VBID (Ending for 2026) took care of the copay or it was in a $0 Tier 1 or $0 Tier 2. Just speculating.
Medicare 2026 Update Vid
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It's not just by state. MA plan offerings are allowed to vary by county or even more granuarly. (Thus the annoying "Check your ZIP code!" commercials.) They're using algorithms to extract profits with surgical precision.
Which by the way I'm not seeing those commercials this season.
Which by the way I'm not seeing those commercials this season.
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Fortunately for the Medicare eligible patients, the insurance companies are losing interest in the Advantage plans - the profits are not as much as they used to be, and their denials of care are getting more scrutiny. I was talking to an insurance expert today, apparently healthcare denials by the Advantage plans went up by 55.3% between 2023 and 2024. About 17% of care ordered by doctors is now denied by the insurance companies.
Yeah, I have no clue but just so you know it’s typically a tier 5 specialty drug of course tears are set by your drug insurance company, but tier 5 is typical. It can not be filled at your typical pharmacy like CVS or Walgreens. It’s filled by a hospital specialty pharmacy or at least in my case it was because of the Doctor who I no longer go to sent a prescription to CVS and they were like huh? We can’t do that here.
He didn’t even know about this new drug. I got the information from Duke University. This local Doctor Who supposed to be a specialist just to say, waited for too long to do a biopsy on me and was completely negligent in getting the proper imaging.
It’s still upsets me so much. I don’t like to talk about it. But I am good to the best of my knowledge, but I was grade 3. I feel mostly because of his incompetence.
I don’t know what VBID is. However this is a new drug and I think, though I don’t have intimate knowledge of it when a company comes out with a new drug they are flexible with pricing to institutions and end customers.
I could be wrong, but I think it’s to get the product out there
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And my guess is that that 17% denial rate is highly misleading as it's a straight average.
Almost certainly that 17% average is distributed according to some kind of scale-free distribution with denial rates being near 0% in the first 10 years (or so) of coverage, and around 50% denial rates in the last 10 years of coverage.
Covering everything when an enrollee is new and not too sick is great PR and leads to lots of stars on the reviews.
But they make up for it on the backend when you're really sick and truly need the coverage-- most everything of substance will have a good chance of being denied.
And there's no hit to PR-- dead people don't fill out reviews.
Probably - as a person ages, their need for healthcare becomes more and more serious. The denials normally are for imaging services, surgeries and inpatient care.
The figure 17% is for the pre-authorizations plus claim denials during the calendar year 2024. When a pre-authorization denial is disputed by the doctor or the hospital, 93% of the pre-authorization denials are overturned. However, only about 10% of the pre-authorization denials are followed up by the providers.
So, in general, if you have an Advantage plan and need serious care, there is a not-immaterial chance that either care will be denied, or will take a while for the denial to be overturned.
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I didn't know about the 10% follow up rate. However, I have seen that while the overturn rate is very high, what they don't tell you is that often the response to an overturn is to file a new denial on slightly different grounds-- usually the next day.
Even though near-identical, the full appeal procedure must be entered again from the beginning. And if you win that, they will modify the denial again (the next day), and you start the process over. And so on...
I wonder if that possibility has an effect on follow up rates. Since all the stats are aways combined, I'll be that 93% overturn rate includes multiple overturns per case, and the failure to follow up is not after the first appeal.
Just speculation on my part, though.
Exactly.
And the key thing to remember is that that will likely not happen in the first 10 years of your coverage, lulling one into a sense of confidence in their coverage.
But in the last 10 years? Lord help you, because the insurance companies probably won't.
50% of Americans are good with advantage plans.
I wonder if many are even in the Medicare system.
And to advocate them going away is a horror.
To be stuck in one system with private insurance companies would suck.
I don’t get why anybody cares. you have two options three actually. Plain Medicare part A and B plus optional D
A Medigap plan to write on top of that which is typically g or n
Or save money and go to an advantage plan.
Why does anyone else care?
I guess some people just want to force you to take something more expensive when they’re happy with something less expensive by far
America is based on choices
And what really blows my mind all of a sudden everybody thinks doctors are always correct, and government run agencies are always the most efficient which advantage plans prove they are not. Then most, most, most of all everybody believes what’s in the media without analyzing it.
The shock value is always how many authorizations and procedures are turned down. Instead of saying, how many authorizations and procedures are overturned once they appeal to Medicare.
I wonder if many are even in the Medicare system.
And to advocate them going away is a horror.
To be stuck in one system with private insurance companies would suck.
I don’t get why anybody cares. you have two options three actually. Plain Medicare part A and B plus optional D
A Medigap plan to write on top of that which is typically g or n
Or save money and go to an advantage plan.
Why does anyone else care?
I guess some people just want to force you to take something more expensive when they’re happy with something less expensive by far
America is based on choices
And what really blows my mind all of a sudden everybody thinks doctors are always correct, and government run agencies are always the most efficient which advantage plans prove they are not. Then most, most, most of all everybody believes what’s in the media without analyzing it.
The shock value is always how many authorizations and procedures are turned down. Instead of saying, how many authorizations and procedures are overturned once they appeal to Medicare.
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Are those 50% who are happy experiencing this happiness in the first 10 years of their coverage, or the last 10 years of their coverage?
Silly conversation. and why ask a question like that? Without stats? If you think the public would stand for government to ban Advantage plans to the elderly forcing them to pay 300, 400, 500, 600, 700 more for health coverage, Its not going to happen. It's so far out there.
In addition to my past post. Private Advantage plans control fraud much better than government and you can bet the cases that are never pursued to be overturned contained some type of fraud on Advantage plans. Not only that, but media hype attacks the less critical thinkers or analyzers to have all the information not a headline.
Meanwhile Medicare that does rarely deny anything, improper payments of ONE HUNDRED BILLION DOLLARS or more was made in 2023.
Who ever said government is better than private industry.
To repeat again, every worker in the country (except government maybe) has the same insurers as the Medicare group. Those workers have no where near the protection that seniors in the system have. It's all media hype, attracts clicks and advertisers.
Medicare A and B at work =
https://www.cnbc.com/2023/03/09/how...d-fraud-became-a-100b-problem-for-the-us.html
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I don't know, man. I'm honestly not sure I've ever interacted with anyone less capable of getting a point than you.
Yes, if Advantage was exactly the same as a Supplement, with the only difference being that Advantage was cheaper, then of course it would make sense for everyone to get Advantage.
If Advantage was exactly the same as a Supplement, with the only difference being that Advantage was cheaper, and Advantage disappeared causing people to pay "300, 400, 500, 600, 700 more" for the exact same coverage, then of course it would be a problem for the former Advantage holders.
Why would I or anyone else argue against that?
The problem is that not all of us agree with you that Advantage necessarily offers the exact same degree of coverage that Supplements do.
Maybe we are wrong on that.
So, many of us like to discuss whether what we perceive as the added coverage that a supplement might provide over Advantage might be worth the extra premium cost. We're trying to figure out the real truth of that proposition.
You don't want to participate in that search for truth (and call those of us that do dumb) because you insist that Advantage is the same as Supplement.
You come to that conclusion because you wear blinders so that you can only focus attention on the parts where Advantage is very similar to a Supplement, and simply refuse to listen, consider, or even understand why some believe that, if you would just look (for just a few seconds and with an open mind) at the areas where Advantage is different, you might come to a different conclusion.
But alas, there will be no changing of your conclusions as you cannot be moved to the point where you even look at (let alone understand) the areas where Advantage might be inferior to a supplement or the lower cost of Advantage might be a false savings in reality.
But, that's fine. As you always say, choice is good, and you have made your choice of Advantage without considering (or understanding) why that could potentially be a bad choice.
So, now that your choice has been made, you've made it clear that you think all of us considering a different choice are all idiots who are willing to pay far more money for the exact same thing that you are getting far cheaper, maybe you could leave us alone to have our discussion of alternatives?
I know it must be painful for you to have to witness us idiots scheming to throw our money away, but not all of us are smart enough to know that one shouldn't pay far more for something when the exact same thing is available for far less money.
So, please have pity on us. We're doing the best we can with the limited ability we were born with.
Thanks for your consideration.
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It was more funding to MA plans that helped target Efficiencies and cost. It offer a range of services but one of the main few were helping to pay prescription copay's & our favorite "healthy food or OTC cards". Next years plans you'll see that you are required to have certain medical conditions to qualify for that card since the funding source VBID is drying up next year. But you're probably right in that there may of been a discount available to you from the drug maker or something. Tier 5 can get pricey I'm sure.
https://www.cms.gov/priorities/innovation/innovation-models/vbid
UHC explanation:
https://www.uhc.com/news-articles/m...ding?msockid=25835fd69f616537195e49919e0e6457
The biggest changes were the removal of PPO plans for 1.3 mil. HMO's to a lesser extent.
https://www.oliverwyman.com/our-exp...-shakeup-in-medicare-advantage-offerings.html
Talks about what's going on in the Part D. Perhaps what I quoted below is what happened to you @alarmguy on that tier 5 drug.
https://www.oliverwyman.com/our-exp...t-d-drug-plans-for-success-under-the-ira.html
"Beginning in 2024, Part D plan sponsors must reimburse pharmacies based on the lowest available price at the point of sale, effectively eliminating the common practice of payers reducing pharmacy payments through post-point-of-sale direct and indirect remuneration."
I like Alarmguy's insights and he has saved me money. People have strong feelings on MA vs supp. I understand the denial uncertainty may drive some of that. However, I know someone who was on one of the two major MA insurer plans for over 30 years and had no issues getting care or having denials.
Interesting. Not sure what the results maybe. Im not concerned a lot of stuff has dried up anyway. I think based on my interpretation is the MA plans for people on Medicaid are going to drastically change. Anytime one searches for MA coverage, it's shocking at the array of benefits for people on Medicaid and/or Snap AND the number of plans offered are way more than people not on "assistance" I suspect that is what will go away. As far as those over the counter "free money" a lot of plans got rid of it with their "normal" MA plans now/
Great information and thanks for your post. I think (but could be wrong) I am going to look forward to the ending of the program. Maybe I am crazy but without the companies being forced to provide some of these benefits the normal MA plans might get more reasonable because right now, in many states companies are just walking away from offering them.
This VBID only same into play in 2017 at that time in 2016 close to 1/3rd the population still had MA plans.
Call me crazy *LOL* I like change, I get bored with the same old/same old ... and I see this as a government requirement that will be going away... it may (or may not work out for the people who pay and dont get assistance, either way, it will still provide the core benefits of MA or maybe possible companies wont offer them. I dont see the plans going away, even at a monthly cost. At times I chose MA plans that had small monthly cost to be in the plan and ignored plans, for instance. I could sign up tomorrow for a plan that will PAY me $180 a month to take the MA plan, I wont do it, the MOOP is to high, not worth it to me. So I am looking at a $0 a month company and I actually would pay $40 a month for a BCBSNC plan which is great and I still may or mayn't call them, a new hospital near us isnt in their HMO plan but is in their PPO plan. I think it's an error as all the other plans have that hospital and medical buildings in it. But either way a Humana HMO plan that has every conceivable medical network including DUKE Medical at $0 is available to me
Thanks again, I had no idea about anything VBID but now I think understand why there are so many Medicaid and Snap MA plans unavailable to the public and slim pickings for us not on those programs, ALSO plans specific to health issues that healthy people cant get into.
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I see the removal of offerings from the MA providers as maybe good. It will prod medicare to increase what they pay for the plans after not giving any increase for 3 years. Clearly if they were making boatloads of money on the plans the companies would not be pulling out.
It's not worth it to them and even the media hype that makes them look like villains to a uniformed pubic. So I say good for them.
I also think as you posted with the removal of that program in 2025 VBID (thanks for the info) it might help these plans. Actually maybe it's why they pulled them from high cost areas. Im clueless... interesting for sure! So far I still have great options here! My old state is a train wreck but that is why I got out of there almost 20 years ago. I saw it starting to happen and it continues the same path.
AS far as my part D that isnt it. The bottom line is you have a Part D deductible. My part D paid over $12,000 for the $14,000 drug however the hospital only took half of that deductible. I suspect it was on the Hospital pharmacy end, possibly in concert with the manufacturer. (btw- I am not on public assistance) All I know is she put my on hold before she was going to send the first month to my home and came back with a new to me cost. (heck as far as I know it was an error but I dont think so and never inquired how*LOL*)
You can also make a case that some things are too important to leave to the private sector, whose goal is to maximize the wealth of their shareholders.
It is a tough, Uber complicated issue. And will probably get more so...
Did you feel that way when you were employed? Your company health insurance had way LESS protections then an Advantage plan.
Private industry works best. However no one is automatically signed up for an Advantage plan, that is an option people chose.
My impression of you was private industry does better. However no one is thrown into a private plan. They are only in government plans, by free choice they choose to leave the government plan and join the private plan. So why would you think that everyone should be forced into a government plan when they are already automatically put in one but then willfully switch? Im sure you remember that government only plans did not work out so well in the old Soviet Union. It crashed and burned. Never met an American back then who wanted Soviet Union health care.
Anyway, free choice, government program or private, not sure if you thought about it because based on your posts I think you believe in individual freedom to choose
I elected out of the government program and saved about, roughly up to $9,000 over a 3 years period with MA plans. All the same medical institutions, tests and doctors. Private works most efficient as it does for 10s of millions of employed Americans who all have private insurance. Just because you are old doesn't mean you should no longer be able to have it.
BTW- estimates are government run Medicare lost roughly 100 BILLION dollars in 2023 due to fraud and abuse some suggest that the number is much higher. Most likely much like the old Soviet Union.
Private MA companies scrutinize more carefully and why they look like a villain when they verify a procedure. Dont buy the mass media story - click bait.
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Ok, I guess I just dont see anything wrong with the system. Other than media hysteria. I wouldnt want health care anyplace but here.
AS you know as some of your friends are, my wife came from overseas a long time ago, still has family there and there are some REALLY good medical facilities there today but they have way more trust in our system and procedures to the point of maintaining homes in both countries with what I just said as a significant reason.
Actually her friend is a doctor who practices in your state but takes that money to bring home for the good of others there. I wouldnt say more, she is well known. Way more than I am willing to reveal but I can post websites of what she does.
