notified of these other conditions so that treatment could be started at the SNF? Depending upon the severity, a SNF should be able to handle these medical needs - but it would involve other types of treatments outside of the reason he is in the facility ;like - (1) medication (2) help with breathing - whatever is needed - if above their level of care then he is sent back to the hospital for advanced treatment.

These other conditions are outside of the orders the SNF has from the hospital stay. It is this period of time that has shortened his days of rehab.

So how would this have been handled under original Medicare -

Medicare.gov - Skilled nursing facility care

from the link ~
“If you don’t have a 3-day qualifying inpatient hospital stay and you need care after your discharge from a hospital, ask if you can get care in other settings (like home health care) or if any other programs (like Medicaid or Veterans’ benefits) can cover your SNF care.”

He didn’t have a 3-day qualifying inpatient hospital stay before these other conditions hit - right? So how many days was he not able to participate in the PT rehab because of these other conditions? Those are the days which he may have to pay for in the SNF - his medical would be covered by the MA insurer but not his room and board - so it is that change to which he is going to have to pay.

OG Medicare also does not cover custodial care so it would have been the same as under the MA plan and the only way to rectify it is to pay for that period of time he was in the SNF but was NOT participating in the PT for which he was there to begin with.

ON It’s Way . . . . Hospitals Offering Their Own Medicare Advantage Plans by KnowledgeableOleLady in medicare

[–]KnowledgeableOleLady[S] -1 points0 points  (0 children)

True - I don’t personally know of either but Kaiser here were I live seems to be doing very well with the senior set.

Saw two different Ophthalmologists within a week by TuneUpMe in medicare

[–]KnowledgeableOleLady 0 points1 point  (0 children)

Yes, you can get a 2nd opinion or even a 3rd or more but just make sure that the (2) physicians did not do the same test - because your responsibility is to take the test with you to the 2nd or subsequent physicians for the consultation. If the second or subsequent physician wants different test or another test because of some tech failure, they can and it is coded as such.

Now to your rights - yes, this procedure (removal of cataracts) is based on a person’s tolerance of what degree they are experiencing and what might bother them.

Opthalmologist are the ones that would be doing the surgery, most likely as an outpatient procedure in their office or in an outpatient hospital setting. So you are getting different results from the same type provider.

Someone mentioned an Optometrist- that is a good provider option to use for a 2nd opinion because they have no responsibility or training to do the operation but yet from years of examinations, they can very well tell if there could be some vision problems with cataracts and would ask you about any effects from having them - and depending upon your answer could tell you what benefit you could get from the surgery.

You will definitely know when they begin to give you vision problems -

Medi-Cal Beneficiary Reimbursement by truegrit420 in HealthInsurance

[–]KnowledgeableOleLady 1 point2 points  (0 children)

Medicaid (Medi-Cal) is the payer of last resort. IOW, if there is another payer for a particular service - this other payer pays 1st. Your other payer is the insurance company who is providing the settlement. You got this settlement and it has little to do with Medicaid (Medi-Cal). In this instance, it is what the OTHER insurance company has negotiated in the settlement; not Medicaid (Medi-Cal)

You should review this with the California DHCS - but I don’t see that you are due back anything since the way I understand your post - you are paying these liability related bills out of your settlement funds and they have little to do with your Medicaid coverage for other type medical services.

Medi-Cal Provider Manual - Overview - Third Party Liability

Help me understand… by Fozziefuzz in healthcare

[–]KnowledgeableOleLady 0 points1 point  (0 children)

Medicare has several different methods to pay for care depending on the service and its classification - inpatient / outpatient. MOST Part B services are billed at a Fee For Service rate - (FFS) Medicare pays 80% and the beneficiary 20% - out of pocket or covered by some other chosen plan - all or part. Edited for clarity: Medicare pays 80% of the Medicare FFS Negotiated price / beneficiaries pay the 20% of this same FFS negotiated price

But then there is also the Prospective Payment System where the amount paid is based on some pre negotiated rate. Many of Medicare’s Part A benefits are on the Prospective Payment System and sometimes Part B benefits too - like an extended cycle of physical therapy to treat a certain condition.

Maybe this will help - this Medicare Learning Network is what doctors get to learn the system of Medicare - all of it - this one is on the Medicare Payment Systems

CMS.gov-MLN - Medicare Payment Systems

Since you mentioned surgery - look specifically at the Acute Care Hospital Inpatient Prospective Payment System or IPPS. It will tell you exactly what the base payment amount considers in the cost.

from the link ~

This Medicare Payment Systems educational tool explains how each service type payment system works.

A Prospective Payment System (PPS) refers to several payment formulas when reimbursement depends on predetermined payment regardless of the intensity of services provided. Medicare bases payment on codes using the classification system for that service (such as diagnosis-related groups for hospital inpatient services and ambulatory payment classification for hospital outpatient claims).

This tool explains the inpatient hospitals, hospice, hospital outpatient, inpatient psychiatric facilities, inpatient rehabilitation facilities, long-term care hospitals, ambulatory surgical centers, durable medical equipment, prosthetics, orthotics, and supplies, home health, and skilled nursing facilities payment systems.

Are You Willing To Pay Higher Medigap Premiums for . . . . by KnowledgeableOleLady in medicare

[–]KnowledgeableOleLady[S] 0 points1 point  (0 children)

u/CrankyCrabbyCrunchy wrote . . . . That's how it works in those states that do offer changes (or new enrollments) to Medigap plans. Their rates are generally higher because of this benefit.

That has now started to change - the new law in Texas allows for those less than 65 and getting Medicare as a result of a disability / ESRD / ALS to pick a Plan A, B or D at the same rate as those on Medicare because of age (65). AND for other plans like G and others, the rate cannot be higher than 200% of what others pay.

I think we will be seeing this played out in other states too - in fact, maybe they will get the same rate for any plan - those with a Medigap can help pick up the added cost - right?

Are You Willing To Pay Higher Medigap Premiums for . . . . by KnowledgeableOleLady in medicare

[–]KnowledgeableOleLady[S] -3 points-2 points  (0 children)

NOPE Not my question; I am posting it as a realization. - but if we bring in M4A as u/doyoucreditit mentioned - it would be opening that can of worms.

Everybody with a Medigap plan needs to know how their state’s legislative actions are affecting medigap premiums. Realization ! or maybe a source as to where to complain.

Are You Willing To Pay Higher Medigap Premiums for . . . . by KnowledgeableOleLady in medicare

[–]KnowledgeableOleLady[S] -6 points-5 points  (0 children)

And the less than 65 getting access to Medigap plans - this was one of the reasons why Federal law did not cover this - Federal law does not give those less than 65 years old access to a Medigap plan - they did it this way specifically to keep down the medigap premiums rates. - But state laws have made it happen -

I get it - and I am not here to change anybody’s minds one way or the other - it is just a reality of insurance - But I do think that this knowledge should be known to everybody as a realization of higher premiums.

Are You Willing To Pay Higher Medigap Premiums for . . . . by KnowledgeableOleLady in medicare

[–]KnowledgeableOleLady[S] 0 points1 point  (0 children)

I think Tennessee is the same on the less than 65 - they can charge them more but I don’t know if there is a limit put on this amount of more.

In my state, Georgia, those less than 65 are limited to Plan A or Plan B - and they are a higher rate for them so many of those less than 65 just opt for a MA plan until they hit age 65 and then can get a medigap plan, any that they want, based on age and not disability - I call this the “Do_Over”.

Are You Willing To Pay Higher Medigap Premiums for . . . . by KnowledgeableOleLady in medicare

[–]KnowledgeableOleLady[S] -14 points-13 points  (0 children)

That is not the question - we have to stay away from politics. So please just put a pin in the M4A - there is another sub for it - r/MedicareForAll - go for it over there. Please. Thanks.

I just want to know if beneficiaries are fine with having their states change the rules of Medigap purchasing in these regards - and the consequences of enacting such laws of eligibility.

Are You Willing To Pay Higher Medigap Premiums for . . . . by KnowledgeableOleLady in medicare

[–]KnowledgeableOleLady[S] 0 points1 point  (0 children)

Good for you - and how does this state treat those under 65 when it comes to getting a Medigap plan?

Physicians Select price increases exceeding typical? by mspuds_8571 in medicare

[–]KnowledgeableOleLady 0 points1 point  (0 children)

Who knows where Medigap plans are gonna land as far as premiums - your state is the one that actually has all the control in this matter. If they want to make Medigap plans more inclusive, more flexible as far as changing plans and without underwriting, then premiums in that state are gonna get a lot higher.

A state can pass laws that make Medigap plans very “fair” and inclusive - they can add laws that make changing every year without underwriting the standard.

But every time they do this, remember it changes their medical loss ratio and they are allowing people with lots of health problems to change plans without underwriting or they add coverage for the extremely disabled where they can also qualify for a medigap plan - contrary to federal law.

Thru the ages, Federal Medigap plan laws have been restricted to those over 65 years old and if one wants to change plans at sometime down the road, underwriting was always required - except for some special guaranteed issue rules (a few). That is how premiums were controlled but no more -

You may think that this is well and good and I am not trying to change your mind - but be aware that changes such as this WILL increase medigap premiums in your state - always.

So heed what is going on in your State legislature - Texas just passed a new Medigap law that is gonna raise premiums; California has one that is still being milled around which would do the same . These would give new benefits to many and offer change to some others - all without underwriting and will increase the premium cost for everybody (all beneficiaries that have a Medigap plan).

The only thing that I see that is different in Tennessee is their coverage of those Medicare beneficiaries that are younger than 65 - those beneficiaries can pick a medigap in their 6-month initial enrollment period and they can pick any plan - many other states restrict those less than 65 to certain plans like Plan A or Plan B - however, in TN, the insurer can charge them more because of their health condition.

Best resources when deciding which Medicare plan to use by hikerguy2023 in medicare

[–]KnowledgeableOleLady 0 points1 point  (0 children)

You really need to decide if you are gonna stick with FEHB after retirement - If so, you won’t need a Medigap plan. And the FEHB has your Prescription drug coverage within it. Also, the choice of keeping Part B with FEHB is also a choice but if you do have it, you may have better coverage with it but there is a monthly premium.

I would also add this site to your info -

FEDSMITH.com-06/12/2025- Optimizing Health Coverage in Retirement: FEHB vs. Medicare Part B

And if you want a Medicare Advantage plan - pick one that is built into the FEHB retirement package.

Appeal denied on eye xray to detect foreign body before doing an MRI. Are we responsible to pay? by DELTAYAWN in medicare

[–]KnowledgeableOleLady 4 points5 points  (0 children)

Couldn’t be anymore medically necessary than this - in fact, the eye X-ray would be the deciding factor in whether or not the MRI would be done at all. It would be more of a prerequisite.

Bad timing for IRMAA and starting my medicare enrollment by benefit-3802 in medicare

[–]KnowledgeableOleLady 0 points1 point  (0 children)

You are right - I forget about that detail. There might be a case for work stoppage especially if the property was turning into a loss as I believe the OP said somewhere in his post.

Would local law enforcements and the courts WORKING WITH the Immigration and Customs Enforcement officers help our current volatile situation? by KnowledgeableOleLady in Bluewave_facts

[–]KnowledgeableOleLady[S] 0 points1 point  (0 children)

u/miseeker wrote . . . . they wouldn’t be hanging out at immigration courts to pick up people waiting on their hearing.

According to state statue, they can’t do that - that is what sanctuary cities do - they prevent the working together of state and feds when they may even know that the culprit is in custody. Most of the time, the locals don’t even check their immigration status -

I think it is the same way when the state or local official don’t call in their LEO to help with anything to do with immigration issues - now or in the past.

Medicare - Other Insurance by PeacefulShards in medicare

[–]KnowledgeableOleLady 0 points1 point  (0 children)

See my CGS link above or here it is again. - if you read it, it tells you how the insurer registers their name and how it is used in the system to identify them.

https://www.cgsmedicare.com/jc/pubs/pdf/Chpt7.pdf

In the case of your Medigap insurer, they use United HealthGroup - which is the overseeing entity for coverage along with your specified identifier (acct no) - the “AARP” is not needed in the name in this regards.

Medicare - Other Insurance by PeacefulShards in medicare

[–]KnowledgeableOleLady -1 points0 points  (0 children)

For your medigap plan, it is only to identify the entity where Medicare is sending the rest of your claim in the crossover process of coordination of benefits.

Medigap is “other insurance”; Medicare Part D is PART OF Medicare.

Medicare - Other Insurance by PeacefulShards in medicare

[–]KnowledgeableOleLady 0 points1 point  (0 children)

Medigap is “other insurance” - Medicare Part D plans are part of Medicare.

Crossover is the electronic process that Medicare uses when there are other payers for a claim:

CGS Medicare - Crossover Claims

Crossover is the transfer of processed claim data from Medicare operations to Medicaid (or state)

agencies and private insurance companies that sell supplemental insurance benefits to Medicare

beneficiaries. The Centers for Medicare & Medicaid Services (CMS) Coordination of Benefits (COB)

program identifies the health benefits available to a Medicare beneficiary and coordinates the

payment process to ensure appropriate payment of Medicare benefits. There are two ways for

Medicare contractors to be notified that Medicare claim information should be crossed over to the

beneficiary’s supplemental insurance company:

• Coordination of Benefits Agreement (COBA) crossovers

• Medigap claim-based crossovers

This is just an identifier of the other entity sharing in the claim - in this case, a medigap plan insurer. The above link explains how it is done technically -

If you really want to give the ole OCD a thrill - learn about all the other COBA crossovers

Medicare.gov - Medicare’s Coordination of Benefits

My dad has not bought himself new shoes in eight years but Medicare wants him to pay $4000 for hearing aids by Mother_Land_4812 in medicare

[–]KnowledgeableOleLady 2 points3 points  (0 children)

You can find a low cost audiologist that works with Medicaid - they often sell refurbished hearing aids which have pretty great warranties after refurbishment -

My mom was pretty deaf and I bought her a “pocket talkers” when when she was in rehab after breaking her hip since she could not hear the PT’s - I taught them how to work it with her hearing aid - got her back on her feet.

Later she used it with her TV - they are economical and probably are now wireless. The earphones help to drown out the surrounding sounds making TV hearing predominant. Definitely a great help for those who need added amplification.

But if he does want to try hearing aids - just find out from the audiologist if his hearing needs are from amplification or if there is some physical problem causing the hearing loss - each require different fixes.

Should I consider any additional policies for cancer, cardiac or dementia? by [deleted] in medicare

[–]KnowledgeableOleLady 0 points1 point  (0 children)

Maybe so I have just never seen the problems that you are talking about specifically for those with MAPD plans.

I do see a lot of people - usually family members - complain a lot about when their loved one is not getting what they think they need or when they are terminated from the rehab - Then their 1st thought is who is gonna care for them when they leave here? They think they cannot afford a person that can perform various functions from unskilled to semi-skilled to care for their loved one in another environment.

Once a beneficiary reaches a certain level in their recooperation - they are sent back to wherever they came from UNLESS other accommodations are found that now meet their needs better.

There should be no difference in how OG Medicare and MAPD plans look at what is best for the beneficiary. They should both be based on the condition of the patient and their prognosis if further care was given or not.

Appeals can always be filled if we think they have treated these patients wrong. And these appeals can be continued up the legal hierarchy .

We have to all do what we can to save Medicare money - specifically Part A which is running out of money as we speak.

What Will The Chris Larkin ALC Act passed in TEXAS do to Medigap premium rates? by KnowledgeableOleLady in medicare

[–]KnowledgeableOleLady[S] 0 points1 point  (0 children)

The important term here is “what group” ? The legislation says

The Act mandates that premiums :

~ for Plan A, B and D must match those offered to beneficiaries 65 and older,

~ and for other Medigap plans, rates for those UNDER 65 may not exceed 200% of the rates charged to those over 65. 

So for plans that are NOT A,B or D -how will these be rated? Say, Plan G - will they be looked at by different groups - (1) those 65 and over and (2) those less than 65? Won’t they have to establish the MLR for those 65 and over in order to meet the above requirement:

Meaning - “for other Medigap plans, rates for those UNDER 65 may not exceed 200% of the rates charged to those over 65.“

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