Kaiser Advantage or ???

[garyb1st]

My former employer announced they are discontinuing their retiree medical plan for employees/spouses 65 and over.  Beginning August 1, those previously insured under the retiree group plan will need to secure coverage on their own.  Those age 65 and older will be given an annual credit which can be used to pay for premium, deductibles, co-pays etc..  My options are to either continue with my current insurer Kaiser, on an individual basis, or obtain new coverage via Towers Watson OneExchange, the insurance broker handling all non-Kaiser coverage. 

Towers has many plans including other Medicare Advantage, HMO's and  PPO's.  But I'm not sure how to do a cost/coverage comparison between Kaiser and other non-Kaiser plans.  While I'm satisfied with Kaiser, I'm not pleased with the prospect of out of pocket costs that can exceed $10,000 a year.  However, if all plans have such significant cash exposure I guess it's a moot point.  Since I'm in good health I have no immediate concerns, but at my age, things can go south rather quickly.  For me, the only down side in staying with Kaiser other than what could be rather large co-pays, is their territorial limitations.  Kaiser does not operate in all states consequently if we relocate outside one of their coverage areas, we need to find another insurer.

For those of you who have compared the Medicare Advantage plans with HMO's and PPO's what's your preference and why? 

For those of you who have the Kaiser Medicare Advantage plan what are your opinions regarding cost and co-pays?

For those of you who full time or travel several months a year, what do you consider the best plans?

GaryB1st

 

[Gary RV_Wizard]

Medicare Advantage plans can be HMO or PPO too. Mine (from Aetna) is a PPO and they offer an HMO version of it too. And different plans have different out-of-pocket maximums - it's basically a trade-off against premium cost. A lower OOP usually means higher premiums, or some reduction in other features to offset the cost.

One thing that makes Advantage plans somewhat easier to compare is that they all have to provide a certain minimum coverage, basically the same a Medicare itself. And one of the options you should consider is to just stick with Medicare A& B. You would have the OOP exposure, but the additional premium (above Med-B) is zero. For people in good health, that's not a bad deal.

 

[Tom]

Here's a prior (long) discussion on the subject of Medicare & supplemental plans. It includes a number of posts on the subject of Kaiser.

We looked at, but eliminated Kaiser from our choices, while Kaiser works very well for some. Bob Buchanan's posts probably have the most info on Kaiser.

 

[garyb1st]

One thing that makes Advantage plans somewhat easier to compare is that they all have to provide a certain minimum coverage, basically the same a Medicare itself. And one of the options you should consider is to just stick with Medicare A& B. You would have the OOP exposure, but the additional premium (above Med-B) is zero. For people in good health, that's not a bad deal.

If I'm reading it correctly the max for Parts A & B is $5,900.  It's the Part D OOP that hard to evaluate.  There's a $4,500 threshold after which the cost of meds drops down for both generic and brand name.  Never having any health conditions requiring meds, I have no idea of what they cost.  However, after reading the thread in Tom's link, it looks like the numbers can be significant.   

 

[garyb1st]

Here's a prior (long) discussion on the subject of Medicare & supplemental plans. It includes a number of posts on the subject of Kaiser.

We looked at, but eliminated Kaiser from our choices, while Kaiser works very well for some. Bob Buchanan's posts probably have the most info on Kaiser.

Tom, Thanks for the link.  I remember reading it initially and being thankful I didn't have to deal with the Medicare quagmire.  After reading Bob Buchanan's post, I'm more inclined to stick with Kaiser.  We've had good experience with them over the past 9 years.  A friend who is a manager in one of Kaiser's Corporate Offices told me Kaiser is great if you know how to work the system.  I have to agree.  It's somewhat intimidating initially but they have great facilities and are quite responsive once you know the right buttons to push. 

 

[Gary RV_Wizard]

Prescription drugs prices are all over the map, largely depending on whether generics are available or not. Some common generics are so cheap that retail store pharmacies in Walmarts or local supermarkets actually give them away. Other drugs, especially proprietary ones, can run $200 or more a month.

Maybe I'm in the minority, but I think Medicare is pretty simple - basically it pays 80% of most everything and the claims process is all computer magic. It does its thing and you get billed for the rest. However, most HMOs cover more of the routine costs, so you have less concern about co-pays and deductibles. That's a trade-off against limited access to outside doctors and facilities, plus most all HMOs are local or regional. For that reason they are often not the best choice for travelers.

 

[Tom]

GaryB, we have a number of friends who have Kaiser and wouldn't change. Since you "know the system", sticking with them sounds like a good plan.

FWIW I beieve that Medicare parts A & B are quite simple and work very well. The quagmire comes with part F (supplemental) plans intended to pay the 20% that Medicare doesn't pay. We found a supplemental plan that works well for us, and it's not a HMO. Medicare puts out an easy-to-read comparison of all the supplemental plans available in your area. (They mail it to you, but the info is also available on their web site.) They also do a pretty good job of keeping the billable costs down, and we rarely, if ever, pay a deductible.  Most providers we deal with have figured out 'how to bill' so they get paid by the Medicare system.

RX plans aren't quite as friendly because of the "donut hole", but we've been able to navigate around that by using Mexican &/or Canadian pharmacies. Same drugs, same manufacturers, a fraction of the price. We only use them for the very high priced drugs that would put us in the donut hole (we'd pay full retail price) or would have high copays.

 

[ArdraF]

Gary, we had Kaiser when we lived in California and loved it.  Had to change when we moved out of their service area and miss it a lot.  Do you belong to AARP?  We have Medicare with PPO from AARP/United Health Care.  We went with AARP because it's good in any state.  If you want to travel more, HMOs can be problematic.  Kaiser was good at covering several emergencies when we were elsewhere, including Australia and South Africa.  We just gave them the bills and they reimbursed us.  That was sometime ago and they might have changed so you might ask.  Some HMOs are the pits from the get go and we wouldn't belong to one unless it was Kaiser because the doctors run the place instead of the bean counters (at least they did when we belonged).  PPOs are good if you want to travel a lot but you do have to make sure they cover you in every state.  We have Part D through another provider and it's about the third one we've used.  In any case make sure you're covered in every state.  Check their formulary for any drugs you may have taken in the past to see if it's covered.  We're also pretty healthy and don't need much drug coverage but life takes strange turns sometimes so you need to be prepared in case they're needed.  Get on the Medicare web site so you can make intelligent comparisons.

ArdraF

 

[garyb1st]

Ardra, Kaiser still reimburses for medical emergencies when outside the coverage area so traveling should not be an issue.  Unless we exit the Golden State and move to an area not serviced by Kaiser we should be good. 

 

[Bob Buchanan]

Kaiser administers Medicare. I believe I've mentioned that somewhere. So I never submit bills to anyone for payment. If I have an out of state ER thing - I just give them my Kaiser enrollment card that contains a number to call. They do and Kaiser gives them the OK to keep me alive or whatever is needed. That hospital then bills Kaiser. Kaiser pays the 80% "and" the supplemental amount as well.

The part I really like is that the hospitals bill in the thousands, and Kaiser only pays them in the 100's. If they bill $10,000 for a procedure or on call doctor, Kaiser will only pay what medicare allows - then the hospital just writes off the rest. The notifications to me mentioning the difference ends with a statement like, "You are not responsible for payment of this difference."

Kaiser Advantage also offers an added insurance plan for hearing, dental, and optical. It provides $350/ear hearing aide allowance, $315 for glasses, and enrollment in one of Delta Dental plans. It costs $20/month and renews the amounts every 2 years for hearing and optical. I just got a new pair of prescription sun glasses and a crown that was $485 through the plan dentist I see.

I pay $126/month that includes the $20 insurance plus another $100 is deducted from the SS check. So again, Kaiser takes care of everything for me. I also like their automation. No manual records - everything is on their computer systems. No matter who I visit that MD or whoever has read my entire history on their computer prior to my arrival. Have never witnessed a doctor write anything down - just data entry behind a computer screen. Also, I carry a flash card with me all the time that contains my complete medical history. It cost $5 initially with unlimited free updates.

One downer this year so far. All my copays are $25 - with an ER $65, and overnight hospital stay, $250 (I think). Blood tests "were" also $25 whereas this year they rose to $45. I solved that by going down the street to a commercial lab and get the tests for $28. In that case Kaiser faxes that, or any lab, instructions and authorization to draw. If on the road out of state, I just find the closest lab if needed.

 

[garyb1st]

Bob, I also have the option to purchase the supplemental coverage for $20.00.  Sounds like it's the same plan.  What is your annual OOP?  Aside from the supplemental coverage of $20.00, Kaiser doesn't charge me anything.  Do you pay $126 in addition to what is deducted from your SS check or is the $126. all inclusive? 

 

[Tom]

The part I really like is that the hospitals bill in the thousands, and Kaiser only pays them in the 100's. If they bill $10,000 for a procedure or on call doctor, Kaiser will only pay what medicare allows - then the hospital just writes off the rest. The notifications to me mentioning the difference ends with a statement like, "You are not responsible for payment of this difference."

Bob, that's pretty much the same with Medicare and our supplemental plan.

Kaiser was good at covering several emergencies when we were elsewhere, including Australia and South Africa.

Ardra, a year or so ago a friend was hospitalized in Mexico. The bill was $58,000, which I believe he eventually got back from Kaiser, but he complained about "battling to get his money" for many months.

 

[Bob Buchanan]

Bob, that's pretty much the same with Medicare and our supplemental plan.

The person at Kaiser handling the payments is administering Medicare - so yes, it would work the same way. I had an ER probably about 4 years ago while in AZ. I had the same problem once while in NCal. The difference was that Kaiser ER fixed it and released me - cost, $65. The AZ hospital not only insisted I spend the night - but put me in ICU. While there they kept throwing stuff at me. First oxygen, then a fellow came in about midnight and had a mist kinda thing that he had me taking deep breaths with. And then they compressed my legs to avoid blood clots - and so forth. Each thing they insisted on doing I would shake my head say, "Folks, Kaiser ain't gonna pay for this". But was really saying, Medicare won't pay for this. It appears they were purposely running up my bill. Their bill to Kaiser was about $24,000 - which Kaiser's Medicare person cut back to about $1,000.

Ardra, a year or so ago a friend was hospitalized in Mexico. The bill was $58,000, which I believe he eventually got back from Kaiser, but he complained about "battling to get his money" for many months.

Wow, did this guy have to pony up $58,000 to get out of Mexico.  ???

When I have been in an out state ER, and am asked by the accounting person how I am going to pay I just give them my Kaiser card and tell them to call the number on the reverse side - and that they will instruct on how to bill Kaiser. Have never had to pay OOP. Not 100% sure as I've never been out of country with Kaiser. But think it wise if I was to make sure that hospital bills Kaiser directly vs. wanting me to pay 10's of thousands to get back across the border.

Tom, that's why I keep stressing that Kaiser administers Medicare. He wasn't battling Kaiser, he was battling Medicare. The Kaiser person handling his event makes the same decisions as if he was sending his bill directly to Medicare. The Medicare rep and the Kaiser rep could possibly have attended the same classes on how to deal with folks having an event in Mexico - or wherever in terms of what is valid. Sadly, he seems to have been blaming Kaiser vs. the rules of payment established by Medicare.

 

[Tom]

Sadly, he seems to have been blaming Kaiser vs. the rules of payment established by Medicare.

Possibly, but the bottom line was that he had to 'fight' to get reimbursed after submitting his receipt(s) to Kaiser. The issue could well be that Kaiser/Medicare didn't have the opportunity to dumb down the charges, but it's unlikely they'd have any leverage over an out-of-country provider anyway.

 

[John From Detroit]

On facebook just now I read all about how "Obamacare" is not working.

Story: Layed off worker choose a Kaiser plan from the health care dot gov web site.

And got a Kaiser plan.. that did not cover the services he needed.

Kaiser is the original HMO.. When I went to work for the state I had my choice of a few selected HMO plans or what is now Blue Cross (Was Aetna at the time) I choose Aetna.. A general traditional health care plan that let me choose my doctors and hospitals. NOT an HMO.. It has morphed further into a PPO but it still covers me no matter the doctor or hospital.

The article, of course, was not about Obamacare,, but Kaiser..  Choose wisely please and for travelers, I do not think an HMO is the best option.

 

[Bob Buchanan]

Possibly, but the bottom line was that he had to 'fight' to get reimbursed after submitting his receipt(s) to Kaiser. The issue could well be that Kaiser/Medicare didn't have the opportunity to dumb down the charges, but it's unlikely they'd have any leverage over an out-of-country provider anyway.

Tom, it would seem his fight over the 80% that Medicare covers was with Medicare, not Kaiser. Kaiser makes no determinations on who gets what. That is determined by Medicare. Kaiser doesn't have a dog in that fight anyway - it's not their funds being paid. With the other 20% covered by Kaiser being the supplemental - that would be a fight with Kaiser.

But it is possible as you point out - that the Kaiser person administering Medicare misread her/his instructions on what was a valid Medicare payment - and he had to fight them on that. But I see that as unlikely. If I was that person with Kaiser or the boss of that person - I would "not" want the member calling Medicare and complaining too often. Which may be exactly what your friend had to do.

Am curious - did he get rejected for the entire $58,000 - and did he have to pay that OOP upfront? Yikes!! Would love to know just what Kaiser refused to pay for. Was it something he could have waited until returning to a Kaiser facility - or was he in an accident and taken to hospital? It would certainly be interesting to know more detail - so I could make sure I don't do whatever Kaiser didn't like. As far as I know from my own experience, my families experience, and friends such as the Fitzgerald's, if a Kaiser member has a life threatening emergency, anywhere, Kaiser (which is really Medicare) does not refuse to pay.

 

[Bob Buchanan]

And got a Kaiser plan.. that did not cover the services he needed.

The article, of course, was not about Obamacare,, but Kaiser..  Choose wisely please and for travelers, I do not think an HMO is the best option.

John, not sure what you are advising or whether you are recommending not using Kaiser - or whether you don't like Obamacare . . . 

If the fellow chose a Kaiser plan that did not cover his needs, is that Kaiser's fault or Obamacare. Of course, here, we're talking about Kaiser Advantage - which does not involve your example person.

One thing that is obvious on my visits to Kaiser - a lot of new folk are signing up. The lines "are" getting a bit longer. Fortunately, I know the best times to get in line. For example, I "never" get lab work such as a blood draw on a Monday morning. After 3:00PM later in the week is best.

 

[Tom]

Bob, I have no idea who was objecting to what, or what the outcome was. Since he hasn't complained about it for some time, I'd assumed he eventually got paid part or all of what he claimed.

 

[Bob Buchanan]

Bob, I also have the option to purchase the supplemental coverage for $20.00.  Sounds like it's the same plan.  What is your annual OOP?  Aside from the supplemental coverage of $20.00, Kaiser doesn't charge me anything.  Do you pay $126 in addition to what is deducted from your SS check or is the $126. all inclusive?

    Gary, my older brother worked and retired from IBM. After Obamacare - his retirement coverage through IBM was dropped. I guess IBM then pays for his new policy which is now Kaiser Advantage. In my case, I pay for both the Medicare and the supplemental. So that is something like $106 plus the $20 (dental, optical, hearing ins) I pay directly to Kaiser, plus, the $100 deducted from my SS check each month.

This year, after the impact of Obamacare, the only changes in fees I have noticed is that ER has gone from $50/visit to $65. If I recall, the hospital overnight went up a bit - and a blood draw went from $25 to $45. The later, as mentioned early, has been taken care of by using a local commercial lab instead. Less expensive and no waiting lines. All of my meds are in the $10 to $15 range for a 100 day supply and appear the same as the past few years.

 

[John From Detroit]

John, not sure what you are advising or whether you are recommending not using Kaiser - or whether you don't like Obamacare . . . 

As I understand it Kaiser being the founder of HMO's is the best one.. but it is still an HMO

What I am saying is two things:

ONE: HMO's which have Doctors and Hospitals they contract with.. Care at non HMO hospitals is usually limited to stablilize and transport, on an HMO approved ambulance (Less you have a MASA membership, then MASA transports).

Two: HMO's generally do have nationwide contracts and thus are NOT the best option for an RVer.

So if you have a doctor you like.. ASK HIM what plans he is with.. Then pick one that both covers what you need, and which has nationwide coverage.

As for Obamacare.. It is still a Baby and it is too soon to be posting an opinion on it that is anything other than political.. As I said the article was about the Kiaser paln the member choose. Which was clearly not the best plan for him. 

The Reporter tried to make it about Obamacare... But if you understand Obamacare.. That's not the problem IN THE SPECIFIC CASE the reporter cited...    So the reference to Obamacare was because that's how the reporter headlined it. And that's all.