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My husband recently had to have unplanned hip replacement after fracturing his upper femur due to a fall. Hospital referred him to a facility for inpt rehab and the pre certification was denied by our Medicare advantage insurance company. Hospital and receiving facilty were both astounded at the denial, as hubby has other complicating factors potentially impacting rehab, so it's not a simple case. We are of course appealing the denial. In the meantime we did manage to get him transferred to a SNF (skilled nursing facility) where he's making great progress. We are "self pay", but fortunate to have long term care insurance insurance that is willing to pay for the stay though not for the therapy services. If successful in our appeal, the Medicare advantage plan will pay retroactively to admission date. We are more fortunate than others in having the LTC insurance, but we hate to have to use it when Medicare should be paying. I suspect if we had traditional Medicare they would not have denied the rehab stay.

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Sorry, this is why I don't do Medicare Advantages. They are suppose to follow Medicare guidelines. Is it they are turning down care or care in that particular Rehab. I had a friend who needed surgery. The surgeon was Medicare and within walking distance from her home. (She lives in a city) Medicare Advantage said she couldn't use him, not in their network. Next open enrollment she went back to Medicare with a suppliment.

Hopefully, someone on the forum uses a Medicare Advantage. My supplimental is thru my DHs employer. Never have these problems.
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AlvaDeer Nov 2019
After the New York Times article I read yesterday I would NEVER suggest it. I gave details on article above and know you can google or other search engine it. I do have Kaiser, but we have ZERO problems with them with anything so far. And no bills. Just our copay and on we go. I love them. But I would do no other.
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Just read in the Sunday New York Times under a title of most frequently asked questions about Medicare that many advantage plans deny care and that only 1% actually will protest that denial with an appeal, that often when they do the denial is withdrawn and the care is given. Access this article if you are able. This apparently is VERY COMMON with medicare advantage programs. Article is named Six Top Questions about Medicare by Mark Miller andis in the Business Section of the November 3 New York Times under "retiring". I know you can get this on google. Good luck.
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Abby2018 Nov 2019
Alva.....My husband had the unfortunate experience of dealing with an appeal and had all the paperwork in order...including the oncologist explaining why the PET scan was necessary. It took weeks for me to get all the necessary documentation and forward it to CMS before the deadline (the hospital took three months to bill....so we were under a very small window). We thought for sure this would be resolved. Nope. Now on to investigating hospital billing codes, reasons for denial on their part, etc. Numerous calls to Medicare (you can't speak to anyone at CMS who are in charge of appeals) and finally someone took the time to look back at the claim. I was told a proper ABN was never filled out (a form stating Medicare would most likely NOT cover the test and advising patient of the cost and the reason it would likely be denied). Hospital still insisted that we pay.....I contacted Medicare multiple times again (going down the chain and up the ladder) and finally they threatened to file a grievance against the hospital for violation of contractural agreement. Weeks later my husbands $10K balance went down to zero.

We had straight Medicare ( with a supplement) and after months of calling and questioning, I finally found that one person who was willing to care enough to look back at the records and was astute enough to pinpoint the error. My advice to everyone.....due diligence does pay off, but you need to be your own advocate.
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Well, my mother has this super crappy new Medicare PPO plan thru Blue Cross that works a lot differently than standard Medicare, and may be similar to what you're dealing with. When she needed rehab after a bout in the hospital with pneumonia, a few rehabs wouldn't take her.....said they were "full". To make a very long story short, I later found out those rehabs weren't full at all......they just wouldn't take any more Medicare PPO plan patients! Apparently, there are only a certain number of beds allotted towards each insurance plan. When that number is reached, everyone else presenting with that type of insurance is DENIED. Hopefully my gibberish makes sense.

So I wound up putting my mother in a rehab unfit for a dog because Medicare PPO plan sucks, basically. Took me 5 days to get her out of there and into a good place and that's how I found out about all of this Medicare nonsense.

I wonder if your plan was rejecting the FACILITY and not the need for rehab?
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igloo572 Nov 2019
My understanding is Medicare PPO tend do post hospitalization care by “bundling”. So whatever the ICD-10 codes are for in the discharge report for them factor in for the post care they get but it’s paid NOT to each providers time but by a bundling of the overall $ amount that will be paid. So say it’s $475 a day but that $475 has to cover daily room&board, medication management, PT, OT, SW and the facility has to ferret out to pay all involved. If the facility has staff that are not true employees but independent contractors (which PT & OT & ST can be as they hold their own licensing), or some services not considered part of rehab (medication management), it’s a mess to pay. Facility might can do 3 -5 of these beds out of 20 beds. But more than that will mean very unhappy employees & negative bottom line for rehab sector. Families visiting see that their elder isn’t going off to PT twice a day like others are and complaining to management.

rehab coverage seems to be glossed over in all the plans I’ve looked at. I wish I knew which plans have in detail what’s covered in rehab.
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Herein lies the problem with the Medicare Advantage plans. Little to no cost to you, but when you need medical attention you find out how little is actually covered and the hoops you need to go through to get that coverage. Could be the hospital billing dept. used the wrong code. Did your husband sign an ABN (advanced beneficiary notification)? If so, was it explained correctly? Is the hospital/rehab in the network? Did he need to get a referral for the surgeon/hospitalization/rehab? Was he in the hospital for a minimum of three days?

The groundwork is relentless....to protect yourself in the future my advice is to check out the supplemental F plan. You can enroll now at a cost of about $235 per month. Covers mostly everything and no need for referrals.....and you are covered in all 50 states. Plus all major insurance carriers have the exact same plan. We learned the hard way....I am not a solicitor for the insurance industry.....just a graduate from the school of hard knocks.

Good luck to you and I hope this is just a hiccup that will resolve itself and you will receive full reimbursement. Getting proper medical treatment should not be this hard......especially when you are under enough stress to begin with.
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igloo572 Nov 2019
Abby for newbies making selections Original/ Traditional MediCARE for 2020 on supplemental or “gap” plans, there’s no more Plan F!
You who have your existing F can roll yours over but no new ones.
oh so not happy as going Original with an F was just going to be what we did when hubs retired. We’re still on his employers “Cadillac” plan (& @ $570 biweekly for family coverage & his insurance it should be a Ferrari) but now I need to research just wtf to do upon retirement since no F.
I think the Plan C is going this route for new 2020 enrollment too.
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Thanks for all the helpful answers. We unfortunately didn't have any choice in selecting the plan as it is the one our former employer contracted with for retirees. Employer heavily subsidizes the premium for my husband and we pay more for mine since I was dependent on his, but the monthly total is still extremely reasonable. Today I waited on hold forever, only to find out the agent handling our case couldn't find a form I'd sent on October 31st that he had acknowledged receiving. I had to send it again to a different email address. I do think one of the problems was poor documentation of need and level of function by the hospital. I'm goi g to check out the NYT Times article right away.
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XenaJada Nov 2019
"Losing" important paperwork seems to be part of their strategy. They wear you down until you give up. Get a fax # and multiple email addresses. Bombard them with copies of their "lost forms" when they try to pull this crap.
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I am new to medicare (as of 1 dec) finally....ive heard too many “advantage” nightmares. I went straight medicare with plan f and part d. My mom has the original supplement plan and never pays a penny for anything except copays for her meds....i used to work in the medical field and at one point did insurance billing....the crap plans that are so well advertised, basically shoved down our throats, are no advantage to a patient, as someone on the forum mentioned not too long ago...
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texasrdr22 Nov 2019
Interesting. I have had an Advantage Plan since I signed up for Medicare (5 years ago). I am healthy and have had no trouble whatsoever getting my plan to cover whatever I need. I have a PPO so don't have to get a referral. I have to stay within their network of doctors, but all my docs were in that network anyway.

I found the cost of the MediGap (supplement) policies to be quite high! Plus you have to pay for a Part D drug plan and still pay the monthly Social Security part (that is automatically deducted). This adds up! My Advantage Plan includes part D. My mother has a different carrier for her Advantage Plan and it is amazing all the things it covers! Neither of us have had problems other than the denial of inpatient rehab which I appealed and it was granted.
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ProPublica has an article out today on RN who was billed $880,000 for her 3 mo early preemie & it’s the hospital group she works for!!!

Its the structure of “Advantage” plans that are the inherent problems.
The whole premise of Advantage is to limit you to a narrow network with an even narrower group of providers. So if the care you need doesn’t fall within basically a subset of a set, just too bad. You pay out of network or you get wage garnishment or go bankrupt or you impoverish yourself to be a dual on Medicaid/Medicare. What’s especially galling is that CMS underwrites a good bit of Advantage Plans. They siphon off $ from original MediCARE for Advantage. All done under the illusion of creating a more “choices for consumers” via underwriting insurers who trot out Advantage plans; and taking $ away from Original MediCARE. What a steaming load.

Single Payor needs to happen in the US. Whether it’s MediCARE for all or the Kaiser model (Alva oh lucky you!) of HMO systems.
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newbiewife Nov 2019
Amen to trying to get a more rational healthcare system in the U.S.! We've never had problems with getting care up until now, as every provider and every facility to which we've been referred is in our plan's network, which appears to be quire extensive. In our case, the problem is getting the appropriate level of care. We just got the denial letter (dated October 29th) on November 4th. It said the requirements for skilled nursng facility was needing skilled nursing or rehab every day that can only be required in an inpatient setting. We, and the sending and receiving facilities, think my husband easily meets the criteria for short-term inpt. rehab, and we're pursuing an appeal.
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First off, keep appealing. I used to write appeals for a Blue Cross HMO before changing career path.

Second-without knowing if he satisfied Medicare’s three day hospital inpatient requirement, we can’t know if he qualified for rehab facility.

Third-Medicare is moving toward outpatient joint replacements, same day discharge, or next day. They are doing this partly to prevent joint replacement patients from qualifying for rehab care post-hospital discharge. Virtually nobody with hip surgery qualifies for rehab now. Just because the model patient without comorbidities May do well with outpatient joint surgery, we all are now expected to recover just as quickly.

Fourth-As others have said, if a person is on a Medicare Advantage Plan, if one can get through underwriting, and if the premiums are affordable, Original Medicare with a supplement, Plan G, is best option, for getting needed care, with all the Advantage Plan restrictions.

You say Medicare PPO, not HMO, correct? You will probably find, as your husband ages, most seniors tend to get sicker and need more care, not less. Insurance companies are in the business of making profit, whether HMO or PPO, and its a powerful incentive to deny as many services as they can get away with. We said good riddance to the south FL Medicare Advantage Plan HMO Humana, when we moved to another state. Both back on original Medicare. We don’t have all the games with insurer denying care now. We are receiving proper medical care, and the screening tests for our various medical needs, plus the accepted medical treatments we weren’t receiving on the Advantage Plan. Strongly urge changing to Original Medicare if you can.
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Wow. I came SO close to changing over to an Advantage policy instead of the supliment one I have now. I pay a very small co-pay at the beginning of the year and from that point on no deductions. And you guys are right, even my doctor's office is trying to get us to with advantage....
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bevwill88 Nov 2019
Wwhich plan do you have; it sounds promising
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Shane1124,
You clearly believe a lot of political scare-talk about Single Payer.
I do not. Nor does most of the rest of the First World, where no one navigates for-profit obstacles or suffers bankruptcy because of medical situations.
Please note where the problems are coming from when the for-profits (Medicare Advantage) are permitted into the government-run nonprofit arena (Medicare),
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Isthisrealyreal Nov 2019
Nor does most of the rest 1st world? That is a huge assumption and I am wondering what country you are referring to, because officially the USA has reached 3rd world status and no one is talking about that.
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Happy update! Our appeal of the denial was successful, so Aetna Medicare Advantage (ppo plan) will pay retroactive to admission to the facility.

To address a few of the questions raised by helpful posters: (1) This was not a planned or elective hip replacement surgery. It was necessitated by a fall that resulted in broken femur, near the head. Surgeon said it was a displaced fracture. Not a total hip replacement, "just" the head of the femur. (2) My husband was admitted to the hospital from emergency room and had to wait a day before surgery because he was on a blood thinner. He was in the hospital over the 3 days required by Medicare to be eligible for rehab. In fact, he was in there several extra days because of the Aetna denial. He has other complicating medical factors that already affect his balance and walking, so we were sure he ought to be elgible for rehab. stay medically as well. (3) We had no choice in having this advantage plan as my husband's employer has contracted to put all their retirees on it. The employer heavily subsidizes the employee's monthly premium, and dependents have a very reasonable monthly premium. Between two of us, we are paying only slighty more than half of what our brother in law pays for just himself on a Medicare supplement plan (United Healthcare). Annual deductible is $300 each, and there's a decent cap on annual out of pocket payments. Prescription (Part D) benefits are included.

I've learned a lot in reading the responses, which I think may be helpful for others as well. Thanks all.
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Maple3044 Nov 2019
Ssorry to hear of your problems. My mother had an advantage plan ( rhymes with Hell Med) who denied her coverage at a SNF 5 days after she had a major stroke. They arbitrarily transferred her to this facility with no input from us. It was extremely inconvenient for us to get to it. Their excuse was that she was making no progress with therapy. We fought them stating that she had had 1 day of evaluation and 1 actual day of therapy. Hell Med did capitulate and authorized 30 days of therapy. My mother never recovered from her stroke but seemed to be content in the SNF until she passed 4 years later.
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Everyone on Medicare makes their own choices of what doctor to see. Medicare is a very generous payor. The days of fee-for-service are gone and never going to come back unless you can afford to pay out of pocket. Ask anyone on Medicare whether they want to give it up and you will get a resounding "hell no!" The amount of misinformation about Medicare is staggering.
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Have the hospital recheck the code numbers they used. You won't believe how often a refusal is caused by the wrong code numbers.

I learned this the hard way - now I make them recheck anytime a charge is refused.
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Medicare advantage is a “in service” hmo or ppo only

frankly, it is super cheap premiums because it delivers very little actual service. Medicare is pushing this hard this year...but...avoid advantage. Their goal is to pay for little to nothing. The internet is rife with the huge number of people denied health service because they have advantage.

you can change to any of the medigap plans anytime...but, you will have to go through underwriting to join a different plan. Check it out.

meanwhile, see if you can find a rehab that is in the PPO for you Medicare advantage plan.
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newbiewife Nov 2019
The facility my husband is in is in the network. that wasn't our problem, but good to know for the future.
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Since this is open enrollment time I wanted to let people know to avoid Humana at all costs. So difficult to work with and they send you in circles when you call them on the phone. Their online pharmacy is ridiculous and you can wait a long me to have Prescriptions filled.
My dad is now with blue shield and we have not had problems with them. I think one reason for this is because the doctor at the memory care facility where he lives is also the doctor on his hmo plan that he is on so super convenient to have him come to my dad. If this were not the case I would not have my dad on an advantage plan.
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Here is one of the obvious problems with "Advantage Plans." They may sound tempting b/c of lower premiums, but there are way too many limitations on benefits.

During this Open Enrollment period, consider moving his coverage to a standard Medicare Supplement Plan. It will cost you more in premiums but it will give you much more in choices and services.
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Dizzerth Nov 2019
My insurance agent told me after you’ve had an advantage plan you can’t get a medigap. You can get an advantage after a medigap but not the other way around.
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Is this Kaiser? Same thing happened to my dad after a fall and hospitalization. They also denied our appeal. They wanted me to put him in a nursing home because they said due to his dementia rehab wouldn’t help him. I took him home with me and Kaiser did finally agree to home health and we got some PT and OT that way. I will not be choosing them for my plan when I qualify for Medicare.
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Igloo, check out plan G. When I was researching for my dad I found that plan F was more expensive and didn't really cover anymore than G.

I used a broker that was able to give me a booklet that showed me exactly how the coverage compared from one plan to the next. It was still complicated but it was massively simplified.

I tell everyone to find a Medicare specialist insurance broker.

Not that I could tell you anything, the clever lady you are, but I wanted to share my experience.
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Ask for a review of the benefits with your plan. It may be that it was inadvertently denied (these are people we are dealing with) or that your plan doesn't have these benefits - which would be really strange! So glad you have something that is working for now. You may want to consider looking into other plans as the open season of enrollment approaches.
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I ran three years of premiums and copays paid for each of us, compared yearly average, and it was about the same yearly cost for original Medicare plus supplement for two seniors. So we are now happily on original Medicare with supplement plan.

The delays and outright withholding of medical care under the Medicare Humana Dvantage Plan in south FL nearly cost both of us our lives, several times. Things like delaying my spouse’s fully blocked carotid artery repair surgery a full five months, trying to not pay for his surgery, waiting for him toile first. Then there was their refusal to order and pay for the pulmonary function tests and overnight oximetry testing for my lung disease, knowing they would have to pay for oxygen for me if they allowed the routine testing that all persons with interstitial lung disease routinely are monitored with. It took almost a year fighting, complaints, appeals, sending copies of the American Respiratory Society recommendations to the HMO PCP, to document I was not receiving industry standard care for persons with lung disease. Then there was my skin cancer, Humana tried to not approve MOHS skin cancer surgery on my face, even though it is industry standard. The HMO doctor kept refusing to make the referral, insisting since I wasn’t a model or movie star, any skin doctor could carve on my face, and to heck with having a cosmetically acceptable surgery on my face. Then there was the years of Humana not performing the yearly low dose CT chest scans on my husband, recommended for high risk persons with history of heavy smoking. It had been their recommended screening for nearly a decade, yet Humana was skipping the screening. When we got here, moved to GA a year and a half ago, moved us back to original Medicare. He got the low dose CT scan of his chest, and sure enough he had lung cancer.

Bottom line is this. If you are willing to be under-treated, have high risk medical conditions and screenings ignored, willing to risk death, by all means, sign up for an Advantage Plan. Don’t say you weren’t warned. For me and mine, even if the company paid for their choice of a Medicare plan, I’d be paying out of my own pocket and pay for the original Medicare plan B, plus a supplement, to prevent careless decisions compromising life, via an HMO or PPO.
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newbiewife Nov 2019
As I noted in my update, we are on this advantage plan because it is the my husband's employer puts its retirees on, and the employer heavily subsidizes the premiums. this has been a good plan for us up until now, and we've been pleased with the coverage and costs. This is the first time either of us was ever denied coverage for anything, and in the end our appeal of the denial was successful.
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Our local Home Health P.T. services are swamped, as Medicare has recently disallowed Rehab admissions, if P.T. and no other medical requirements are required. The Therapist that told me this, did not mention if it was just for Medicare Advantage plans.
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Girlsaylor Nov 2019
Medicare has gone to drive thru joint replacements, shortened stays for many surgeries and medical admissions, to get patients out of the hospital before the three day inpatient stay required for rehab. They are forcing people to go home after total hip and total knee replacements in 23 hours or less, some same day as surgery, despite age and additional medical conditions. It was done to me. Virtually nobody on Medicare is qualifying for inpatient rehab now. Despite diabetes, lung disease, nobody to care for me, I was practically thrown out of the hospital after my most recent hip replacement. I was in excruciating pain, not at all under control, but as long as you aren’t throwing up the oral pain pills, you will now be discharged hastily.
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Will they cover the expense of in-home care? PT coming? I'd rather be safe in my own home any day compared to these places...
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newbiewife Nov 2019
As noted in my update, husband is getting therapies at a snf facilty for now, and our appeal of the denial was successful. I do think they might have covered in home therapies, but we know those are only a few times a week as opposed to 5 days a week he's getting as an inpt. I think his rate of progress is way more un inpt than it would have been at home. After discharge, we're told by the folks at the snf that he'll be able to get a few additional weeks of in home pt and ot. After that, he should be recovered enough to go to outpt if he needs more.
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Apeal, apeal, and apeal. The third apeal is the only one that is reviewed by doctors in my plan!
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You all make me feel better about staying with our supplimental which is not a MA. Yes, we don't have all the advantages of a MA but I rather pay what we do than go thru the MA mess.
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RedVanAnnie Nov 2019
Yes yes. You want to stay with your regular Supplemental Plan. All the Advantage advertising hype about "you may not be getting all the benefits you deserve" really galls me.
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To Dizzerth:
Wow! I did not know one could not move from and Advantage Plan to a regular Medigap Plan. Ever? Did your agent maybe just mean you could not change plans between enrollment periods? I thought you could make a new choice of any kind during Open Enrollment.

To newbiewife:
Not sure if you have been able to make headway on your appeal, but you are presenting an example to all of one of the downsides of Advantage Plans. Regular Medicare/Medigap typically pays for 30 days of rehab. At least that was my own experience. Medicare/Medigap then continued to pay for in home PT and OT visits until I was permitted to drive myself to outpatient Rehab which was also paid for by Medicare/Medigap.
Good Luck!
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Girlsaylor Nov 2019
You can move back and forth between Original Medicare and the Advantage Plans. The issue is that if you want to go from an Advantage Plan back to Original Medicare, during open enrollment, you will be subjected to medical underwriting if you wish to purchase a supplement plan along with your Original Medicare. There are some exceptions, where you can qualify for a supplement without having to go through underwriting. One is when you are first enrolled in Medicare, ad have selected an Advantage Plan. There is an 11-month trial period, allowing you to go back to Original Medicare plus supplement, guaranteed issue. Another exception is if you move out of the Advantage Plan area, often to a different state, you can go back to Original Medicare plus a supplement, with guaranteed issue of the supplement, no medical underwriting. That was how we both qualified to bypass medical underwriting when we moved to another state. Otherwise we would never have been able to get through underwriting.
Whenever asked, I always recommend Original Medicare plus a supplement. It’s the rare person who gets healthier in old age. As we become sicker, take more meds, have multiple diseases, the Advantage Plans lose their attractiveness, with increasing copays for more visits, more tests, more hospitalizations. And, the risks of managed care plans undertreating serious medical conditions is very real. Sometimes they simply refuse care, even when such care is standard for the medical condition.
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Sooooo much advertising right now for Advantage Plans during the Open Enrollment period!!!!
Please, everyone know what you are buying. There are so many stories here on the forum of how Advantage Plans fall short when it comes to providing benefits.

Don't be tempted by retired athletes making excited promises on TV. These plans are a great revenue source for the companies that sell them, but they Take Advantage of the consumer.
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igloo572 Nov 2019
You know the “Advantage” plans get $ from CMS (MediCARE) for marketing & promotion. All in the guise of providing choice for consumers. Yeah & im getting back into those size 6’s in my closet. Rotflmao!
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