Medicare 2026 Update Vid

[alarmguy]

Actually, a C plan is. Medicare is not asked at all until after the insurance company denies the payment, and the patient or their representative has to make that request.

A Medigap plan is going to pay because there is a decision by Medicare has already approved. If they don't pay for whatever reason the patient is not financially responsible. Generally this is for serious "never never" hospital mistakes which though they were planned and proposed as medically necessary and approved treatments, they were done so improperly (e.g. operating on the left knee instead of the right one) that Medicare won't pay the hospital either.

Same meaning different way of saying it. If you get denied on an advantage plan, but it’s a Medicare approved procedure Medicare will overturn the denial.

 

[alarmguy]

This is not completely true. If the physician has the patient sign a form(such as ABN) ahead of time, indicating it is possible their insurance may deny payment or claim something is not medically necessary, then it is allowed to turn the cost of the service to the patient. Insurances such as MA plans routinely require prior authorizations for almost everything that I do for my patients, yet they make clear even that is "no guarantee of payment"

OK I see your doctor and I certainly believe you. I don’t know what state you’re in. I did read and you do have your patients sign in ABN.
Without one it’s a problem. I haven’t seen one since on Medicare on company health insurance I have but whatever you are correct obviously because you’re a doctor.

I’ll certainly look out for one now however hopefully I don’t need anything else for a long time!

It was still a burden on the medical practice, but I can’t get into a scenario. I never been in so you would know better.

 

[Jim Rogers]

Same meaning different way of saying it. If you get denied on an advantage plan, but it’s a Medicare approved procedure Medicare will overturn the denial.

Unequivocally false.

"...it’s something that never happens to me so I’m not concerned."

"I won’t get into the subject because I don’t feel like researching."

The roots of the problem.

 

[alarmguy]

In a nutshell. I guess it’s good that only 50% of the population want an advantage plan.
If everybody did the cost would go up!

Medicare Pre-Authorization: When Is It Required and How It Affects You​

https://themedicaresite.com/medicare-pre-authorization-when-is-it-required-and-how-it-affects-you/

Pretty much no different than anybody in the workplace with company health insurance. Actually far better than company health insurance they don’t have the federal government looking over their shoulders like they do with advantage plans because the federal government pays for the advantage plans they don’t pay your private insurance is my feeling

 

[nomas]

My wife had back surgery . The Hospital sent us a bill for 65k . The Doctor failed to get authorization . Their response was basically " oops " . It took a couple of months to resolve but a review board finally told the Insurance company to pay it . Thank you Jesus ...

 

[Jim Rogers]

In a nutshell.

I would suggest you go beyond these simplified, consumer-friendly websites that give "nutshell" conclusions.

They are good starting points, but you need to move beyond them in order to get the true picture of how all this works.

As it is, you appear to simply stop researching the minute you receive the confirmation bias you seek, and it's causing you to conclude things that are badly off.

Dig deeper, keep an open mind, and be careful giving authoritative advice to others until you've done that.

 

[alarmguy]

In case it got lost in all these pages of debate.
If you’re on Medicare or about to go on Medicare, this is a pretty good video outlining your options.
One of the best I’ve seen and it’s up-to-date.

 

[alarmguy]

My wife had back surgery . The Hospital sent us a bill for 65k . The Doctor failed to get authorization . Their response was basically " oops " . It took a couple of months to resolve but a review board finally told the Insurance company to pay it . Thank you Jesus ...

Was this on a Medicare plan? If so, which one did you have?
Glad the review board worked for you!

 

[fantastic]

False, and they do it all the time.

I do see where the gov. does fine or disallow private co. to participate if they've done some major financial discrepancies. Private co's don't always do what is required that's for certain.

No Medigap plans have been eliminated.
Partially correct a number of years ago they closed off some plans to any new Medigap participants in those plans. But the existing people did not lose their plan.
However, almost a mirror image of new plans came out for new Medigap applications of which the gold standard is plan G currently as well as plan N

Post number 22 shows you everything is still available.

I’m not sure what it’s awful about Humana pulling out of three states. Plans are canceled all the time though nowadays a lot more being canceled because government stopped giving them increases for a period of three years.
But the question would be so what?

It kind of stinks, but those people are free to go back to medigap without underwriting/automatic approval. It’s kinda like a testament to how much people love their advantage plans, take it away and people don’t want to pay thousands of dollars more a year for a Medigap plan when they were getting an advantage plan for nothing more than the part B monthly premium.

Just for the record, I agree with you. I’m not thrilled either but government is clamping down on how much they’re willing to give these companies or better yet they didn’t give the companies an increase for three years and the first increase just came through in year four recently.

I’m going to be very upset if I’m forced to start paying for a Medigap plan sometime in the future, but I suspect being the increases to these companies have started back up it will be at a status quo now I hope. Lower cost states still have a pretty good selection of advantage plans.

Some of the states, just for the record that the advantage plans are pulling out of and plans being cut are because of additional state mandates over what the federal government requires in those particular states. New York is a prime example much written on it, but I don’t think appropriate in this forum other than to say New York State, along with a handful of others, requires companies to allow you to switch back-and-forth between Medigap and advantage plans further increasing their costs in some of these very high cost states.

I should've been more clear. I was referring to mainly MA plans being pulled & not Medigap. I think the MA plans were hit hardest recently. It isn't great for the same reasons you've detailed & point out. Cost from an MA plan can be more affordable than going back to Medicare & Medigap so removal of more options can leave one in a "Desert Area". I would assume that some areas may still have other options but if they also leave? Not great. You know what I mean.

Full disclosure, this is an example. I had an Aetna HMO plan in 2024. (previous years I was in UHC HMO plans) It was fantastic. Aetna even bought me three Pickleball paddles and an Apple Watch. they also in the last three months of 2024 paid for every single test without question. This included a PSMA PET scan, biopsies, consultations with local specialists and consultation with a panel of doctors up at Duke University cancer clinic, a 3 Hour drive from my home, my wife and I stayed in a hotel the night before. The three doctors, one from each of the respective fields spent the entire morning with both my wife and I just to consult with us on treatment options, to give you the caliper of the people. One of those doctors was the director of research at the cancer clinic all paid for by my Aetna HMO plan.
However, toward the end of 2024 I was notified that plan was being canceled so for the heck of it since at that point I knew I had cancer. I went into Medigap plan N for 2025.
2025 is almost over, my cancer treatments, mostly all successfully completed and at this point 80% sure I will go back to an advantage plan in 2026. I have a couple more weeks to make up my mind.

Like we've discussed before, the wife's B cancer was mostly paid for w/a Humana PPO. We were quite happy w/the outcome.

Maybe some of this will explain to others my zeal for advantage plans.

I will point out that both @Jim Rogers & you make good points to ponder. I will also point out, to the both of you, that when it comes to the statement of "MA covers everything Original Medicare does" to better detail. It seems Medicare allows MA plans to outline their own criteria of what is deemed "Medically necessary" for some services.

Plans must cover all medically necessary services that Original Medicare covers. For some services, plans may use their own coverage criteria to determine medical necessity. Plans may also offer some extra benefits that Original Medicare doesn’t cover. (Page 4)
https://www.medicare.gov/publications/12026-understanding-medicare-advantage-plans.pdf

Again, false.

 

[alarmguy]

I do see where the gov. does fine or disallow private co. to participate if they've done some major financial discrepancies. Private co's don't always do what is required that's for certain.

I should've been more clear. I was referring to mainly MA plans being pulled & not Medigap. I think the MA plans were hit hardest recently. It isn't great for the same reasons you've detailed & point out. Cost from an MA plan can be more affordable than going back to Medicare & Medigap so removal of more options can leave one in a "Desert Area". I would assume that some areas may still have other options but if they also leave? Not great. You know what I mean.

Like we've discussed before, the wife's B cancer was mostly paid for w/a Humana PPO. We were quite happy w/the outcome.

I will point out that both @Jim Rogers & you make good points to ponder. I will also point out, to the both of you, that when it comes to the statement of "MA covers everything Original Medicare does" to better detail. It seems Medicare allows MA plans to outline their own criteria of what is deemed "Medically necessary" for some services.

Plans must cover all medically necessary services that Original Medicare covers. For some services, plans may use their own coverage criteria to determine medical necessity. Plans may also offer some extra benefits that Original Medicare doesn’t cover. (Page 4)
https://www.medicare.gov/publications/12026-understanding-medicare-advantage-plans.pdf

I’m happy for the outcome for your wife and wish her well.
Cancer is a horrible thing, 15 years ago my wife was diagnosed with breast cancer. I still remember the call and exactly where I was driving at work when I found out. It was crushing, I called my brother/sister-in-law and fell apart in tears, telling them the news.

Good news after all these years, she is still cancer free.

Now me … my first health crisis since fourth grade anyway …I just finished six months of radiation and drug therapy for prostate cancer.
Now I will have a lifetime of monitoring

 

[fantastic]

I’m happy for the outcome for your wife and wish her well.
Cancer is a horrible thing, 15 years ago my wife was diagnosed with breast cancer. I still remember the call and exactly where I was driving at work when I found out. It was crushing, I called my brother/sister-in-law and fell apart in tears, telling them the news.

Good news after all these years, she is still cancer free.

Now me … my first health crisis since fourth grade anyway …I just finished six months of radiation and drug therapy for prostate cancer.
Now I will have a lifetime of monitoring

Thank you & same to your family...you have stayed strong. I think there is no doubt we can appreciate what we have been given in return in our MA plans that far outweigh a lot of these obstacles. But we are going to stay in tune w/the changes. Wife has to have annual mammograms as I'm sure your wife does. Lucky for her there is a rule that allows free of charge when reaching 40 years of age. Otherwise it's one between 35-39 yrs old.

 

[Jim Rogers]

I do see where the gov. does fine or disallow private co. to participate if they've done some major financial discrepancies. Private co's don't always do what is required that's for certain.

True.

CMS requires detailed reporting of denial rates, maintenance of appeal processes, and reasonable utilization management practices. Because of this, MA denial rates do tend to cluster in a narrower band (roughly 6–13%, skewed much higher in the later years), due to these structural involvements and constraints imposed by federal rules and audits.

However, CMS does not individually decide whether a specific claim “fits their criteria.” Instead, CMS ensures that MA plans are broadly in compliance with Medicare coverage rules and appeal rights.

So, CMS is involved only at a structural level (setting broad general rules, contracting IREs, auditing plans), but not at an operational level as a direct arbiter of individual claim disputes.

As I keep saying, it's nuanced and complicated. I'm not 100% sure I fully understand it!

I will also point out, to the both of you, that when it comes to the statement of "MA covers everything Original Medicare does" to better detail. It seems Medicare allows MA plans to outline their own criteria of what is deemed "Medically necessary" for some services.

Plans must cover all medically necessary services that Original Medicare covers. For some services, plans may use their own coverage criteria to determine medical necessity. Plans may also offer some extra benefits that Original Medicare doesn’t cover. (Page 4)
https://www.medicare.gov/publications/12026-understanding-medicare-advantage-plans.pdf

Correct-- MA providers are given full operational control to decide what they will deny, and CMS just monitors to make sure no one is doing something like denying 90% of claims.

So, CMS sets the guardrails as to "the limits of crazy," but MA providers make all the decisions within those guardrails.

It is not as simple as "if Medicare covers it, MA covers it."

It's more like "if Medicare covers it, MA must consider covering it but has broad authority to deny coverage if they deem a claim to not be medically necessary."

That decision authority is a huge hammer to hand to the insurance companies, and they have a well-earned reputation for using it often and effectively.

 

[JeffKeryk]

Last year my Med Advantage Plan was cancelled in my area, so I switched to a Plan G.
Years ago my father had an ambulance ride when he fell and badly gouged his arm. His insurance denied the ride and charged him $8K or something like that. I argued it for months and they finally paid.

There are plusses and minuses to our medical system. I wish you luck. I believe medical expenses are the #1 reason people go bankrupt ad most of them have insurance.

 

[Jim Rogers]

Last year my Med Advantage Plan was cancelled in my area, so I switched to a Plan G.
Years ago my father had an ambulance ride when he fell and badly gouged his arm. His insurance denied the ride and charged him $8K or something like that. I argued it for months and they finally paid.

Are you saying your father was on an Advantage plan?

Did you choose your original Advantage plan before your father's incident? If so, why switch now (if that was a known issue at the time of your original sign-up)?

 

[JeffKeryk]

Are you saying your father was on an Advantage plan?

Did you choose your original Advantage plan before your father's incident? If so, why switch now (if that was a known issue at the time of your original sign-up)?

Honestly, I do not remember what plan my Dad was on. I think he also got some benefits from his Navy enrollment.

My father's incident had nothing to do with my choices. I had Kaiser HMO for years at work, but kicked them to the curb and went with a plan that offered Stanford Hospital. After I retired, I took an Advantage plan, but just switched to Plan G when the Advntage plan was cancelled in my area.

Sorry I don't have better responses; but I hope this clarifies my post.

 

[Jim Rogers]

Ok, but would you be willing to share your reasoning for switching from Advantage to G?

Not making any point, just curious.

 

[Jango]

Ok, but would you be willing to share your reasoning for switching from Advantage to G?

Not making any point, just curious.

He gave his reason in his post.

 

[Jim Rogers]

Last year my Med Advantage Plan was cancelled in my area, so I switched to a Plan G.

After I retired, I took an Advantage plan, but just switched to Plan G when the Advntage plan was cancelled in my area.

Years ago my father had an ambulance ride when he fell and badly gouged his arm. His insurance denied the ride and charged him $8K or something like that. I argued it for months and they finally paid.

My father's incident had nothing to do with my choices.

---------------

He gave his reason in his post.

Well, maybe you can help me find it-- what was the specific reason he switched from Advantage to G (as opposed to a different Advantage plan) when his original Advantage plan was canceled?

 

[JeffKeryk]

Ok, but would you be willing to share your reasoning for switching from Advantage to G?

Not making any point, just curious.

It's a fair question and I am happy to respond.
As the video pointed out, a Plan G is considered the gold standard. See any doctor, no approvals, etc.
In my area, you have to go through a qualification to switch to a Plan G unless your current plan is discontinued.
My agent advised me this was a good opportunity and the time might be right. I agreed. The additional monthly cost was in the budget.

I am certainly not as well versed in this topic as @alarmguy; not even close. Perhaps he might chime in.

I hope this helps.

 

[Jim Rogers]

It's a fair question and I am happy to respond.
As the video pointed out, a Plan G is considered the gold standard. See any doctor, no approvals, etc.
In my area, you have to go through a qualification to switch to a Plan G unless your current plan is discontinued.
My agent advised me this was a good opportunity and the time might be right. I agreed. The additional monthly cost was in the budget.

I hope this helps.

Thanks.

Not doubting the decision at all (sounds like a reasonable move to me), but still wondering why moving to G now is a good idea if it wasn't originally.

Is it just that you're older now, and making an actuarial decision that the risks of not having the gold-plated plan early on were worth the savings, but at a more advanced age, it makes more sense to pay more than it did at the beginning?

Or are you worrying about denials in your later years?

I'm always curious about those who switch from Advantage to G when the opportunity presents itself to them. Seems like there has to be some sort of clue as to the real value of the competing plans hidden somewhere in those decisions.

alarmguy did the same thing, despite the fact that he sees no deficit in Advantage coverage.

Just trying to learn as much as possible about the larger picture by examining the more local decisions people make.