I realize this forum also has members from other countries, so pls excuse my question about a US program: Medicare.
Does anyone know if there are professionals out there who know Medicare rules well so that I can hire them to help me navigate the Medicare maze? Specifically, I am interested in knowing what various benefits are available to my husband with advanced dementia. The Medicare handbook is thick and I don’t have the time to study it myself. Hiring a professional seems easier and faster.
See several if needed. Don't use anyone that won't come to you.
Thus is what we did for my husband and it was super easy to decide which plan to get.
What you need to do is weigh having straight Medicare with a supplemental or a Medicare Advantage plan. The more you pay, the better the policy may be. Medicare contracts out to Insurance Companies. Those companies are suppose to cover everything that Medicare covers under parts A & B. Not always the case and may mean u fighting for what you deserve. Understand in and out of Network. MAs used to be HMOs, you used their doctors. I have seen lately that they have changed to PPOs. If you stay in network you save more money. States only allow certain companies to write policies in their State. When I had to deal with my Moms coverage, NJ only allowed 3 companies to write policies so I did not have too many to chose from. But FLA were my MIL lived allowed 10 companies to write in their State.
The Devil Is in the Details
Medicare Advantage plans do not offer this level of choice. Most plans require you to go to their network of doctors and other health providers. Since Medicare Advantage plans can’t cherry-pick their customers because they must accept any Medicare eligible enrollee, they discourage people who are sick by the way they structure their co-pays and deductibles.
Author Wendell Potter explains how many Medicare Advantage enrollees don’t find out about the limitations of their Medicare Advantage plans until they get sick:
“Although Mom saw her MA premiums increase significantly over the years, she didn’t have any real motivation to disenroll until after she broke her hip and required skilled care in a nursing facility. After a few days, the nursing home administrator told her that if she stayed there, she would have to pay for everything out of her own pocket. Why? Because a utilization review nurse at her MA plan, who had never seen or examined her, decided that the care she was receiving was no longer ‘medically necessary.’ Because there are no commonly used criteria as to what constitutes medical necessity, insurers have wide discretion in determining what they will pay for and when they will stop paying for services like skilled nursing care by decreeing it ‘custodial.’”
You can see how a Medicare Advantage Plan cherry-picks its patients by carefully reviewing the co-pays in the summary of benefits for every plan you are considering. To give you an example of the types of co-pays you may find, here are some details pertaining to in-network services from a popular Humana Medicare Advantage Plan in Florida:
Ambulance – $300
Hospital stay – $175 per day for first 10 days
Diabetes supplies – up to 20% co-pay
Diagnostic radiology – up to $125 co-pay
Lab Services – up to $100 co-pay
Outpatient x-rays – up to $100 co-pay
Therapeutic radiology – $35 or up to 20% co-pay depending on the service
Renal dialysis – 20% of the cost
As this short list of co-pays demonstrates, out-of-pocket costs will quickly build up over the year if you get sick. The Medicare Advantage plan may offer a $0 premium, but the out-of-pocket surprises may not be worth that initial savings if you get sick. “The best candidate for Medicare Advantage is someone who’s healthy,” says Mary Ashkar, senior attorney for the Center for Medicare Advocacy. “We see trouble when someone gets sick.”
You can often find them on the back pages of your church bulletins.
The next time that I wanted to change my plan, I used a broker who came to my house
My nephew is in Medicare with Medicaid. Medicaid is his supplemental, his prescriptions, dental and vision. United heath is his prescription plan. The beginning of the year we found out he was switched to United MA without permission. We were able to take him back to Medicaid and the UH prescription plan thru Medicare. But, Medicare was not surprised this had been dine. I think Medicare is all for MAs. Less work on their part. Everytime i see a MA commercial, I think...too good to be true.
Senior Health Insurance Program.
Each State will have a listing of them in your area.
You can Google SHIP counselor near me or in (your State) and you should get info.
Grandma1954