Is Your Medicare Plan Dis-Advantaged?


A medically fragile home has few issues more compelling than how to cover medical costs. Being income restricted, and mobility strained, getting the right information to make decisions is essential.

Functioning in my disabled state means doing things as efficiently as possible.  Keeping long-term goals of health in mind, I look to utilize as many outlets to accomplish that as possible. I heavily use, nontraditional thinking to open hidden doors. Some doors open to marvelous things, others open to, “ah, can we all pretend that didn’t happen” awkwardness.

In addition to challenging myself to think differently, I sprinkle in an equally oddball humor. I get so amused when I see ads celebrating the happy life of a retired couple, romantically gazing into each other’s eyes and relaxing on a porch, while a narrator tells how much their Medicare Advantage Plan has helped them achieve that moment. I genuinely find it funny, right alongside with pharmaceutical commercials that has a girl running through back mountain trails without pain because she is taking Lyrica for example. And as she glows in the glory of the peak’s stiff breeze,  announce rapidly the list of potential dangers, accompanied by classical music, with statements like death, arms dropping off, or eyeballs popping out.

The entire sell is an excellent testament to manipulative redirection, so you focus on the possible benefits and overlook very likely risks. Of course, this is not an across the board issue. Our sue-happy society has pushed many companies to over proclaim things in an attempt to offset lawsuits. It indeed has become a joke and point of entertainment. My absolute guilty pleasure watching – entire household of fans, friend Lilly here knows just what I mean. If you need a lighter moment, and a great laugh, check out her humor presentation of just what I mean. We luv you girl by the way. Keep it up!

As humorous as it is making fun of such commercials, I see Medicare Advantage announcement ads exactly the same way. I find the notion of using them with an expectation they are without question, a better option than using Medicare directly, absolutely hilarious. This is in response to knowledge in many states, the contracts reached between mainstream private insurance companies and some medical providers,  profit by, taking “Advantage”, of consumers lack-of-knowledge about those deals.

I am not looking to have a politics specific article here, but it is frustrating to hear an ill-informed President keep shouting how National Healthcare is broken, without first fixing the private medical insurance giants he is so anxious to hand my health over too. The self-proclaimed deal-maker seems to be endlessly coming up short on seeing anything as a big deal other then himself. It is a shame in many ways. For as much as I disapprove of his handling of the nation, he does have some good abilities. I wish those were dialed and purposed to use them wisely,  and ensure those agreements are done in a manner to save patients lives, not save a very small few their fancy summer homes. To have the potential to transform redeemable qualities, and fail is quite regrettable for everyone. I grieve for the families hurting and feeling betrayed.images

I may not like it, but people want to make money and save it at the same time. Those goals oppose each other. The only way to allow everyone to enjoy advantages is to have the right form of payment each desires to have. Medical systems want to spend less on patients, insurance companies want to spend less to care for patients, and the Government wants to cover less for the patient.

Patients want to be healthy, be cared for, and not robbed of the ability to support themselves and loved ones. How do those desires work together? Endless cost increases, reducing services and lowering quality of care allowed to be given, place too much strain on a medical infrastructure currently doomed to collapse. My 15-year-old son has said something so wise. He says, “… it makes no sense to demand payment from an already poor person. How do they expect to collect payment from six feet underground”!

Back in 2016, I required complicated surgery. It was proving to be a lost-cause fight to get it approved. I was with a BCBS Advantage Plan. After getting all the quotes, projected costs from the hospital, and the portion I would be responsible for, it did not add up.

The concept put out to the public is, using an Advantage Plan will lower costs achieved by the insurance company contracts with providers. However, they are happy to still charge the 20% you are traditionally responsible for since Medicare covers 80%, and when questioned quickly remind you that. But using a more traditional private plan disguised in an Advantage Plan, you are also subject to excessively high copayments. There are no adequate laws preventing companies from forcing the Medicare recipient from having to pay the carriers 20%, which may not at all match what the original 20% would have been if they were not involved. In fact, you might pay far more than the original 20 %, as many insurance carriers manipulate the billing to make sure a profit is received.

Being disabled with a spinal cord injury, I see my neurosurgeon a lot. Those office visits are costly, even more than a regular specialist. While using my Advantage Plan, I had to pay $60 co-pay. That itself was double from the previous year. Most providers require that before seeing you. If you do not have it, you must reschedule. So you pay that, have your visit and then get a bill in the mail claiming you still owe 20%. It should be that all you do is pay your co-payments if utilizing a private based Advantage Plan. However, it plays out very differently. Over 24 months, I tracked all my medical costs, each Dr, each visit, every drug. A pattern emerged that concerned me. So I dropped my Advantage Plan and utilized Medicare directly. Doing that meant I only was responsible for my 20%. No copayments, just the straight up %. Additionally, since medical providers get a specific fee set by Medicare, often you are billed the 20% later.

In the event, you must pay that percentage at the time of appointment be sure to follow-up later to verify any possible overpayments. Most often payment occurs on the back side. This very point made sense to me and gave me better care. My finances at points were lean enough I did not have the $60 copay, which meant I had to walk away not cared for or did not bother making an appointment in the first place. Being caught in those funding gaps, and having a genuinely pressing health matter ( not necessarily an emergency), I was forced to use the ER, creating more cost for everyone.

In my set of circumstances, utilizing Medicare directly brought my neurosurgeon office visits down to $17.93 per encounter. Not only did I benefit huge savings, but also had the advantage of paying that fee after receiving the medical treatment so urgently needed. Honestly, delayed treatment only serves to destabilize chronic conditions more and in the end, creates much greater cost, causing increased financial loss. When it comes to chronically ill patients, the best way to cut costs is to keep them stabilized. Emergency room cost can quadruple medical costs compared to preventative care in the physician office.

Much of the problems are the payment contracts between medical systems, insurance carriers, physicians and Government agencies. Within them are the blueprints designed to ensure their profit lines. As the laws stand, consumers have no rights to know what those blueprints are, and how we carry the most financial risk. I am confident they would disagree with my assessment, but their trustworthiness is not a characteristic I would credit them with. Over and over investigations uncover many layered cheats built into the system of contracts, ones that remain secret and hidden most of the time. The whole design has caused a heavy toll on medical consumers.

In a 12 month period, I was able to reduce my out-of-pocket costs by $4000, not including the savings of no longer paying monthly Advantage Plan premiums. I also was able to have two surgeries my previous BCBS Plan kept denying. Even though my surgeon proved it to be medically necessary, and after the conditions worsened not completing those surgeries earlier. By dropping BCBS I had my surgeries, and Medicare covered and at a lower cost for everyone. What I appreciate so much is Medicare carefully send a statement to disclose the maximum amount the Dr can bill you. They let you know, your surgeon submitted a $3000 bill, and we covered $2700. They can only bill you for $300. Whereas with an Advantage plan, lots of structured cheats occur, and you cannot always verify accurate cost, not with ease anyway. Bottom line, not only did I save money, I received the urgent surgery I needed to remain healthier.

Before I made my final switch, I diligently took time to sit with multiple physician practice billing departments. That initiated an entirely new desire to dig much deeper. I interviewed eight separate billing specialist. They are unrelated practices and varied health systems. Included were, a family practice, NeuroSurgeon, Orthopedic, Rehabilitative Therapy, Hematology/Oncology, Ear Nose Throat, and two Internal Specialty Offices. To each, I took a stack of my past medical bills for analysis. I was pretty amazed to find out the first thing all of them suggested was to consider dropping my Advantage Plan. Their accumulated reasons for that were patients needing extensive surgery, medically fragile, or with more than 3 diagnosed chronic diseases do better financially on direct Medicare, rather than the private plans available in my area. It is noteworthy to state, that because every medical system or medical practice establish their own insurance carrier contracts, fees you get billed will vary. In some cases, I uncovered that Medicare, Medicaid patients were contracted at completely different fee points than private pay. As an example, the same cataract surgery for 3 sample patients in addition to my own, was a range of about $230. The most expensive was charges billed to Medicaid, being an average of $800  more than the others. That particular point was not new information to me. Because Medicaid is very strict, doctors feel they lose money by servicing that population, too offset that, they overcharge to ensure a profit. My years as medical practice manager I did often trend additional administrative cost to satisfy Medicaid documentation needs to pay physicians, but rarely was there any real income loss to doctors. Its a bit of moan-n-grown disposition as my physicians wanted nothing to do with the amount of paperwork asked for.

medical billing

In regard to many other details, all my professional experience did not yield me the same level of results, this research did. When I worked, Medicare functioned differently, and insurance giants were not clamoring for Medicare dollars in the same way I see now. Much has changed in the last ten years, and processing the business end is drastically different than resolving the patient end of the medical consumer encounter.

For my health requirements, an Advantage Plan proved to be overcharging, willfully impeding needed care and offering fewer preventative services. These restrictions only benefited the plan provider. Going to a direct Medicare process simplified my life, saved money, and created a greater level of reliability in what the bottom line cost was. I don’t expect any Advantage Plan to suddenly disclose the truth based on one blogger’s article. They have plenty of well-paid lawyers to fog the lens of truth.

I absolutely do not mean anyone should rush out and drop their Advantage Plan. In some states, the Advantage Plans offered are far fairer, have more reasonable options and even lesser restrictions. Plans are locally established to your area. What I am encouraging is rather than assume an Advantage Plan is all it claims to be. Take time to research what fees you are paying and compare shop. Not just between plans, but compared to Medicare directly. You can get a surprising amount of information by actually calling Medicare. Their willingness to disclose helpful information was very refreshing. I regularly call to ask them questions just as I had with my previous plan’s customer service or claims department. As a side note, I found the majority of representatives to be friendly and professional.

I keep in mind medical insurance carriers, and my really great doctor of 22 years are in the profit business and although I know my primary care physician wants me to be healthy, he also will not see me if my funds are not available that day. That kinda says it all.  That has also contributed to quite a few physician friends being just as frustrated as the patients. There is a current trend of physicians pulling back out of corporate medicine to reclaim their private practice status. What is driving that trend is their desire to gain some control back, be able to manage their own contracts and provide a higher level of care to their patients by being less hog tied by insurance carriers and large corporating CFOs. Who by the way, often have no clinical medical knowledge at all. No understanding of how a dirt cheap dressing for IVs compromises the patient’s skin, as an example. They want to fix, what a corporate medicine structure has damaged. I applaud them and celebrate so many of them as they regain clinical, practice independence.

For homes caught in the delicate balance of critical health issues, revisiting your insurance plans is essential. Stress is placed to do those processes during enrollment periods but anytime is sufficient to look at your billing charges. If you also receive Extra Help prescription assistance through Social Security Assistance, you can change plans at any time. You can also apply at any time, it’s easy and if approved kicks in immediately.

It’s possible you can ease the financial burden on your home by verifying if any Advantage Plan is right at all. There are no penalties for dropping them. Just be sure to enroll in a new Part-D Prescription plan first. In the event you get it all wrong, the emergency backup prescription plan for Medicare is through United Healthcare currently, and your pharmacist can set it up while you get through an insurance gap.

The enrollment period is directed more towards new enrollment and less about dropping a specific Advantage Plan when you are doing so to switch to Medicare directly. Even if a fee ends up being charged, you might be surprised it is lower than the extra premium payments you were handing over every month.

As with any big decision, do your homework, know the plans in your County and balance that against where you receive current care. I find that using Medicare directly I have a much larger size of providers to select from and experience fewer problems getting to specialists. My circumstances may not relate to yours at all, and therefore what has now worked for me, might be inappropriate for your own set of challenges. The goal is to have access to the best care, at the most reasonable costs. Sometimes paying a little extra is worth it. Sometimes the stress of figuring out the whole confusing mess is too much at the time. Along with any recommendation to check things out is a more urgent one to only do that when you have the mental time to do it right. I regularly table things if there is too much to manage. So don’t feel bad if you are caught in a case of the duh, blahs. You really don’t want to see me on those total energy meltdown days. It’s a bit scary to behold, I might not even manage a good hair brushing those days, yikes. Keep that our secret, tell no one, seriously!

If you need a place to start your own research you can use some of the helpful links below. As always offered, if you want some ideas from other families you can always post in the comments section, email me at or use the contact form, (which is finally working).

Author - Image–Author Pamela Juers

5 Ways to Revisit Medicare Plans & Assistance Options

1. Utilize sites with good ToolKits. These often are well organized and less overwhelming.

2. Visit Medicare’s Extra-Help page and use their quick eligibility and application. It is very simple. Many people don’t know they qualify.

3. Inquire with your state’s DHHS (Department of Health & Human Services). Often a call to your County office or website can provide income ranges for assistance. Applications are complicated, but thankfully many organizations stand ready to help if you are unable to manage yourself. In some cases, DHHS will send someone to your home to complete this. It’s worth checking out especially if you are caring for a disabled family member.

4. Get support and connect with people who have been there done that. In addition to myself are many others having the same mountains climbed. Check out a few I have turned to over the years. Advocate agencies are a good resource for some.

5. Make sure to update Health Care Power of Attorney along with any plans changes that are related. Some insurance carriers require documentation to openly discuss and allow changes to be made.


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