Health plan education question: For Medicare Advantage plans (MA) is there a name for a document that contains the limits for the services the plan covers? Or do MA plans have to use the Part A or B limits for how much the plan pays to see a provider before they stop approving PAs or claims? Or are the limits a secret?
Asking to try to help a family member figure out their MA plan. Not a diabetes issue but I figure people with diabetes know more about health plans than your average person on the street. Even if you don’t know the answer to my question have you found a good resource for health insurance education?
As a friend who is a primary care doc at Mass General Hospital told me yesterday, Medicare Advantage Plans are not a good fit for people with complex medical issues - not only T1. If your family member can afford decent supplemental and drug plans choosing a Medicare Advantage Plan may turn out to be poor long term strategy.
In other words there is no limit on either “original” Medicare or Part C; both continue paying, without limit.
This is not the case on non-ACA plans where the limit was traditionally at least $1,000,000; in other words private plans would stop paying anything after that amount. I’m saying this for younger Americans who weren’t born before the ACA, or at least were on their parent’s plan and didn’t take much notice.
In practice MA plans as well as “original” with a Medigap (pretty much a requirement) also provide a limit on how much we pay. I.e. they don’t just stop the insurance company copping out when they’ve paid a couple of million, they also ensure we don’t pay more than a certain amount per year. This is the “out of pocket maximum”, I regard it as the big deal; I would like to see a lifetime OOPMax (as I normally refer to it), just like the rich guys got a lifetime OOPMax for their own pockets prior to the ACA.
Today on the ACA you need approximately $10,000 per year to stay alive. On “original” Medicare the numbers are in flux but seem to be less. On MA I believe the numbers are broadly consistent with the ACA - $10k/year, hence @still_young_at_heart 's endo’s comment.
Of course his endo did not point out that once you have signed up for -the army- MA you never get out.
I agree about MA plans. But once you’ve chosen a MA plan you’re generally stuck with them. Lets circle back to how to exit an MA plan after I figure out how to find the service limits.
There are limits on certain services for Parts A and B. I’m asking if there’s something I can look for to find limits for a particular services covered by a particular MA plan. The EOC just says covered, copay, PA, in network only.
I think part of my problem is “limit” is the wrong word, I keep getting search results for the limits you mentioned which aren’t what I’m looking for. I’ll try “cap” and “maximum”. Any other suggestions?
While that document explains the different sort of MA plans it does not explicitly say that the different sort of plans prices are limited by the Medicare rules however, in the case of Private Fee-For-Service plans it explicitly says that this may not be the case:
If your provider doesn’t agree to the plan’s terms and conditions of payment, the plan is only required to pay them for emergency services, urgently needed services, and out-of-area dialysis. For other covered services, you’ll need to find another provider that will accept your PFFS Plan.
Note: A PFFS Plan may also allow “balance billing,” which means that a provider can charge up to 15% more than the amount Medicare pays, and bill you for that amount.
The Google AI says the following when I query using, “can an MA plan charge more than Part B”:
No, a Medicare Advantage (MA) plan cannot charge you more than the Part B excess charge limit for a service, but this is because MA plans are designed to cover both Part A and Part B benefits and have their own out-of-pocket spending limit. However , Medicare Advantage plans do not cover the Part B excess charges themselves. Instead, their annual out-of-pocket maximum can protect you from paying charges that exceed the plan’s limit.
I couldn’t find that information in the links provided. It may be mistakenly derived from the information about fee-for-service plans above. Nevertheless it wouldn’t make sense to me to document an exception for PFFS plans alone if possible for other plans.
Notice that original Medicare does provide a limit. This seems fairly simple for Part A (unless you spend more than 365 days in hospital, when Medicare stops paying). For Part B it depends on accepting assignment:
It seems consistent with the AI and the above document if Part C is limited to the +15% for all Part B items. What is more Part C is meant to cover Part A+Part B (except for hospice care). They seem to make money by restricting providers not charging more:
So the limit should be the same as the CMS approved amount plus, in some circumstances, 15% so long as the rules for the MA plan itself are followed.
Finding this stuff after enrollment is easy; just ring up the plan. Finding it before enrollment can be more difficult but SHIP is intended to help with that:
Depending on where you live SHIBA may be available, search for “SHIBA Medicare”, it’s funded by SHIP. OR and WA have SHIBA, CA doesn’t but has something similar.
If you are talking about time limits I don’t think they can do that at all; Part C has to cover Part A and Part B, so any time limits are the Part A ones (there are no time limits in Part B).
Medical necessity will be used to limit coverage, but that’s not a time-limit per se and it’s in Part A (check the rules for in-patient post surgical care, which is in Part A not Part B).
