ON It’s Way . . . . Hospitals Offering Their Own Medicare Advantage Plans

[GailL1]

KFF.org - 01/26/2026-Sick of Fighting Insurers, Hospitals Offer Their Own Medicare Advantage Plans

Seems like a normal course of change - rather restrictive in some cases but it seems like it should work pretty well.  Several already do this - 

I would imagine most are HMO type but there could be some PPO types too.

Wonder if beneficiaries would trust this type of MA plans any better than those from  MA insurers.

What do you think?  Anybody have one - I guess Kaiser could be one and is a good model but what about other hospitals in your area - are they going this way and would you consider them as your MAPD insurer?

Are they all HMO type plans ?  What about offering other benefits like dental, vision, hearing?  

[TRL1111]

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@cat0w wrote:

My suggestion, research the plans that are available in your area. Look at what is provided by AARP in your state. 

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AARP/UHC Advantage plans may be a good fit, but they might not.  Anyone who reads this forum should realize that there is very little that is "special" about an AARP "endorsement."

That's especially true with AARP/UHC Medigap (not Advantage) plans.  They have a huge market share, which could theoretically provide some stability, but not necessarily.  And they're unique in their somewhat deceptive declining discount and "community" rating.

But it's not all the insurer's fault.  Insurance is highly variable from state to state, and is highly individual on top of that  There is no one-size-fits-all or even one-size-fits-many solution, but people seem to think there is.  Best to remember that AARP has not shopped insurance FOR YOU, and act accordingly.

[GailL1]

@TRL1111 

Just wanted to point out that this thread has nothing to do with any AARP/UHC plan - the subject is about various Hospital chains designing and implementing their OWN Medicare Advantage Plans - 

Since many “insurers’ seem to be getting a bad rap right now due to [whatever] reasoning - some true / some not - then Hospital Chain Spedific Medicare Advantage plans seem to be somewhat of a solution.  

But is this a good thing?  Is it as complete as a MA plan from an insurer rather than a hospital?

[cat0w]

I have had this for several years through Baylor Scott and White in Texas. Plan, SCAP, is HMO-POS and Dental is PPO. All health, dental and eye coverage is through my plan. 

My suggestion, research the plans that are available in your area. Look at what is provided by AARP in your state. AARP In Your State

[GailL1]

@cat0w 

I saw that Baylor Scott and White were mentioned in the KFF article that I referenced in my OP on this subject.

But I have a question on this type of specific Hospital Designed MA plans -

How do they handle prescription drug coverage?

Most MA plans today contain their own Medicare Prescription Drug coverage formularies - so when one picks a specific MA plan they are not only accepting the plan for services, they are also accepting the prescription drug coverage within that plan.

So do you find that your specific Hospital Designed MA plan of Baylor Scott and White adequate for most all Medicare beneficiaries that want such a plan or all they constantly having to file for prescription exceptions?

Also is Baylor Scott and White an HMO type or a PPO type - if the later, are most providers on the hospital registry in-network?  Can your pcp refer you to a specialist that is outside of the plan ? Maybe even within the plan of a competing specific Hospital Designed MA plan.  

I am sure that in most cases it works great but for the perhaps somewhat unusual cases, do you not consider it too restrictive ?  IDK, I  am asking cause in one respect these sound great and could actually be the answer to affordable care and coverage.

ALSO just wanted to point out that this thread has nothing to do with any AARP/UHC plan - the subject is about various Hospital chains designing and implementing their OWN Medicare Advantage Plans - 

[cat0w]

@GailL1  

BS&W, my plan that I have is HMO-POS. They have their own Pharmacies. Cost for the prescriptions and or copays depend on what plan a person selects.

[GailL1]

@cat0w 

But this is a Medicare Advantage plan (the Baylor Scott and White) plan that you have - so normally the drug plan is within the Medicare Advantage plan - not a free standing Part D plan that is used when one is on original Medicare.  

So back to the same question -

So do you find that your specific Hospital Designed MA plan of Baylor Scott and White adequate for most all Medicare beneficiaries that want such a plan or all they constantly having to file for prescription exceptions?

[cat0w]

@GailL1 My plan is under their Advantage plans. I pay for what my plan provides. The Pharmacy I use is a BS&W Pharmacy and they send me messages when I have a prescription that is in need of being refilled or needs a new prescription so they can notify the correct doctor and get a new refill written.

For part B and C, I pay $457.90 a month.

[GailL1]

@cat0w 

What I meant by my question about the meds - is if the formulary is adequate for your needs and the needs of all those with the plan WITHOUT having to get your doc to file a bunch of exceptions for meds that are not on formulary?

By your response to @TRL1111 - it sounds like this is a “retiree” Medicare Advantage plan that was linked to your past employment - or maybe a union.   Those type of MA plans are known to be different with better benefits and less hassle sometimes.  But they do come with a higher premiums.

I think the Hospital type MA plans sound good to me - even the regular type because it seems that the in network should be very adequate to those in the area , the doctors have a closer relationship to the plan insurer (the hospital)  and thus tend to know what meds they can order and what procedures can be done without all the prior approvals.  So service-wise they sound like a +.  Like the VA system - doctors in the VA system know what they can prescribe and do - cause they work for the VA.

But I wonder if they are competitive in pricing?  If yours is a “retiree” plan, this may be hard to measure compared to a regular MA plan.  But I still think the benefits of the hospital plan may beat regular MA plans - just because of the close knit of the plam/

[cat0w]

@GailL1  @TRL1111 

The plan I had when I first retired was the retiree plan through the city. After a couple of years of retirement, I attended a meeting provided by Scott and White providing information on their advantage plans. That is when I found out I could save money by moving to their plan. 

I have never looked into other plans. I have been retired for eighteen years and have been very happy with BS&Ws advantage plan. For all my services most of my spending has been for copays on some prescriptions.

For the dental plan I have my cleaning and checkup twice a year. The only charges are when I need additional work done and the copay has been very reasonable with the insurance covering the rest.

I have my eye exam once a year and have no copay for it. I have had cataract surgery on both eyes at no cost to me. After the surgery I no longer need glasses so there is no cost/copay for those.

[TRL1111]

I'm glad you're happy with your plan, but it does come at a pretty high cost.  Maybe lower than your former employer's plan, but it's the highest-cost Advantage plan available to anyone in your area.  With that you get lower copays, and with pretty much any Advantage plan you get extras like dental and vision coverage. 

But as mentioned in the original article, there are trade-offs present in Advantage plans don't exist in Original Medicare.  You apparently haven't come up against them, which is great.  But they are there, and people choosing a Medicare plan really do need to understand what those trade-offs are.  Original Medicare and Medicare Advantage plans are two very different animals.

There are SHIP volunteers in all states who can explain the differences, and they don't sell any products.  There are independent brokers who represent more than one company (but not all companies--something to be aware of); they're supposed to keep their client's interest in the forefront of their mind, but the fact is that Advantage plans pay a higher commission than Medigap supplements that are purchased to cover out-of-pocket expenses under Original Medicare.

Medicare is exceedingly complicated, and getting advice from one company, especially a company that sells only Advantage plans, is probably not the optimal way to find out about options other than Advantage plans.

[TRL1111]

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@cat0w wrote:

For part B and C, I pay $457.90 a month.

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Gracious.  You're paying $255 a month for your Advantage plan.  One of the major attractions of Advantage plans is their low premium, often $0.  

What led you to select your Advantage plan when for the same or less money, you could get a Medigap supplement and avoid the Advantage pitfalls of networks and prior authorization requirements?  

[GailL1]

@TRL1111 

Sounds like it may be a “retiree or union” type MA plan - which are very different from regular type MAPD plans and yes, they are more costly but also have added benefit - or better benefits.

[TRL1111]

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@GailL1 wrote:

Sounds like it may be a “retiree or union” type MA plan - which are very different from regular type MAPD plans and yes, they are more costly but also have added benefit - or better benefits.

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No, the $255 Advantage plan cat0w has is a "regular" Advantage plan, available to the public.  You can see it among the options on the BSW website, and it's also on the Medicare.gov plan finder (where it's the most expensive among the 27 plans available in zip code 76541).

mybswmedicare.com/medicare-plans/central-texas/?county=Bell&state=TX 

[GailL1]

@TRL1111 

Thank you for the knowledge about this plan and the link - I am not familiar with this or most any MA plan -

It sounds great - all of them - so the beneficiary just gets to pick the one that suits them best and isn’t that what is of prime importance anyway - and then if they need to. for whatever reason, they can pick any of the others without causing major changes to their medical team - the docs, the formulary, the hospital.

I give it a 👍🏆

[TRL1111]

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@GailL1 wrote:

I give it a 👍🏆

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But surely with the caveat that it's still an Advantage plan.  

From the article you linked to:

But Tsai warns seniors that hospital-owned Medicare Advantage plans operate under the same rules as those run by commercial health insurance companies. He said patients should consider whether the extra benefits of Advantage plans "are worth the trade-off of potentially narrow provider networks and more utilization management than they would get from traditional Medicare."

I noticed that cat0w said, I'm not sure about what you mean when you say, "avoid the Advantage pitfalls of networks and prior authorization requirements?".

Maybe he just didn't understand the terminology I used, but I think it's more likely that he's like a lot of people on Advantage plans who don't realize there are the disadvantages that Tsai described, and Tsai didn't even mention cancer being covered at 20% coinsurance, which will blow past any out-of-pocket maximum with a quickness.

And in cat0w's case, he's not saving a ton of money by having an Advantage plan, which is why I'm wondering why he made the choice he did.  People who pay $0 for an Advantage plan often do save money (if they don't hit their out-of-pocket max) because they're not having to shell out a premium for a Medigap plan.  But paying more for an Advantage plan than what a Medigap supplement would cost is definitely not the norm.

[GailL1]

@TRL1111 

The plan that cat has 

Chemotherapy Drugs

0%-20% coinsurance

but it also has a MAXIMUM out of pocket of $ 4800 - a beneficiary does not just keep paying and paying on a MA plan, that’s the best things about it - it has a maximum out of pocket. 

One chemo might meet this amount - IDK what their pricing is for chemo drugs - some are much more reasonable in price than others and you must get them in order - similar to step therapy but some are based on the stage or whether it is recurrent.

The plan details:  HMO-POS Premium Rx- BTW

[GailL1]

@TRL1111 

OK - better a large hospital MA plan than a regular MA with a private insurer.  I do see the benefits but of course, as always it is a personal choice based on needs and one’s pocketbook.

[cat0w]

@TRL1111 

I have been with Scott and White, now Baylor Scott and White for a long time. When I retired and compared what I was paying to stay on the city's plan, Scott and White vs the S&W Senior Care Advantage plan it was a lot lower, so I changed.

All the benefits I get are worth the monthly cost.

I'm not sure about what you mean when you say, "avoid the Advantage pitfalls of networks and prior authorization requirements?".

I don't have any problems. When needed, I get online go to my BS&W Chart and talk with my doctor's, place refills for my medicine, look at future appointments or schedule appointments when I need to. It's easy to take care of things online.  

[TRL1111]

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@cat0w wrote:

I have been with Scott and White, now Baylor Scott and White for a long time. When I retired and compared what I was paying to stay on the city's plan, Scott and White vs the S&W Senior Care Advantage plan it was a lot lower, so I changed.

When you made that decision, did you also consider, instead of getting an Advantage plan or staying on your city's plan, keeping Original Medicare and getting a Medigap supplement?  Did anyone help guide you in your decision?

[TRL1111]

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@GailL1 wrote:

I saw that Baylor Scott and White were mentioned in the KFF article that I referenced in my OP on this subject.

FWIW, Baylor Scott and White has offered ACA plans on the exchange for several years.

What's interesting is that cat0w is in a suburb of Austin that spans two counties:  Travis and Williamson.  (Or close enough that they ice skate there.) 

All but a little section of Austin is in Travis County.  Williamson County includes a sliver of Austin along with the town/suburbs north of Austin--in the direction of Temple, which is where Scott & White Hospital was established over a century ago.  Scott & White merged with Baylor Healthcare System several years ago; Baylor is located in Waco, which is a little farther up the road from Temple.  It's Austin, and then Temple (Scott & White) 60 miles north of Austin, and then Waco (Baylor) 40 miles north of Temple.  So including only the northernmost part of the Austin area makes sense, I suppose.

But BSW's ACA plans are available to residents of both Williamson County and Travis County.  

So BSW offers ACA plans in both Williamson County and Travis County, but offers Advantage plans only in Williamson County, and not Travis County.  I would think that healthcare plans offered by a hospital would be more than typically focused on a given geographical area, and I wouldn't think the networks in an ACA plan and Advantage plan offered by the same hospital would be so significantly different, but it's insurance we're talking about, so who knows.

Actually, I just checked and BSW offers 10 ACA plans to residents of Travis and Williamson Counties--they're they same plans, and all are HMOs.  So they run HMOs in Travis County for ACA plans but don't offer anything in Travis County on the Advantage side.  About five or ten  years ago I noticed that BSW offered PPO ACA plans in Austin, which was exciting because Blue Cross had quit offering any PPO plans in Texas, but it turned out that BSW's PPO plans had access only to a limited local network.  And now they don't even offer that--it's all HMOs with ACA plans.  HMOs that are in Travis County, while Advantage plans with the same company don't offer any plans in Travis County.

Weird.

[GailL1]

@TRL1111 

I am sure that some geographical consideration are included BUT what is MORE important may be the DEMOGRAPHICS and perhaps the law (state or federal) when it comes to the ACA plans.  

The demographic considerations between beneficiaries on Medicare and those seeking coverage for an ACA plan are very different - IF NOT, we wouldn’t have Medicare for the aged and the disabled - we would just all be on private individual plans and sharing the risk - I bet those younger folk would hate that - imagine them paying premiums that covered the people with lots of health claims - the disabled and the elderly and sometimes the “really” elderly, like me.  

EDITED to add:  Are you in Texas?