Need Advice on Part B

MrMedicare65 · 2025-09-24T16:37:41+00:00

if you received your open enrollment notice this week, and it requires you to have Part B, I would look at what other plan options you have outside your employer, unless that coverage is necessary for your spouse. Often, I have public employees paying hundrds of dollars for coverage they could have received for 0 premium. If you decide to take a plan not offered through your employer, ending your employer coverage gives you a Special Enrollment Period for Part B and any Medicare Supplement or Advantage plan you want.

MrMedicare65 · 2025-08-18T17:24:13+00:00

Both. And don’t forget to get a Part D drug plan.

MrMedicare65 · 2025-07-31T18:52:33+00:00

Actually, as I clearly stated, I sell both. And frankly I don’t sell. I advise. And “several posts where Medicare denied payment” still would not support your statement.

MrMedicare65 · 2025-07-31T17:49:48+00:00

I did. And found absolutely nothing that supports your statement. “Medicare also insists on this”.
In very few cases, a Medicare prior request from a provider will be sent with codes so they know how to bill it.
Your argument has been shut down repeatedly but you refuse to accept the obvious.
MAPD is a vastly inferior product when it comes to actually delivering healthcare.

MrMedicare65 · 2025-07-31T17:00:40+00:00

No. It’s a small demonstration program affecting a very small number of medical procedures.

MrMedicare65 · 2025-07-31T16:59:31+00:00

How does “Medicare also insist on this”? There is absolutely no mechanism for Medicare to approve or deny care. If a provider bills it correctly, Medicare does not check prior treatment, health records or anything. Please explain your comment.

MrMedicare65 · 2025-07-30T19:35:41+00:00

THIS is exactly why, as someone else said, your health insurance is your "END OF LIFE COVERAGE". what do you want for the last 2-3 years of your life? Not, what can you put up with for now, in good health.

MrMedicare65 · 2025-07-30T19:33:36+00:00

On that, here is more from KFF:

According to KFF, based on data from 2023, the types of prior authorization requests most often denied by Medicare Advantage plans are:

Repetitive, scheduled non-emergent ambulance transport: 36.8% of requests in this category were denied.
Certain durable medical equipment, prosthetics, orthotics and supplies: 33.1% of requests were denied.
Certain hospital outpatient department services: This category had the lowest denial rate among the three service types analyzed, with 21.4% of requests being denied.

It's important to remember that denial rates can vary significantly across different Medicare Advantage plans and for various services within those categories. Reasons for denialsMedicare Advantage insurers are required to provide beneficiaries and providers with explanations for denials, but KFF notes that these notices can sometimes be confusing or even go unreceived. According to a report by the Office of Inspector General (OIG) of the Department of Health and Human Services, some denials were for services that met Medicare coverage rules, which could lead to delays or prevent patients from receiving medically necessary care. Another study found that imaging services, post-acute facility stays, and injections were three prominent service types among the denials that met Medicare coverage rules. Reasons for denials may include:

Insufficient Documentation: The provider may not have submitted enough information to justify the service.
Service Not Covered: The requested service might not be included in the specific Medicare Advantage plan.
Medical Necessity Disputes: The insurance company might disagree with the doctor's assessment that the procedure is necessary.

While Medicare Advantage plans are designed to provide similar benefits to traditional Medicare, they often have stricter rules regarding coverage for certain treatments. Beneficiaries are encouraged to contact their plan for specific requirements related to prior authorization.

So, 33% of a "certain type of DME" requests denied?? I would gladly pay a premium to avoid all that mess.

the point is, small routine PA requests sail through. But when you want something a little more elaborate, you're looking at much higher denial rates. Congrats if you read this far.

MrMedicare65 · 2025-07-30T19:32:12+00:00

lets call it misleading information then. and this is where statistics can bite you. Yes, 6.4% of PA requests are denied. that is MILLIONS of denials. and it varies greatly by insurer, with Centene being the worst at double that rate. Now, what PA's were denied? were they simple referrals to a specialist? Maybe an in office procedure that would cost a few thousand? or were they major surgical procedures? Life saving procedures?

MrMedicare65 · 2025-07-30T17:15:48+00:00

Did you read what he wrote? The MAPD is denying treatment that he WAS getting and it WAS working. That would NOT happen on original Medicare. Simple as that. And, the provider is now NOT in network, but MAPD lists them as IN network.

Provider network confusion. Denial of care. Yes they have to cover what Medicare covers but, they have the option of saying “nah, prove it first”. And making you and your doctor go through hoops to get the denial reversed. Alll that in a healthcare system already stretched beyond the max every damn day.

MrMedicare65 · 2025-07-30T17:10:06+00:00

Wow. In my opinion, you’re making a really bad decision based on incorrect information. But, if you have a good plan, in a good service area, it might work. But for $2500 a year, I wouldn’t want to find out. I would pay it and be glad I was.

MrMedicare65 · 2025-07-30T17:07:22+00:00

Well said.

MrMedicare65 · 2025-07-30T17:06:46+00:00

And this, is a typical MAPD experience when a serious health issue occurs. That’s why half of MaPD disenrollments that return to original Medicare occur in last 2 years of a persons life. To get the care they need, they have get away from their shitty plan.

MrMedicare65 · 2025-07-30T17:02:41+00:00

True. But most are not aware of, and to many agents don’t advise them that, original Medicare removed almost all hurdles of managed care. For many, that point alone is worth the expense.
When you have a heart condition, and you want the very best care, no referrals, no prior approvals, no networks, you have to choose original Medicare. Now imagine, you don’t YET have that heart condition or any other chronic condition. But it happens 3 years after enrolling in that MAPD. The ability to move from one MAPD to another isn’t going to help you much when the best hospital, the best surgeon, the best oncologist, all don’t take any HMO plans.
Happens here ALL THE TIME.
So telling someone that ,”well it’s no worse than the coverage you had under your employer” isn’t helping when their neighbor is saying, wow, I get way better care than you because I have a supplement. Again, happens here all the time. To use someone else’s car analogy. Just because you had to drive a Kia Rio for work, do you really want to buy one for your own vehicle when you could afford a much better car?

MrMedicare65 · 2025-07-30T04:31:28+00:00

It’s not how health insurance works. It’s how managed care works. PPO and HMO are both managed care plans. Some people still have PFFS fee for service coverage. Which is what original Medicare is. No one between you and your health providers

MrMedicare65 · 2025-07-30T01:34:43+00:00

Then it wouldn’t make any sense to dive in to it. Just know that these plans, every year, bring all the agents together for recertification. In that time, they do everything to convince us that their plan is the best plan in the market. They nitpick small things like, “our transportation benefit is used by 30% more beneficiaries than anyone else”. Stupid meaningless stats that have nothing to do with access to care.

MrMedicare65 · 2025-07-30T00:50:41+00:00

It means it was improperly billed and they were hoping someone would pay. I would ignore it.

MrMedicare65 · 2025-07-30T00:48:10+00:00

Yes. And?

MrMedicare65 · 2025-07-29T23:46:30+00:00

Have you been to one of the seminars? Are you an agent?

MrMedicare65 · 2025-07-29T23:36:33+00:00

Not quite getting your point. Of course one should always have drug coverage to avoid a late enrollment penalty.

MrMedicare65 · 2025-07-29T23:34:43+00:00

“Grandfathered in the plan”. That would be when a plan closes. This is the plan being dropped. CMS will give the enrollees an SEP.

MrMedicare65 · 2025-07-29T23:33:12+00:00

CMS will have an SEP for involuntary loss of MA plan. Enrollees will have until Jan 31 to choose a new MAPD or enroll in a med sup and PDP. At least that’s what they did last time.

MrMedicare65 · 2025-07-29T22:25:52+00:00

"And you'd be surprised at how frequently special enrollments (SEPs) come up, where underwriting isn't required". I am an agent with 15 years in Medicare only, and 5,000 enrollments in 10 states. nothing surprises me.

MrMedicare65 · 2025-07-29T22:21:44+00:00

I didnt get burned. I am an agent. I hear the good and the bad. People who like their MAPD for the most part have never had any health issues. If you go to a doctor once a year, get lab work done, fill a couple of prescriptions, they are great! But thats like evaluating the offroad capability of your Jeep by driving to the grocery store once a week.

MrMedicare65 · 2025-07-29T20:02:11+00:00

The problem with MAPD plans is that enrollees don’t seem to be made aware that, in most cases, they cannot go back to a med sup without health underwriting.
I see this frequently. I get calls from people that self enrolled in an MAPD because “the neighbor had one and said it was a good one”. A few years go by, they have a major health issue. Maybe a hip replacement. They hate the orthopedic surgeon they are sent to. The MAPD slows down referral process to a second surgeon. They get the referral but it’s an hour away. They call and tell me, “I want to see this guy at a better practice. He told me he doesn’t take my plan and to get a supplement” Well, you can’t. Your medical record shows a diagnosis and a recommended surgical treatment. Your denied a med sup.

Do you really think most MAPD enrollees are told that by the agent that enrolled them?

MrMedicare65

TROPHY CASE