United Healthcare

[JimG454455]

Just curious when you guys are going to address and speak to this issue. My guess is many of your members are negatively affected by Advantage plans and more specifically the ones AARP endorses - United healthcare. I am currently living the nightmare of dealing with UHC. Their denial, delay and defend strategies have all been applied to my care which has had a significant negative impact to my care and recovery.  I joined AARP because of your advocacies for seniors. What is currently in the news about the horrors of our healthcare system that are affecting seniors most needs to be talked about.

The fact that AARP has been mostly silent on these matters AND endorses the worst offender is a disservice to your members. You lend your respected name, which I know your are paid handsomely for,  at the peril of your members.

The exposure and pressure to reform their cruel practices needs more coverage, not just a silent endorsement.

Please step up and help us on this issue.

Regards

Jim Groll

[Tonster521]

@TRL1111, I am sure you know that by the time one attains age 65, the vast majority of folks have health issues. Some issues are more serious than others. Some folks acknowledge the issues by obtaining a medical opinion and treatment. Some do not. The CMS has the job of distributing tax dollars via protocols to the various approaches for medical care: Traditional medicare and MA (i.e., HMO, PPO,POS, etc.) so that it is as equitable as it can be. There are various numbers that appear from article to article that indicate the costs for the various approaches. You can pick any cost from the articles and work back to arrive at a cost per person. However, you will find that the amounts vary from author to author. So, I suggest to use amounts that SS Actuary uses currently for Part B which is approximately $740/month or $8,880/year. Most of us pay $185 or 25% of that cost and the Government pays the other $555 of that cost. Is it an exact science? No, in any given year actual costs may be lower, the same, or greater based on morbidity that varies. More important, how many folks who were once average are now above average health risk or even catastrophic? The article that you linked from the WSJ indicates that MA Plans receive a base of $3,735 per person which is less than 50% of the Part B average of $8,880. So, the CMS created an approach using Risk Assessment Evaluations (RAE) to be equitable. Otherwise, CMS would not have any bidders to accept such health care risk wherein you are guaranteed to fail. So, is the CMS approach the correct methodology? 

I thought it may be a good idea to provide statistics for a medical issue such as hypertension so the readers have a better understanding of medical issues in the over age 65 population.  https://www.cdc.gov/high-blood-pressure/data-research/facts-stats/index.html#:~:text=In%202023%2C%20... The statistics indicate indicate almost 50% of folks over age 65 have hypertension. You can drill further and find other articles that indicate the percentage that are not treated or do not follow treatment protocols. The article that you linked discusses cataracts including diabetic cataracts. So, here are more statistics on diabetes including the over age 65 population. https://www.cdc.gov/diabetes/php/data-research/index.html#:~:text=Prevalence%20of%20both%20diagnosed...). As you may not know, diabetes is a terrible diagnosis and a continuing day to day challenge for the folks with diabetes. I am adding another link that provides pertinent information about diabetes and cataracts. https://pmc.ncbi.nlm.nih.gov/articles/PMC6422859/  The questions are: should MA Plans receive more than the $3,735 base; and, if so, how much more? 

The WSJ article that you linked has an agenda. I did not read about any solutions to the RAE approach. I did not read if the WSJ determined the protocol that MA Plans use and CMS accepts is an issue or is it incorrect/inaccurate RAE by the RN, APRN, or Physician or is it a computer program created to increase morbidity or something else such as a third party vendor simply making inept decisions. As you may not know, medicine/healthcare is not an exact science. Medical practitioners provide opinions. Sometimes they are right and sometimes they are not right. If you have ever witnessed medical litigation, you will find physicians testify a person has a severe loss or totally disabled and another physician testify that same person has minimal issues and can return to work. The SSA deals with thousands of cases like the above. 

As I mentioned in a previous reply, the CMS should review the cases that the WSJ identified. CMS should determine if the appropriate protocols were used. If not, were there mistakes, incorrect assessments, or outright fraud. Depending on the results, appropriate action should be taken by the CMS.

[TRL1111]

I've never said I have a problem with Advantage plans being paid more for members who have health conditions that result in Advantage plans having to pay more money on their behalf.

What I do have a problem with, and have said so over and over, is insurance companies being allowed to decide what conditions their members have, regardless of what the member's own doctor says, especially when the insurance company will make more money for each condition they diagnose.  Sure, it's possible someone could have a condition they haven't sought medical treatment for, and therefore have no doctor diagnosis, but realistically, how many of these would be revealed in a home health visit?  And even if they are revealed in a home health visit, if the person goes to a doctor about it, the doctor will enter the diagnosis, which will trigger the extra money for the Advantage plan.  Sure seems like a route that's less open to fraud than someone who's not a member's doctor just entering a few keystrokes on a computer and...viola!  Extra money for the insurance company!

And not discussed so far is that it's not just the insurance companies making extra money that's problematic.  The member may not even know the insurance company has given them a particular diagnosis, and might find out only when they decide to switch to traditional Medicare and buy a supplement, and they fail underwriting because of the insurance company's diagnosis.  

[Tonster521]

@TRL1111, I forgot to add the 2024 NAIC Report https://content.naic.org/sites/default/files/2024-annual-health-industry-commentary.pdf I got timed out and forgot to add the Report after the reload. The data on the healthcare industry should be helpful. The industry is not a big money maker like I-Phones. What is amazing to me is that folks continue to pay about 5 times the cost of production of an I-Phone. Yet, for Medicare Part B, we pay 1/4 times or 25% of the cost. The Federal Government picks up the other 75%.

[Tonster521]

@TRL1111, Once again, it appears to me that you are suggesting that the RAE procedure established by the CMS is subject to fraud. And, it can be, but it is due to people such as Physicians, RNs, APRNs, maybe Physician Assistants, others in the Medical field with titles I am not aware of. A human has to make a diagnosis/analysis based on an examination regardless if in an office in a Medical Building or clinic, rented office in a Hospital campus, an inpatient room during a Hospital confinement, a Community Health Center, or a person's home. The point is that the physical location is not critical. Although I will say that today it is easier to obtain labs, X Rays, EKGs, etc. if your Physician is located in a Medical Building that has such services available. Back in the day, you had to drive to another location and wait for results which sometimes never made it to your Physician, Physician Assistant, APRN, etc. So, record keeping has improved with one stop medical care. However, when folks have had multiple treatments from different medical practitioners, you hope that the different medical record systems are compatible, data is entered accurately, the ICD codes are correct, and the staff is conscientious identifying folks with common last names such as Smith, Johnson, Jones,etc. Many readers may not understand the additional detail that is needed just to ensure you have the correct person. When I was in the pension business (both monthly pension and retiree health insurance (self funded)), of approx.114,000 pensioners and approx. 90,000 with health benefits there were over 400 folks with both the same first and last names. We issued additional ID numbers. Because of being self funded (that means we paid health care benefits from profits, if any), each year we audited select hospital claims that exceeded dollar amounts, frequency, and every catastrophic (duration) episodes. We challenged charges that did not have written orders or were extremely high cost (the proverbial $10.00 aspirin, the $1,000 Xray, etc.. Back then, there were many hospitals using the "cook book" approach to billing and did not place much emphasis on details. The audits did not challenge medical needs or necessity, but focused on the inefficient billing activities. The results were that organizations auditing hospitals saved money. And now, each item that you receive at a hospital is scanned by the nurses unless they forget to do so. Negotiated payments including discounts, DRGs, etc. have somewhat reduced the need for detailed coordination between Medical (all departments) and Billing. The point that I am providing is that the WSJ took a shot at the details of the RAE process (which I continue to repeat) was established by the CMS. So, more audits by CMS are good and will "weed out" questionable cases not by challenging medical conditions which would need an independent medical exam, but by medical record review. In other words, reviewing the details in the medical records. I am sure that CMS auditors will find cases that will result in some savings, but I cannot imagine several millions cases out of 30 million folks enrolled in MA. It would be interesting to find out the amounts paid to HMOs which may or may not use the RAE process. 

Anyway, if folks in the medical field are "cooking the books/records" in order to convey a person with greater medical needs, I would think CMS would have grounds to challenge such person's medical license/registration. If the MA insurers are using some type of computer program that is designed to increase morbidity based on just data from medical records, that program should have surfaced by now inasmuch as MA has been around for 20 years. If there were concerns about using such programs for a greater allocation, there may be fraudulent activities cases that the CMS may pursue. 

I thought it would be helpful if I added the NAIC 2024 Annual Health Industry Report which will inform readers of the ever increasing cost of Health Care. You can scroll through the Report which gets sorted by Medicare and even MediGap. The Medical Loss Ratios are in the high 80 percent category. This means almost 90% of the premiums are paid in health care benefits. You do not want to be in the health care business. 

I have some experience with folks with diabetes mostly from an employer/employee/retiree perspective; and, I mentioned in a previous reply, it is a challenging illness. I found a link to statistics that put a light on the magnitude of diabetes and prediabetes.  https://www.cdc.gov/diabetes/php/data-research/index.html#:~:text=Prevalence%20of%20both%20diagnosed...). I am surprised that the good doctor from Arizona that the WSJ used did not know that almost 50% of folks over age 65 are prediabetic and may become diabetic over time. Moreover, that average may be applicable to his patients as well. Maybe he was only addressing the complications for diabetics after cataract surgery which may take years to occur. This is why we always should obtain a second opinion if time permits. Enough said. With regard to the folks with no knowledge of their health issues (diagnosis), how many actually review their medical records/files especially if they have seen multiple medical practitioners over the years? Or, do they discuss there health with their Physicians? Do they ask questions?

[TRL1111]

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@Tonster521 wrote:

 I am surprised that the good doctor from Arizona that the WSJ used did not know that almost 50% of folks over age 65 are prediabetic and may become diabetic over time. 

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Who cares?  In fact, who cares about any of this? 

The issue is insurance companies diagnosing members with conditions for which the insurance company gets paid more money, without any involvement from any of the members' actual doctors.  The insurance companies themselves are even offering to stop it as long they all have to stop it.  

[Tonster521]

@TRL1111, I believe the patient is the most important person that should care. As you know, there are folks that do not accept medical advice (i.e., stop smoking, eat healthy, reduce weight, more exercise, drink in moderation, etc.). So, those folks don't care. Then there are folks that do not see a physician unless there is an acute episode. So, they do not care until learning of a medical problem or experiencing a physical limitation. I believe the majority of folks care about their health and will seek a new physician especially, if a physician fails to diagnose a medical/health concern or misdiagnoses a medical/health concern. This happens every day. With regard to the diabetic diagnosis, some physicians use an A1C of 7 or more to indicate diabetes. Others use 6.5 and may consider results just below 6.5 as a warning to start changing what you eat, drink, reduce or eliminate sugar, loose weight, exercise, etc. Folks receiving an early warning may be able to avoid the various medications, daily glucose monitoring, insulin, as well as possible vision and kidney complications. I am sure the good doctor from Arizona received the patient's medical records as well as the primary physician's examination results regarding the patient health status for cataract surgery. Additionally, follow up is generally done by an optometrist if the practice is large. Problems are referred back to the ophthalmologist who performed the surgery. If there are no problems, there is no need to see the such surgeon. Maybe this is the reason why the surgeon in the the WSJ article only sees a few cases.   

It is clear that you keep alleging that the insurance company is diagnosing MA members without physician involvement. It appears to me that you are basing your allegations on the WSJ article which, in my opinion, does not describe the CMS procedures at all. Unless you worked with Traditional Medicare and Medicare Advantage, you will not be aware of the details required by the CMS including entering data into the CMS system to affect MA payments. I suggest you reread GaiL1's posts/replies on July 27th and 28th and research the concepts you do not understand. If you take the time to study the issues, it should be abundantly clear that the funding MA is a CMS program/procedure and not the  insurance companies program/procedure. To help you study, I am providing a link to Medicare Managed care manual. https://www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r118mcm.pdf The beginning informs the reader that in 2014, the Manual was revised to include ICD-10 (10th Edition with approx. 70,000 codes) which replaced ICD-9 (9th Edition with approx. 50,000 codes). When I left health care funding, ICD-9 was the governing coding program. The point is that the CMS quantifies an enormous amount of diagnoses with codes. It should be abundantly clear that people get sick when they age. It gets more complicated with various CMS Models as GaiL1 has indicated. The first and probably the most used is the CMS-HCC which uses Hierarchical Condition Categories. Once again, I suggest you scroll through the link I provided and carefully read Chapter 7 - Risk Adjustment and Chapter 8 Payments to Medicare Advantage Organizations. It should be noted that the CMS does require a "face to face" approach with a physician or a physician extended (i.e., Physician Assistant, APRN, RN, and many others noted in the Table of Physician Extended) and supporting medical records. My post/reply on July 26th informed the readers of the "face to face"requirement which was common knowledge from about 20 years ago. The MMA of 2003 provided a three year transition so 100% of the procedures were in place by 2007 including Risk Adjustment Evaluations (RAE). By providing a procedure for prospective risk adjusted payments, the CMS developed stronger incentives for MA Plans to participate in the Medicare program. Since 2007, MA has grown from about 8 million to 33 million (2024 enrollment) which is about 54% of all eligible for Medicare. It is projected to continue to grow to about 65%. Based on the current CMS procedures, MA Plans will continue to receive greater Medicare payments by design inasmuch as MA Plans have an incentive to identify as many health conditions as possible. Is that a bad design? From a health perspective, this may be a better approach since addressing health issues before they become chronic or even catastrophic has value. There is an implied assumption that folks with Traditional Medicare (TM) and MA have similar healthcare spending. We now know that is not the case since MA members have, generally, been healthier. This is referred to as Favorable Selection in funding healthcare risk Moreover, as we read in the Forum, some MA members transfer back to TM once they begin a chronic and/or catastrophic episode of illness/morbidity. Many States have passed legislation that encourages such transfers (adverse risk) by allowing folks to buy Medigap policies upon certain events such as birthdays, etc. even though the previous MA Plan has been, in effect, paid in advance for covering that risk. TM pays providers based on the number of services they provide (fee for service approach), not the number of diagnoses which is how MA is, in effect, paid.

The suggestion from Humana that prospective risk adjusted payments should be revised or eliminated does not solve the MA funding issue. The WSJ article did not indicate what might be a replacement for RAE; namely, retrospective reinsurance. In other words, CMS provides reinsurance for such chronic and catastrophic cases whether by self funding or transferring such risk to an insurance company for a premium. I have not seen any numbers on this approach and it may be a greater cost than the RAE approach. 

Lastly, you continue to state that the diagnoses are not in the MA member's medical records. If this is the case, there is a bigger problem which borders on fraud. It can affect Physicians and Physicians Extended who actually do the required face to face visit with the MA member. The WSJ article indicates that MA members do not know the medical info in their medical record. What else is new? How many folks review their medical records which are available to everyone via electronic review. Of course, you need a computer, smartphone, etc. to access your medical record along with a user name and password. Additionally, you need a printer if you want a hard copy. Otherwise, some medical offices will charge a fee for not only the time to obtain a medical record but also a copying fee. CMS audits should uncover whether the MA Plans keep two separate medical records with separate medical info. From an operational perspective, that would be a great cost to maintain and what value would that have not informing a patient/member of a health issue?

[TRL1111]

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@Tonster521 wrote:

Lastly, you continue to state that the diagnoses are not in the MA member's medical records. If this is the case, there is a bigger problem which borders on fraud.

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Yeah, fraud by the insurance companies when they diagnose conditions that are anatomically impossible.  The reason it's not in the member's medical record is that it doesn't exist.

[LisaS961881]

   TRL,

      I appreciate what you wrote in this post.  Full Disclosure - I diligently read everything that you, Gail and Tonster write on this subject - thanks!

If I just might add, there are public feedback/reviews of these  “home health visits” on the BBB website, as well as sites such as TrustPilot - you just have to search for them using the name of the subcontractor that employs the individuals who perform these visits.  As they were eleven months ago when I first searched for them, they are shocking descriptions of unprofessionalism.  Despite the recent news that the veil has been lifted and this issue is now being examined, as of this past week’s reviews, these companies have neither altered their aggressive “boiler room” tactics, nor, by and large, informed patients of the results of these visits.  (My interpretation, and I might be wrong, is that these subcontractors don’t seem to “running scared” or modifying their tactics/actions in any manner.  This concerns me.)

Again, thanks for the info.  Now that I’m 65, I need to keep myself informed about all of this.

~Lisa 🙋

[TRL1111]

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@LisaS961881 wrote:

(My interpretation, and I might be wrong, is that these subcontractors don’t seem to “running scared” or modifying their tactics/actions in any manner.  This concerns me.)

And don't forget that even Humana has said it's willing to back eliminating payments based on insurer-driven diagnoses based on home visits and medical chart reviews, unless the diagnosis is confirmed.  Of course they're not willing to stop the practice on their own, and instead want them and their competitors to be forced to do it by law, but that's to be expected of a publicly traded company because their first duty is to the shareholders.  

msn.com/en-us/money/companies/humana-to-back-curbs-to-medicare-advantage-billing-practices/ar-AA1G8n... 

If an insurance company is queasy enough about one of its income streams to be discussing it in public, that should tell you something.

[SusanM664094]

Humana is right there with UHC. This happened last year in my area, leaving many of us to scramble to switch docs mid year. We've been sandwiched in the battle of carrier vs provider. And not just my region. So far this year, my coverage is stable with a local managed care provider. Fingers crossed. 

[LisaS961881]

  TRL,

Thank you for sharing this.  

A little over a month ago, I do remember thinking, “OK, NOW we are getting somewhere” when I read that the DOJ had begun conducting targeted interviews.

 When I read “nurses told the Journal they were trained to record sometimes obscure or questionable diagnoses” in the link that you provided, I actually muttered, “Gotcha!” 😊

I realize that I need to be more patient, and that this reform is going to be a slow, grinding process.  I do find some comfort in knowing that we’ve finally left  Oz in that we are no longer being exhorted to “Pay no attention to that man behind the curtain!”.

Thanks,

     ~Lisa 🙋🌈

[CBtoo]

The trouble is "fake" diagnoses is also the problem of the electronic medical records systems. It takes nearly an act of god to get wrong stuff out of there and have it stay out of there. With EPIC (mychart) the person who put it in there has to take it out, or at least someone in that practice and not another practice using EPIC. I have been beating my head against the wall trying to get wrong diagnoses out of there, let alone get some listed as resolved. I get it fixed in one system and it doesn't usually cross over unless the person who put it in there takes it out. Um and just how can that happen when people retire, move...?

So since this happens (using the cataract example) with advantage plans, original medicare, employer insurance, ACA insurance, medicaid, etc, I'd suspect a good chunk of this is laziness on the part of someone to fix the mess in someone's medical records rather than deliberately leaving it in there. I feel like I am playing wack a mole trying to get my records fixed in "care everywhere" (a section patients can't see but various physicians have allowed me to photograph) along with with individual doctors (who often just copy/paste what they have written before without updating it)

[LisaS961881]

  Gail,

     I did take the time to read the two links that you provided.  Thank you.

     I feel a bit better that you are asking the same question that I’ve been asking myself for the past eight months.  (And, from what you’ve written, you’ve been “at this” a lot longer than I have, and have a depth of knowledge, whereas naive me was just shaking my head and wondering why they weren’t fixing what they knew needed to be fixed all those years ago.)

I do see that they aren’t just talking the talk, but are allocating resources - tech, workforce, auditing -  but again, like you wrote, they could have done that years ago, and chose not to do so.  I do hope that they aren’t just putting lipstick on a pig.

Maybe you are right - would it be a seismic adjustment for Traditional Medicare to absorb the top 3 MA Insurers’ patients if these insurers pulled out of the program?  So CMS is treading lightly?  

I am just trying to remain positive about all this.  I worry about how all of this impacts some of the seniors that I meet when I volunteer at the food pantry - many who just don’t have the strategies to navigate through this morass of choosing a Medicare program that is right for them.  I know that, until I turned 65, my employer chose what Medical Insurance/Prescription Plan I received - I never even had to think twice about it.   Then, POW! 65 and a bazillion choices! 🤔

To veer off topic and to provide an example of just how cumbersome even non-Medicare Programs are for Seniors, last week I showed two Seniors in their mid- 80s how to go online and apply for the new “Stay New Jersey” Initiative.  New Jersey now has three Property Tax Relief Initiatives:

https://www.nj.gov/treasury/taxation/staynj/
There’s the Anchor Rebate ($1,500), the Senior Freeze (Seniors within a certain income will receive a refund check for any Municipal tax increase paid), and the NEW “Stay New Jersey”, which will halve (up to $6,500) Municipal property taxes.  (Well, what is left after the Anchor and Freeze are sliced off the top. 😇)

This was a cumbersome process for them.  First, I had them register for ID.me, which was required (and rightly so due to past fraud) on the state’s application site.  (Neither one had ever even attended a Zoom meeting, so this was a novel experience for them. ). After this, I gave them a well deserved break before having them gather tax paperwork, then apply for these three programs online.  They both did great navigating the application, which was very user-friendly, and  I was just so thankful that they’ll be getting this Property Tax relief.  They had just fallen through the cracks and had no idea that they were entitled.  (Just one more hoop for Seniors to jump through.)

Gail, I wish I were certain that CMS is taking steps that will actually improve the current situation.  As I wrote in my post, I’m trying to remain optimistic, but I have lingering doubts.

Thanks for your post.

  ~ Lisa 🛶 ⚡️ ⛈️. (..scurrying indoors due to lightning! )

[CBtoo]

IF the top 3 MA insurers pulled out what would likely happen is the sickest would move to original medicare (since there is guaranteed issue and no need to pass medical underwriting if your plan is closed) and the rest would move to another advantage plan. That would drive up the cost of supplements since a higher percentage of people in them would be sicker. 

[GailL1]

@CBtoo 

Any of them could go to traditional Medicare if their MA plan closed down in their area.   But Only if they could afford a Medigap plan.  

Otherwise, they would just pick another MA plan.

But yes, I agree that it would drive up the cost of Medigap plans especially if they were sicker.  

[Tonster521]

@LisaS961881, I replied to GaiL1 with an analysis of the MA funding issue. I do not know how to copy you with the reply. So, maybe you can take a look at my reply to GaiL1 which is for all readers to read and review. Additionally, I found a fact sheet regarding the MA Payment Structure. https://www.bettermedicarealliance.org/wp-content/uploads/2020/03/BMA_OnePager_Payment_Structure_201...  Of course, there are more complex terms to developing adequate funding for MA Plans. However, obtaining a copy of the CMS manual and regulations that govern the process is a reading challenge that very few will undertake. I think the Fact Sheet will help understand the process in 2 pages, 

[LisaS961881]

   Tonster,

       Thanks so very much for providing this link!  I’ve just finished reading it while sipping my morning coffee. ☕️      

        Maybe I’m just being a “Monday Morning Quarterback”, but, after reading these two pages, I have a better understanding of how and why those upcoding shenanigans might have readily occurred.   I also remember gaining a better appreciation of this process when reading Senator Warren’s  conversation with Dr, Oz that was on her website months ago.  I appreciate that you took the time to share this.

     I’m trying to move forward and not dwell on why CMS didn’t tweak this system when the DOJ requested that they review it.  I guess I’m a bit of a Pollyanna in that I am trusting CMS to correct this now.  So much money has already been misspent.

Thank you,

       ~ Lisa 💰🌈☕️🙏

[LisaS961881]

Susan,

   I agree.  Now that this complex issue continues to be in the spotlight, I am more optimistic than I had been just a few months ago.

  ~ Lisa

[CBtoo]

PS Gail - I think the other issue that would help is if medicare didn't give advantage plan issuers more money than they give to original medicare for people. That would help keep medicare solvent. 

[CBtoo]

Think twice about getting care? So I choose not to get chemo and die? (I've had 3 major cancers close together). I choose to puke 24/7 because I can't afford full price for anti nausea drugs? I just deal with having a UTI until it turns into a kidney infection and have to go the ER at a place that won't turn you away if you can't pay your copay up front? Around here there are 4 "systems" that 90% or so of the doctors are part of (as employees, At 3 of the 4 if your bill goes to collection care is cut off and you are sued. I already go without some of my meds.

I don't think providers can modify some of their prices that much simply because of the costs of things they have no control over. And hospitals are paid more for the same services that doctor offices are paid for so maybe, for starters they need to even that out. 

The people who have the most problems, even with insurance, paying their medical bills are those who are above the income to get medicaid help on premiums and drugs through about 400% oft he poverty line for their family size. Those are the people who will die younger because they can't afford care. I am in that group. I saved a fair bit for retirement and then what happened was the cancers. This state did not expand medicaid so I had to spend all my retirement money to pay for that. Now I am broke. I guess that is my fault and I don't deserve medical care if I can't afford it?

I have no clue what "other arrangements" I can make to pay for my care. Dumpster drive? I am already working. Either you have enough money or you don't. People in other civilized first world nations have universal health care. Yes they have some problems too and some countries the system is better than in other countries ( worked and lived in 6 countries). At least people can get care and don't go bankrupt due to the cost of health care. 

[GailL1]

@CBtoo 

So what kind of healthcare coverage do you have now?  

[CBtoo]

Traditional medicare and G+ (no plain G when I first was eligible or I would have signed up for that) AARP/UHC. No way I'd get an advantage plan. I want care in any state where the facility accepts medicare. And because health care is so awful in this state good thing I could go to MD Anderson Cancer Center (which doesn't accept most advantage plans, even in state ones, nor does they Mayo just for starters) who gave me a chemo that locally no one had even heard about. I just miss the cutoff for medicaid assistance with premiums now. And due to this state not expanding medicaid pre age 65 with me and having to spend all my retirement on health care since I then didn't make enough for ACA care that pretty much wiped me out financially.

[CBtoo]

As much as I'd like to get our state to change I doubt that will ever happen. We are last in the nation for health care, didn't expand medicaid, and our university medical center is joint commission D rated and the people who run this state don't think that the poorer people in the state deserve anything because, acording to them, the poorer people brought their problems on themselves (adults not working at least half time can't get snap, there is no medicaid for adults under 65 even if they are working, etc.). Unfortunately the state insurance commission has their own issues as well. The voters likely won't vote for a change as, I believe it was last year, voters no longer have any way to get anything on the ballot to be voted on. Our state government outlawed that as a way for voters to make changes. Too bad global warming won't bury the entire state under the Gulf of Mexico, only just part of it and that won't include the capital.

I have no clue what you are talking about with respect to how gap plans are rated. I know insurance companies are rated for customer service, paying bills in a timely manner, denials,  etc, but I didn't know each and every gap plan has a rating. I don't know how this works for the disabled under 65 either other than they eventually get medicare. That wasn't part of anything I was talking about anyway though. 

And I never said anything about getting rid of either supplements or advantage plans so not sure why you are addressing that in a reply to me either. Personally I'd never ever get an advantage plan due to network limitations, changing networks, the problems with denials, the max out of pocket that you get hit with if you actually have medical issues where you actually need to use your plan (and then likely will fail medical underwriting where you'd save money with original medicare and a supplement), etc. I'd rather have the freedom to go to any practice in any state that accepts medicare. And if you look at places like the Mayo and MD Anderson Cancer Center - good luck to people with nearly all advantage plans if you want to go to either or them (or a number of other top places). 

As someone who lost her job over 2 cancers in one year and had to buy health insurance on the open market (I didn't make enough for ACA care and this state didn't expand medicaid) I am well aware of just how expensive health insurance is for crappy coverage when you are buying an individual plan outside of ACA, an employer, etc. I went through most of my retirement money paying for that so I wouldn't die of cancer. Most seniors wouldn't have the money to do that year after year after year. The life span in the USA would drop even lower as many seniors would have to do without at least some of their needed health care for financial reasons (some are already doing that, especially with meds) so I am not advocating for dropping that.

I do think that there needs to be some sort of action on the part of AARP to make sure that their royalty relationship is in line with what they state is their mission and that they step in if there are issues or drop UHC and get their for profit arm money from some other endorsements that create less issues for the users whether or not they are AARP members. I think the issues are likely more on the advantage plan side since on the original medicare side there isn't the approval/network issue, although likely there are premium issues that include a significant amount of money tacked on to premiums due to the need for UHC to pay for the royalties. 

I don't know if UHC has figured out how to put us into community rated blocks which will drive up costs as they close blocks (rather like is happening with F with no younger people in that - which is why I didn't join even though I was the last year that had that option as I knew what would happen in a community rated plan). My understanding, talking to someone in the USA (USA fortunately as talking with many in their foreign customer service operation can be frustrating at times) several levels up the UHC hierarchy is that G, without extras, was also an attempt to get the healthier (thus more likely to be younger too) people into that one rather than the original G with extras, so that premiums would be lower (not just lower because they didn't have to pay the fees when users used the extras - which many don't, but also lower due to healthier people in there - and those who can pass medical underwriting may want out of G+ into straight G which would make those in G+ collectively less healthy and so costs would go up). They used a different subsidiary to do that. 

[GailL1]

@CBtoo 

Just a few corrections in what you said 

MEDICAID:

You wrote:   . . . . there is no medicaid for adults under 62 even if they are working, etc. 

Of course people less than 62 can get Medicaid.  In Federal law they can get Medicaid IF THEY ARE  LOW income disabled people or elderly or blind with few assets.  

The ACA only widened the scope of MEDICAID to childless, abled bodied adults that meet the (MAGI) low income threshold.  

Even then most states have increased their Medicaid coverage to children under the CHIPS program and to pregnant women, some even cover the woman and the child after birth for an extended period like 12 months.

MEDIGAP plans rating options

You wrote:  I have no clue what you are talking about with respect to how gap plans are rated.

Premiums for a Medigap plan can be rated in one of three ways  to set the initial premiums and then as part of the increases in premiums going forward.

1.  Community Rated 

2.  Issue Age 

3.  Attained Age

You wrote:  I don't know how this works for the disabled under 65 either other than they eventually get medicare.

People who have been declared disabled who are less than 65 get access to Medicare after receiving a SSDI (Social Security Disability Insurance) payment for 24 months or have a diagnosis of ESRD (End Stage Renal Disease) or ALS (Lou Garrett Disease or      )  for which they get immediate access to Medicare. 

Federal law does NOT give people less than 65 years old access to any Medigap or Medicare Supplemental policy.  So these folks are either forced into a Medicare Advantage plan to protect themselves financially OR the state where they live passes a state law giving them access to SOME Medigap plans usually Plan A and/or Plan B - which are both less than the lucrative benefits in Plan G or the others.  Even when they, as disabled folks, are given access to certain Medigap plans by a state because of the high utilization they have of health care, their premiums are pretty astronomical in some states.  I am talking $500 - $ 1000 a month just for a Medigap plan over and above the Medicare Part B premium.  

So in many states, these disabled folks opt for a Medicare 
Advantage plan to save in premium, and medical cost.

When they turn 65 years old, they get a “do-over” with Medicare and can re-enter the program under their 65 year old guaranteed issue period and enroll in a Medigap plan without underwriting under their initial Enrollment Period (IEP).  

Yes, having Traditional Medicare with a lucrative Medigap plan, at present, gives a beneficiary access to a lot of providers that accept assignment or even some that have signed up as “non-participating).  “Non-participating” providers can charge a beneficiary up to 15% more and some Medigap plans cover this too.  Those providers who have “opted out” have to do so for a minimum of 2-years and the only way they will work with you as a Medicare beneficiary is under a contract basis - Providers who have opted out, do not bill Medicare and neither do they get any reimbursement from Medicare either.  Opt-out providers are on your nickel and under contract which usually has their cost outlined.  

Yes, MOST AARP/UHC Supplemental plans are community rated.  However, in those states that have expand their guaranteed issue rights in some way - all of their premiums are much higher than in other states because the insurers in those states have to contend with a much higher risk.  

There are (4) states where a beneficiary can pretty much sign up for a Medigap plan at any time, at any age and without underwriting - these are the states with the highest Medigap premiums - and they are all, I believe, community rated.

CT, MA, ME and NY.

Then the other states that have expanded GI rights let the beneficiary CHANGE plans without underwriting during some set time of the year.  (i.e. around ones’ birthday so some of them are known as birthday rule states). Premiums are still high in these states too - CA, MO are a few of them but there are others.  In these states, if one wants to switch a Medigap plan it’s has to be to an equal or lesser (in benefits) plan.  

I hope I have just added to your knowledge of the program of Medicare.  I do know that an Independent Medicare Plan broker in your state and area will know better than anybody else which insurers are likely to rate you during underwriting more or less leniently based on your health.  

Sometimes BCBS (and perhaps others) might open up their Medigap coverage with no underwriting if they are wanting to build their Medigap business.  Again, an independent Medicare plan insurance broker will  be aware of these types of offerings.

Also know, you might already know this, that a Medigap insurer can refused coverage to a beneficiary outside of IEP and the surrounding period, they can also charge a beneficiary more out side of that IEP and the surrounding period, or they can not cover any preexisting condition for around 6-months.  

If there is anything different in your state about Medigap plans, your state’s SHIP office or the state Dept of Insurance should know about it and they usually have it somewhere on the states website all the particulars.

Goo Luck in finding and getting the coverage that you need and want. 

[CBtoo]

IN MY STATE THERE IS NO MEDICAID for "regular" (eg non-disabled) people under 65 because it was not expanded. Not even if you work 1/2 time. I live in one of the states who won't give out food stamps to people under 62 not working 1/2 time either. Apparently their goal is to kill the poor to solve the poverty problem. 

I am not disabled so this is not relevant to me. Not to mention your entire post is irrelevant to what myself and shamit are talking about which you are sidestepping by changing the subject.

I don't have minor children so CHIPS and pregnant women are irrelevant to me as 20 years after menopause if I were to have a child at my age that would be a miracle. I am sure if that happened the Catholic church would be interested and I'd be set for life. LOL

Rating. I thought you were talking about number of stars rating. What you are talking about is the RISK POOL. That is not a rating. That is a risk pool (community, etc.). They are entirely two different things.

I am well informed about medicare for 65+. I am sure most of us are aware of network issues and accepting medicare. Most insurance you have when you work is that way too. 

Brokers have a financial incentive to steer to people to the plans where their commission is higher (usually advantage plans give the highest commissions - often twice what supplements do and D is the least with some now not giving any). I am on an insurance forum for agents and am floored at what some of them post. While not all do that many do. I am not sure I'd trust an unknown to me broker because of that. And brokers usually don't write for all plans available in a state. 

On medicare.gov I put the zip code in for a nice residential area in a major city in each of the states as I was looking for which states offered G and G+ (15 of them) that also had a birthday rule or equivalent (a total of two of them: IL and OK) because moving there and back would also solve my problem if I fail medical underwriting to switch. The rates were NOT higher in each and every one of those states, only some of them. One was lower and several were within a couple of dollars. I saw the rate for someone my age, sex, etc. in medicare.gov as I checked it in each state. I also checked on UHC via the AAPR link to get over there. Same results. So that is not correct information. Sure the odds of them being higher would be there as sicker people could move from advantage plans where now that they actually needed care they couldn't afford the out of pocket and limited networks so that would increase the number of sicker people in medigap but it is NOT true rates are higher in all those states. I was surprised at that. 

[SusanM664094]

Maybe some of us are suggesting we'd like to see other options available. The "AARP" name on products does carry some intrinsic weight. Otherwise it's just another marketplace without much value as intellectual property....it's somebody else hawking their wares.

[robin24]

I also brought this up in a post last week, but my post was removed.

[CBtoo]

Hmm I discussed royalties in a reply today. I wonder when that post of mine will be taken down. AARP owns these forums so freedom of speech is not our right when we post here. AARP though might find it useful to read about complaints and then think about how they can make folks happier or discuss it with UHC (and others they get royalties from) to see if they can get them to fix issues. That certainly would be in the mission of AARP if they so choose.

[SoulSurvivor61]

Regardless if it's United Health Care or what ever medical plan you have and how benefits are severely cut each year. The truth of the matter is, The United States does not and never has, properly cared for Seniors and/or disabled citizens. It's shameful... a disgrace compared to other countries. This country was built on capitalism, greed and it is a detriment to survival.  Dare I say, I wonder who will be shot next?