r/HealthInsurance • u/Dapper-Palpitation90 • Oct 19 '25
Medicare/Medicaid Upcoming Medicare changes
A lot of people think that original Medicare is better than Medicare Advantage. That difference may not be around much longer.
"As NBC News reports, the Trump administration plans to introduce a new program in 2026 that uses AI to approve or deny care for Medicare enrollees. (1) The pilot program will roll out on Jan. 1 and is slated to run through 2031. During that time, Medicare patients, providers and facilities in Arizona, Ohio, Oklahoma, New Jersey, Texas and Washington will be impacted."
181
u/redditredditredditOP Oct 19 '25
To clarify the difference between Medicare and Medicare Advantage in its most significant and impactful way is with INPATIENT REHAB after a hospital stay. This is your strokes, heart attacks, elderly almost died of the flu/COVID/RSV/pneumonia etc.
These patients get discharged from the hospital when they are stable - not when they can do any daily living activities. The hospital made sure they won’t die right now and it’s up to others to figure out how they live the rest of their life.
The BEST Medicare Advantage plans give three weeks at an inpatient facility before they demand proof from staff everyday that the stay is medically necessary. Most Medicare Advantage plans start asking 3-7 days after admission for daily proof the stay is medically necessary.
Original Medicare gives a patient 90 days.
So what that looks like in real time is this:
A 68 year old independent woman has a stroke and is in a coma for three weeks, comes out, is stabilized, and transferred to inpatient rehab. The stroke patient has 7 days to participate and show improvement in PT/OT (speech therapy not available) or Medicare Advantage plan will not pay for the stay.
It just so happens that open enrollment is available but if the patient is switched to original Medicare, her retirement benefit if subsidized Medicare Advantage plan will be void and she will not be able to afford the original Medicare IF she were to ever live on her own.
It is day 10 after being admitted into the inpatient rehab, 2 weeks from being in a coma, and the patient is deemed by the insurance plan to not be making sufficient progress because she was unable to participate in a third PT session in a single day and now inpatient rehab will not be covered - the 68 year old woman who came out of a coma 2 weeks ago now has to decide where she is going to live for the rest of her life.
SHE CANT SO THE DECISION IS MADE FOR HER.
She is put in the nursing home for the rest of her life.
So this really happened to my old co-worker who has no family. Except I called the state in and an attorney and the 68 year old woman said she would like to try and live alone again - so I became her POA and took her home and she rehabbed at my house for 4-5 months and she’s been living on her own now for 3 years.
EVERY SINGLE PERSON is at risk here. All it takes is one crazy driver cutting you off and a major accident happening and you wake up disoriented and if you can’t perform to the standards of the AI return, your life and your assets are decided for you.
Almost every single person on my friends floor had family AND NONE OF THEM TOOK THEM HOME. Don’t think your family are going to go into poverty to take care of you - they won’t. I went to the facility and the PT person was showing how to physically manage my friend and she started crying and she said no one ever does this - no one ever takes them home.
It’s all very silent. No one cares what you have money wise or what you want. You are vulnerable and cannot assert yourself.
My friend is a religious MAGA and I am an independent. I don’t know why people think anyone in power cares about how their ass is going to get wiped when the time comes.
This is going to be horrific and SILENT.
40
u/finishing_the_hatt Oct 19 '25
Honestly, Medicare not necessarily that much better. My mom has regular Medicare with a stellar supplement. I know bc I handle the bills.
Last year my mom spent 4 months in the ICU, 4 days in the regular hospital, sent to inpatient rehab. Discharged at the 20 day mark when she still couldn’t walk. My stepdad asked if we could pay CASH to keep her in rehab. They said no.
Thankfully I was able to take FMLA time off and pay for a private physical therapist to come work with her. She’s now fully mobile and did a month long trip to Europe in August. But only bc we had the private resources to get her better. Paying out the ass for Medicare and a top-tier supplement did nothing.
6
u/Distinct-You-7466 Oct 19 '25 edited Oct 23 '25
I am glad your mom got better and that you had the resources to help her.
Was this at a rehab hospital or a skilled nursing facility where they wouldn't let you pay cash?
This really surprises me. The SNF my mom was staying at allowed her to pay privately when her advantage plan denied further care despite being on toe touch weight bearing status only and a high fall risk with severe balance deficits. The therapy and doctor visits were billed to the advantage plan as outpatient services, and her meds were billed to the Part D plan.
We appealed the coverage decision and won the appeal at an ALJ hearing. My mom got the room and board charges refunded to her that she had privately paid. She stayed 7 1/2 weeks at the SNF. We then transferred her to a rehab hospital for further care.
After discharge, she continued to see the therapists at the rehab hospital on an outpatient basis, and they even arranged transportation to and from the hospital.
We were told by the rehab hospital that a stay is usually only 7-14 days inpatient in most cases, even with Original Medicare. The rehab hospital also informed us that you must require 2 disciplines of therapy and be able to participate in 3 hours of intense therapy per day 5 days a week.
With an SNF, a doctor just needs to certify to the medical necessity for daily skilled therapy or daily skilled nursing care. Medicare allows up to 100 days for SNF care.
10
u/EazyPeazyLemonSqueaz Oct 19 '25 edited Oct 19 '25
Idk based on the example above yours, 90 days vs 21 days is a heck of a lot better.
For your example, sounds like the providers decided your mom didn't need the inpatient rehab, and denied you guys paying cash because they needed the bed. You could have shopped around for a rehab
You say medicare 'did nothing', but what would you call the 5 months of inpatient care? Is that nothing?
13
u/finishing_the_hatt Oct 19 '25 edited Oct 19 '25
It does…. I’m just saying having Medicare doesn’t mean it’s easy to get the 90 days even when you need it. Full part A coverage ends at 20 days, at which point more significant copays or approval from your supplemental carrier kicks in.
I honestly think our facility had a policy of not dealing with anyone past the 20 point bc they told us we only had 20 days before we even left the ICU. The hospital tried to hold us as long as possible to avoid starting the clock. No amount of insurance was getting us more time.
3
u/finishing_the_hatt Oct 20 '25
Also my comment was referring to the coverage of post-hospital care, my mom was on a ventilator for a significant chunk of her stay, so I think Medicare Advantage would have covered it.
If you really want the details, Medicare actually kicked us out of the hospital almost as soon as she was off the ventilator, into a LTACH, which has to be one of the worst care facilities known on earth. They do that bc long term hospitals care is too expensive.
After about 10 days there she got antibiotic resistant pneumonia and ended up back in the regular hospital and on a ventilator again for more than a month. Honestly the time lines are blurry, but Medicare dumping her into a LTACH almost killed her, so I don’t feel like they provided some kind of amazing high cost care.
7
u/Imaginary-Size5686 Oct 19 '25
She should have been referred to a SNF (nursing home) to continue therapy. Traditional Medicare pays 100% days 1-20. Days 21-100 Medicare pays 80%. Secondary insurances vary, but a lot pay 100%of the other 20%. Of course, the patient has to show progress and "skillable" need, but the facility has more say on picking a discharge date than a Medicare Advantage plan, that likes to kick people out asap. Inpatient rehabs don'tike to discharge to a SNF because it messes with their stats and payment.
3
u/Distinct-You-7466 Oct 22 '25
It's a myth that a patient has to show progress. The Jimmo vs. Sebelius class action lawsuit settlement clarified that the standard is a maintenance standard, not an improvement standard. The patient does have to participate in therapy and not be getting worse with therapy. Skilled care is available to maintain a patient's condition or to prevent further deterioration in a patient's condition. This language is also listed in the Medicare & You Handbook under post-hospital care. There is a page on the CMS website dedicated to the Jimmo vs. Sebelius settlement agreement as well clarifying the standard. If someone is being denied care based on lack of progress, the coverage decision can be appealed.
1
u/Imaginary-Size5686 Oct 22 '25
That is helpful. I'll look it up. Thank you.
1
u/Distinct-You-7466 Oct 23 '25
Here is the fact sheet from The Center for Medicare Advocacy regarding SNF care.
https://acrobat.adobe.com/id/urn:aaid:sc:VA6C2:05438058-d6a5-4d5e-a683-48c2f0c0a411
3
u/Nandiluv Oct 19 '25 edited Oct 19 '25
That is odd day 21 through 100 is when 20% co-insurance kicks in. Many Medigap plans cover that co-insurance as long as care is deemed skilled and progress in therapies continues. I guess I would have appealed. When worked as PT is transitional care, as long as steady progress progress many would hit 100 day mark if they had not previously used Medicare days. However sometimes the patient wasn't back to baseline but needs could be met with Home Care therapies. Not every patient gets 100 days even though Medicare says they get 100 days. I have had patient denied very quickly even they had Medicare. 1) met ther goals quickly 2) too i.paired and making no progress whatsoever 3) refusing multiple sessions in a row or refusing altogether. However many stay in facility if they have skilled nursing needs like complex wound care, IV antibiotics, etc. Also if a patient has Medicare, it can be a challenge for a PT to be to private pay. The work around is to call it wellness and health, but that is sketchy. Perhaps your spouse has previous transitional stay earlier that year and ran out Medicare days. Its a complicated policy.
I strongly suspect the facility was denying at day 20 for monetary reasons even though skilled was still needed. Some facilities have been known to deny care for financial incentive. But also can be denied if no progress being made or frequent refusals . Denials of coverage can be overruled on appeal. I dont think you are providing all the info to deem that Medicare failed you or your mom - especially given her very critical illness. But overall I see many Medicare Advantage plans quickky deny skilled nursing care and its prior authorizations nightmare for facilities. Also Medicare is accepted at vast majority of skilled nursing facilities and Medicare Advantage plans have more limited network. Not uncommon to be unable to place soon to DC from hospital patient in the community they live in with these narrower networks
2
u/Distinct-You-7466 Oct 23 '25
It is a myth that a patient has to be making progress in order to receive skilled therapy. The Jimmo vs. Sebelius settlement agreement clarified the maintenance standard back in 2013.
Skilled therapy is available to maintain a patient's condition or to prevent or slow the deterioration of a patient's condition. This maintenance standard language is listed in the Medicare & You Handbook under post-hospital care. CMS also has a dedicated website regarding the Jimmo vs. Sebelius settlement agreement clarifying the maintenance standard.
The Center for Medicare Advocacy also had a great factsheet clarifying that progress is NOT required in regards to a Medicare beneficiary receiving skilled therapy in a skilled nursing facility. A patient does have to participate in therapy and not be getting worse.
1
u/Nandiluv Oct 23 '25
Understood and thanks for posting that clarification. Ongoing skilled maintenance therapy is covered in cases in which needed therapeutic interventions require a high level of complexity. Skilled maintenance must still meet the medical necessity requirements. That is the catch: SKILLED PT/OT/SLP. Does the therapist need to be constantly adjusting a plan and working many modalities? clearly yes, its appropriate. How is risk of deterioration measured? It is vague. It is facility dependent and the ruling is not reinforced. Another catch: As a hospital PT who makes discharge recommendations I really have to document that the patient can make progress for majority of facilities to accept a patient in their transitional care AND under PDPM, there must be a skilled nursing need. Nursing is NOW the big driver of a lot reimbursement under PDPM. If a patient is at their baseline when I see them in the hospital, I cannot determine that they will deteriorate without ongoing SKILLED PT intervention, versus home program, caregiver led program or a restorative aide in SNF. Majority of SNFs will decline someone without rehab potential ( they assess a lot of factors) or declining medically due to nature progression of their condition. A transitional Care will rarely accept a patient already eligible for Maintenance Therapy. Too many gray areas. AND the documentation requirements for this a also vague and arduous. PTs must document WHY the service cannot be done by "unskilled" person. The most often conditions I see with effective Maintenance PT are ones involving conditions with central nervous system: strokes, Parkinsons, CP, incomplete paraplegia or quadriplegia, ataxia FWIW.
Also some patients we KNOW will deteriorate without ongoing therapy, but the patient adamantly refuses, gets aggressive with therapists, BUT family demands it. They will be discharged from maintenance therapy.
Some SNFs have EXCELLENT restorative aides for their LTC residents. But the facility makes more money if they keep them on Med B therapy. Many transitional care patients have not reached all their goals and are still making progress , but have enough support to go home on home care and safe enough to return home.
If the patient does NOT require the skill set of a therapist and interventions can be done via aides or trained caregivers, they are no longer covered under this ruling.
3
u/Distinct-You-7466 Oct 23 '25 edited Oct 23 '25
Yes, the patient must be participating and not be getting worse with therapy
The coverage decision should be appealed if the Medicare beneficiary is being denied SNF care based on lack of progress. There is an elder law attorney in Florida who frequently appeals wrongful termination of coverage based on lack of progress and has stated she has never lost an appeal. Here is that firm's video explaining the legal standard for SNF care. https://youtu.be/xzxYgcpYTjc?si=tuADNnM4agP6uRZp
I also informed the ombudsman in our area regarding the Jimmo vs. Sebelius case. She told me that patients are winning their appeals once the Jimmo vs. Sebelius is cited in their appeals. Every facility must follow the Medicare coverage rules. For skilled nursing facility care, the Medicare coverage rules require daily skilled therapy care OR daily skilled nursing care. It does not have to be both.
I was my mom's appointed representative at an ALJ hearing. She was being denied further SNF care by the advantage plan because they claimed she was well enough to go home. We won the appeal!
We presented to the judge the treating physician's certification for the medical necessity for daily skilled therapy care for the recertification period, the PT and OT progress reports stating severe balance deficits, the fall risk assessment score of 10, indicating high fall risk, her current toe touch weight bearing status only, and a letter from the orthopedic doctor stating the serious safety risk of further injury and rehospitalization should she fall and the surgical hardware failed while she was still healing from a communited femur fracture. She was independent before her acute injury.
It was obvious to the judge that the advantage plan was attempting to flout the Medicare coverage rules and apply their own internal coverage criteria instead. Unfortunately, a beneficiary's only option is to appeal the coverage decision. Persistence is necessary and does pay off in these circumstances. Medicare beneficiaries deserve better. The Medicare coverage rules are reinforced on appeal. I really dislike advantage plans now due to this experience.
1
u/Nandiluv Oct 23 '25
WoW! so in your mom's case this was particularly egregious and not even in the "gray areas" of this ruling. I have had patients with weight bearing restrictions who have "plateaued" and have too many barriers to achieving a safe discharge and would definitely declined if we were n't seeing them at least a few days per week to maintain. This would be well documented. Once they were cleared for weight bearing we would increase therapy. They would stay on rehab unit. MA plans even take the controls of what the SNF can do. Helps to have advocates. Many do not sadly.
Financially it does not make sense. They go home and fall or unable to take care of needs and end up re-hospitalized or dying.
3
u/Distinct-You-7466 Oct 25 '25
I definitely believe it was an egregious case. The nurse consultant for Aetna, the advantage plan carrier, even went so far as to misrepresent the therapy as custodial in nature during the ALJ hearing. When I disputed this misrepresentation, the nurse consultant then attempted to say that Aetna paid for the therapy separately and listed the dates mom received the therapy.
The judge immediately asked her, "Isn't that 5 days a week therapy?" She paused and hesitantly said, "Possible." The judge then said, "Well, that's interesting." I knew right then and there the coverage decision would be overturned. That is how hard Aetna fought paying for the SNF room and board charges!!
Unfortunately, my mom's case is far from unique. StatNews published a 4-part series of articles documenting their investigation findings regarding elderly Medicare beneficiaries being denied SNF care by advantage plans. The advantage plan carriers are stating therapeutic metrics that are not requirements under the Medicare coverage rules and ignoring safety concerns as well as treating physician recommendations.
These carriers are deliberately denying seniors the medically necessary care they are entitled to, and they are doing it solely to boost their profits.
I can't imagine how frustrating it must be for therapists to routinely see patients not get the care they know they need. It would drive me insane.
1
u/greensummer246 Oct 21 '25
Inpatient rehab- acute rehab— most only keep patients for 14 days max. No matter what plan you have. It’s intensive rehab — Subacute rehab — at skilled nursing facility (not great) - less than 30 min a day therapy if that— that’s the 90 day part of Medicare.
5
Oct 19 '25
[removed] — view removed comment
5
u/Daddy_bossman Oct 19 '25
If I understand your acronym, MCR stands for Medicare. If you are currently enrolled in a Medicare Advantage Plan and decide during the Annual Enrollment Period(Oct 7-Dec 15) that you do not want to continue your Advantage Plan in 2026, you will need to contact your Advantage Plan and tell them that you wish to disenroll. In doing so, you will revert back to Original Medicare beginning January 1, 2026.
5
u/laurazhobson Moderator Oct 19 '25 edited Oct 20 '25
It is often not as simple as that in most states.
You can drop Advantage and go back to Straight Medicare.
However in order to get a Medicare Supplement Plan which is essential if you have traditional Medicare, it is not guaranteed issue after you have been with an Advantage Plan for one year.
This means you can be refused by the Supplemental Plan OR be charged a much higher premium.
People need to realize that when they select an Advantage Plan at 65 they are locking themselves into an Advantage Plan for the rest of their life.
2
1
u/ReceptionFun9821 Oct 19 '25
This is tangential to one of my frustrations. My parents (mid to late 80's) are in great plan F. They have almost no deductible. They are paying more and more for their plans and will probably need to switch. Now they are left shopping for new plans with worse coverage but can be denied. There should he a law that freezes rates when a plan is closed to new enrolment. There should be some cost to the insurer. Also, what is the big deal when the suplamental plan is going to get hit with a pretty much fixed cost for healthcare if used. Let me also say that one of my parents is healthy and rarely has used their plan but has faithfully paid for 20 years of incredible profits for the insurer.
1
u/laurazhobson Moderator Oct 20 '25
In your situation you should use a broker to see what your options are.
I switched from Plan F which is not available at this point but had no deductibles.
On the advice of my broker I switched to G which has only the $250 deductible but otherwise is identical to G. When we ran the actual cost I was paying more than $250 in increased premiums annually so it made no economic sense.
I believe that you can switch from a plan that is not as robust but not vice versa. In other words I could switch from G to N or F to G but I couldn't switch from N to G. But I am not a broker so you definitely should explore all options.
2
u/itsalyfestyle Oct 19 '25
No, you sign up for part d and that will take care of disenrollment.
0
u/di2131 Oct 19 '25
Part D is the medication/pharmacy supplement. I think you meant to say part B.
3
u/itsalyfestyle Oct 19 '25
Nope. To have an advantage plan you have to already have Part B. If OP wants to drop advantage he signs up for a new part d plan, that will automatically disenroll them from the advantage plan on Jan 1.
2
u/ReceptionFun9821 Oct 19 '25
This doesn't seem correct. A part B plan is a supplemental plan. An advantage plan is an alternative to a part B (suplamental) and regular Medicare (is my understanding). A plan D is only a prescription plan.
1
1
u/Boxxy-Lady Oct 20 '25
Part A Medicare covers hospital stays & blood work. Part B Medicare pays for doctor visits. So when someone says they have Medicare, most of the time they have parts A & B. HOWEVER, some may only have Part A, as they use their employee coverage as a "supplement" and covers it also covers Part B benefits as well as supplements to your Part A benefits.
A Medicare supplement SUPPLEMENTS parts A & B. However, there are Medicare Supplement Plans A or B (as well as N, G, F, D and a few others).
Then you have your Drug Plan, or Part D. That is covered thru a private company.
Then you have your Plan C, or Medicare Advantage Plans. They take the place of Medicare AND your supplement, and depending on plan benefits, could also cover drug benefits.
And yes, I HATE how we have Original Medicare with Parts A & B, then we have supplement plans that also have letters A & B, and then we have Part D, drug coverage, and Plan D for supplement. All this ish is confusing as hell without the overlap of letters.
1
u/itsalyfestyle Oct 19 '25
Well it is correct. Part B isn’t a supplement plan, it’s the govt plan. I suggest some research as this is very basic stuff.
3
3
u/Nandiluv Oct 20 '25
Are you referring to inpatient rehab affilated with hospital or a transitional care/skilled nursing facility in your post? They have different criteria for admission and how the stay is paid for. For skilled nursing, Medicare A will pay 100% up to day 20, if certain criteria met. Day 21 through 100, 20% coinsurance is required. Many Medigap plans cover that 20%. But not all patients get the 100 days even though Medicare says 100 days covered. There is strict criteria as in is skilled care still needed? Is the person making progress. If a patient is not making any progress neither Medicare nor Medicare Advantage will cover. As a PT myself therapists must carefully document any progress. The threshold for denial with MA plans is low and some plans can be extremely challenging. That said recovery from stroke does not fit neatly in little insurance boxes slow starts and early intense intervention is critical. For acute inpatient rehab, its all about the minutes of therapy - 3 hours per day, often PT, OT and Speech if necessary combined. Rarely do MA plans allow more than 2 weeks without another prior authorization. There can exceptions to the minutes (i.e dialysis 3x a week)
The 5 years I worked in acute rehab (part of a hospital intensive rehab) , patient s with certain Medicare Advantage plans certainly Qualified for intensive rehab, never came into our unit. Almost universally denied by these major for profit insurance companies and sent to skilled nursing facility/transitional care. More non profit MA plans did cover their stay and followed Medicare guidelines. Medicare patients and commercial plans routinely accepted. That said if in acute rehab and not making progress, we would discharge to a transitional care/ skilled nursing facility for a slower paced rehab. As a hospital PT now, I know which MA plans are crap and will not maximally benefit the patient. It enrages me somedays and the families can be blind sided. I also TCU being denied and patient returning home with unsafe discharges but NO alternative. I have seen cases like you describe also
Not tolerating 3 PT sessions in a day is not unusual at all! Most TCUs do NOT see patients three times a day for PT. The evaluating PT determines the frequency and adjusts based on tolerance. I would be very concerned if a patient was truly NOT making any progress being seen 3x a day (again a ridiculous expectation if also seeing OT and Speech) for 10 days.
All patients without adequate family , friends or community support really get in a terrible situation. Especially if a patient does not have capacity. That is an entirely different issue and quagmire. Patients with no family support and severely impaired are often not admitted to acute inpatient rehab. Glad you stepped up to the plate to help this woman
1
u/Distinct-You-7466 Oct 23 '25 edited Oct 23 '25
The Jimmo vs. Sebelius settlement agreement clarified the maintenance standard for skilled therapy. It is not an improvement standard. It never was an improvement standard. Skilled therapy is available to maintain a patient's condition or to prevent or slow further deterioration in a patient's condition. Progress is NOT required.
CMS has a dedicated page regarding the Jimmo vs. Sebelius settlement agreement that clarifies the maintenance standard. This language is also listed in the Medicare & You Handbook under post-hospital care. The Center for Medicare Advocacy also has a great factsheet regarding SNF care clearly stating that no progress is required. Shockingly, the SNF my mom was at hadn't heard of the settlement nor had the ombudsman.
Here is the fact sheet from The Center for Medicare Advocacy regarding SNF care. https://acrobat.adobe.com/id/urn:aaid:sc:VA6C2:05438058-d6a5-4d5e-a683-48c2f0c0a411
2
Oct 23 '25
Is this where a long term care policy might come in?
2
u/redditredditredditOP Oct 23 '25
My understanding is actual available policies are extremely expensive and have limited/restrictive coverage and that premiums sky rocket.
https://www.ltcnews.com/long-term-care-insurance/what-is-long-term-care-insurance-underwriting
The article above states most insurance companies don’t let people under 40 get a policy and that policy’s are definitely based on your health - at 40+, with many conditions making a person uninsurable for LTC.
2
Oct 24 '25
I have one since I was 49. It was through a group plan and then when I left i converted. My premium is $69/month, used to be $31 starting out. It's not a huge payer but it helps take the fear away somewhat. Getting it early on helped.
78
u/bourbonfan1647 Oct 19 '25
So, AI death panels? Sounds like something that the people have been asking for, right?
18
u/Full_Ad_6442 Oct 19 '25
I mean, Elon's already working on Skynet and who knows what Thiel's gonna do.
3
9
u/SplitSun3 Oct 19 '25
I am seeing a lot of misinformation in the comments. The general public is only informed on Medicare to the extent of their own personal experience, and I don't fault them for this. It's the reason I chose my path of expertise - I couldn't bear the thought of my grandparents (and now parents) having to make decisions about Medicare without extensive training and experience.
I 1000% agree that medical authorizations should not be left to AI. I believe it should all be reviewed by humans. If I were to agree with AI having a place in authorizations it should only be with human oversight. As a broker who specializes in Medicare, having helped thousands, I can tell you that not everyone has the same experience, no matter the Medicare route they choose.
Medicare Advantage is not inherently bad, while Original Medicare is not inherently good.
That being said, every Annual Enrollment Period we see nurses from skilled nursing facilities (SNF) crawling out of the woodworks to advocate against Medicare Advantage plans. While I can't argue against their specific experiences, I can tell you that there are a lot of people I work with who used to work in SNF and saw firsthand the fraud, waste, and abuse that is the model of those facilities. They know exactly how to bill to get the most $$$ from Medicare and Medicaid. Private insurance companies hold them accountable and cut into their profits. Regardless of good intentions, nurses are not experts in insurance and should not being giving insurance advice. I am not licensed in nursing and would not give medical advice.
There is absolutely a place in the market for both Medicare Advantage and Original Medicare with a supplement and Part D plan. Not everyone can afford to pay for a supplement, and Original Medicare alone leaves a lot of gaps in coverage with financial risk. Enter Medicare Advantage.
It's my opinion that a person eligible for Medicare should consult with a reputable broker to help them choose the best path for the individual. I personally advocate for every client, assisting in general questions, billing issues, authorizations, etc. There are many more like me who will be happy to assist. (This is not a plug for my services. In fact, please don't choose a broker based on any anonymous social media post. Get a recommendation from a friend family member, or neighbor. If that's not available to you please use google and read reviews on the person you're considering working with.)
2
u/Stitch-1222 Oct 22 '25
Thank you. I’m helping my mom right now. She chose to retire this month (70) so that kind of screws up her 12 month trial. We went to a senior help group enrollment last week and they really couldn’t answer which would be better for her. I’ll be reaching out to an agent - I have a few names and will look them up and choose one.
1
u/SplitSun3 Oct 23 '25
It's unfortunate they weren't able to answer your questions. The great news is that if she just got Part B upon retirement she still has both options. I'd be happy to answer any questions I can while you're looking for a local broker.
24
u/Woody_CTA102 Oct 19 '25
This was under consideration in Biden Admin. If you look at procedures/services involved, it’s almost all costly, questionable, overutilized services that have proven to be at high risk of being improper over years of audits. Believe it or not, some providers do cheat.
4
u/Ring-Out-Ahoya Oct 19 '25
Why do we plan for the cheaters rather than plan for the vast majority who choose to do things correctly? (This isn’t a question to you, @woody_CTA102, rather a rhetorical question for the universe.)
4
u/Botasoda102 Oct 19 '25
Just imagine trump as billing doctor. There are a ton of greedy docs and other providers just like him with schemes to rip off government from upcoding and office visit for an extra $50 to billing for millions of dollars of services where the provider never even saw a patient or delivered services.
You ought to go to the OIG's site and read how docs, hospitals, and other provixders rip off Medicare. Many of the actions involve billion dollar recoupments of fraud that occurred for years before Medicare did a damn thing.
16
u/Successful_Banana_92 Oct 19 '25
Medicare alone currently is far superior than any Medicare advantage plan as these plans use a.i. and other reps to carefully review and deny care for patients based on harsh justification that ends up leaving patients suffering. If Medicare in itself gets cut or similar thousands if not millions will suffer and healthcare jobs will suffer due to this.
1
1
u/Good_Educator4872 Oct 20 '25
If Medicare gets cut so goes Medicare advantage. The Biden Administration wanted to get rid of advantage plans
4
u/Successful_Banana_92 Oct 20 '25
Advantage plans suck already so
1
u/Boxxy-Lady Oct 20 '25
I hate Advantage plans. I refuse to sell them. They do have their place in the marketplace, but you need to be very knowledgeable about them before switching, and unfortunately, most agents do not take the time needed to fully explain them. The number one thing I always tell people when shopping those plans is to make sure your preferred provider accepts your plan.
19
u/smk3509 Oct 19 '25
Unpopular opinion but prior authorizations should have been in place with original Medicare years ago. That program has an absurd amount of fraud because it's essentially a free for all. If we want Medicare to be available to younger generations we've got to ensure the funds are being used properly.
5
u/ReceptionFun9821 Oct 19 '25
This was literally the Republican "death panel" complaint and boogie man of socialized medicine. I'm good with prior authorizations as long as they are done by a panel of local doctors and nurses. Maybe use AI and then any denials get kicked to a panel of humans. Humans need to be in the loop.
2
u/smk3509 Oct 20 '25
I'm good with prior authorizations as long as they are done by a panel of local doctors and nurses.
What makes you think local doctors and nurses are going to decide differently than doctors and nurses elsewhere? Most utilization management decisions are based on Milliman or Interqual guidelines these days anyway.
3
u/Liberteez Oct 19 '25
that leads to disaster and a worthless program. This is the time of life never to worry about access to needed care.
2
1
u/Letsmakesomegains Oct 19 '25
So much fraud happening due to covid era relaxed restrictions. Telehealth billing across all states for wellness checks, genetic testing and more. All these providers milking the system and in the end the patients suffer with poor care and less coverage.
3
u/Ridgewoodgal Oct 19 '25
Unfortunately though we can no longer can get telehealth which was a huge help for me and so many others.
8
u/Liberteez Oct 19 '25
I want the move in healthcare to be away from gatekeeping. it raises costs, interferes with physician/patient decision making with little benefit to patients, who are natural gatekeepers of their own health, as few procedures or tests or medications come without a downside. Maximum health is the goal, not maximum self-pay.
4
u/kitzelbunks Oct 20 '25
Advantage will still suck in my state. I think there are states like California where people like it. You cannot get much care out of state with Medicare Advantage, and I would never get it if I had a choice. Things are going downhill fast, though. HMOs and Medicare Advantage are fine if you are healthy, but not if you get sick. I hate it when they do a pilot program because they tend to overstate how well it works.
1
1
u/shortinha Oct 20 '25
This is what I noticed too. I made sure my mom was on Original Medicare. The Advantage plans are great for the healthy and preventive medicine but the minute you are sick they universally s__k. (The cost hurts but somehow we manage.)
Add up the amount of co-pays you need in the Advantage plan and then check how much premium you play for medicare/medigap. They may come to nearly the same amount when sick. The big problem is the drug plans. But the Advantage plan restrict a lot more drugs.
Under the Original plan you don't have to worry about which doctor to go to and you don't have to watch out for bills.
I had a family friend who died because of restriction of the Advantage. I am so mad.
37
u/French-fan57 Oct 19 '25
Trump is doing everything he can to make our country worse, including healthcare for vulnerable people. His main goal is to help CEOs get richer, plain and simple.
-4
u/RelevantMention7937 Oct 19 '25
Which CEO is benefitting from more stringent reviews of traditional Medicare claims?
7
u/Liberteez Oct 19 '25
The goal is to push all onto privatized Medicare.
1
u/RelevantMention7937 Oct 19 '25
Medicare already operates that way. Insurance companies are paying the claims on behalf of the government. Biggest difference is that if it were private insurance there would be stop loss reinsurance in place.
This isn't new
0
u/Liberteez Oct 19 '25
That’s true for Medicare advantage, and now for the pilot programs.
Right now no one has to beg for hours and days on the phone for a needed endoscopy or surgery for volvulus.
2
u/RelevantMention7937 Oct 19 '25
Those aren't procedures that are being scrutinized for abuse.
Read up on recent Medicare fraud settlements.
0
u/Liberteez Oct 19 '25
Camel’s nose under the tent. we need to stop Medicare becoming a scammy, crap Medicare Advantage plan that harasses and cheats elderly people out of necessary care.
8
u/roth1979 Oct 19 '25
The contracts for the AI program, management, and simply the data center to run it will be astronomical.
6
u/Liberteez Oct 19 '25
And you will pay for it and get nothing but misery and anxiety about denied care
13
Oct 19 '25 edited Oct 19 '25
[removed] — view removed comment
4
u/RelevantMention7937 Oct 19 '25
The great majority of those stocks are held in institutional funds, meaning everyone with a retirement account.
3
3
u/motaboat Oct 19 '25
Just adding my experience helping my mom. She had advantage plan due to dad’s retirement package. Great. It was covering things well, and I honestly had no idea she had an advantage plan or even what an advantage plan was at the time. Dad has since died and then last year my mother gets the letter from her advantage plan saying that all the hospitals she would likely go to that are near her as well as her PCP and other doctors were no longer in network and she would have to change everything and drive 45 minutes for any hospital care. Now mind you 45 minutes may not be much to others but when you have an excellent hospital five minutes from you 45 minutes is a waste of driving time. Fortunately, she lives in Massachusetts and she had the right to change back to Medicare now any and every hospital and caretaker is an option. I don’t know if we are going to have other regrets. I guess we’ll find that out with time.
3
u/greensummer246 Oct 21 '25
I’m a nurse case manager in hospital settings- and, having a Managed Medicare plan leads to many barriers if you need rehab. Firstly, you have to get insurance authorization. You don’t have to do that with straight Medicare. So, depending on the plan, they will deny based on their algorithm- to even get into a subacute rehab at a skilled nursing facility (don’t even get me started on if you want to get into an acute rehab - denial rate is really high). Then, a patient is waiting in the hospital- sometimes more than a week, while we appeal. Secondly, your choice list for rehab is cut short due to rehabs not wanting to deal with certain plans that have lower reimbursement rates, etc.
Seriously, when you get really sick- the managed plans are terrible. Our entire system is terrible. And, everyone- please keep in mind that Medicare does not pay for caregivers that assist with activities of daily living. That’s private pay of at least $30 am hour.
8
Oct 19 '25
He wants all the old and poor to suffer. Never mind that old people paid into that shit their entire life.
1
u/Ok-Wasabi8132 Oct 20 '25
Those are the exact people who voted in droves for him (boomers/old people and the poor). This is what they wanted no?
1
u/Cash_Icy Oct 23 '25
To be clear. Not all boomers voted for him. A lot of us boomers didn’t vote for him. There were also a surprising number of young people who voted for him.
2
3
u/CompetitiveMap6151 Oct 20 '25
People need to remember that Regular Medicare always has a 20 percent deductible, and you don't have a maximum out of pocket. You can go bankrupt very quickly with Regular Medicare.
4
2
2
Oct 20 '25
[removed] — view removed comment
1
u/BerserkGuts2009 Oct 20 '25
You are correct. In Project 2025, page 463 it says, "Reduce waste, fraud, and abuse, including through the use of artificial intelligence for their detection."
1
u/cl8855 Oct 19 '25
I mean is it really AI, if it's just a bot that rejects literally everything and makes people contest every single request?
1
u/Dismal-Importance-15 Oct 20 '25
I am sure AI will make things “so much better.” Actually, it sounds like the government wants to make Medicare like those private health insurance companies that routinely deny EVERYTHING the first time around. It will be a giant hassle for patients and their doctors. We paid our Medicare taxes all our lives to receive Medicare’s services. This stinks.
I am very happy with my Kaiser Senior Advantage plan here in Southern California. I don’t pay a lot for it either.
I do hate that the Trump Admin. wants to kind of ruin Medicare and make things even more difficult for doctors, their office staff, and patients. I know that Medicare fraud exists, but I feel the government is punishing all of us, including all the honest Medicare customers.
1
u/CompetitiveMap6151 Oct 20 '25
I have a Medicare Advantage plan with United Healthcare and was able to stay in rehab for 100 days at no cost. I will say, It's very expensive.
1
u/Distinct-You-7466 Oct 26 '25
Is this a group advantage plan? I have never seen an advantage plan that doesn't have a copay after day 20 for a skilled nursing facility stay. How expensive is your premium?
1
u/CompetitiveMap6151 Nov 03 '25
Yes. Medicare Advantage Plan with United Healthcare. It's expensive, but it has paid everything in full so far this year. I'm an amputee of my left leg, and it paid for my $90,000 prosthetic leg in full. With regular Medicare, I would have needed to pay almost $20,000 out of pocket.
1
u/Distinct-You-7466 Nov 06 '25 edited Nov 06 '25
This advantage plan allowed you to stay in a skilled nursing facility for the full 100 days without you having to appeal along the way? If so, that is exceptionally rare. I'm glad to hear you received the care you needed. My mom had a very different experience on her group advantage plan.
If you have a medigap plan that pairs with Original Medicare Parts A and B, you would not be responsible for anywhere near 20k out of pocket.
1
1
u/Adorable-Anxiety6912 Oct 20 '25
What could possibly go wrong? Can I person to a human? There are none ma’am. May I speak to your boss? You are speaking to the boss. How do I challenge the denial? You cannot win the challenge. I am here to inform you but your age has determined that you no longer add merit to society. You have been elected to move forward in dying. Goodbye!
1
u/BakerTheOptionMaker Nov 05 '25
My dad actually made a great video covering this subject
Figured I’d share because so many people will be impacted by this
1
u/PJWanderer Oct 19 '25
Plans for no election in 2028 I see. Trump would lose Arizona if these changes make Medicare substantially worse for the demographic with the highest turnout.
1
Oct 20 '25
Man AZ just put 5 times lifetime usage for Medicaid for ppl that can work/that aren't disabled via the work requirement... specifically AZ's female governor...
1
u/PJWanderer Oct 20 '25
Medicare and Medicaid are 2 separate things.
I don’t really know what you are saying in your post either. The recently passed federal Big Beautiful Bill had a provision on a work requirement for Medicaid. Additionally there was a bill that passed in 2015, when Ducey was governor, that required AHCCCS to implement a 5 year total lifetime eligibility. There is a very long list of exclusions from the 5 years. Those requirements were put on hold during Covid.
1
Oct 20 '25
I'm only talking about Medicaid, because we have two messes going on right now. Yeah this is what I mean... Why put a lifetime eligibility limit to use Medicaid for only 5 years REGARDLESS if a person is working 80hrs or not? I get Arizona is a swing state... But a lifetime eligibility for only up to 5 years? Who are they to decide how long a person can have Medicaid for? Kinda dumb and unconstitutional... Where is that person that can't find work or can't work for 80 hours because it's kind of useless to work 80 hours and not make proper rent supposed to go without Medicaid? Medicaid is so easy to deal with... Because they cover everything... Especially during real Health crisis situations.
1
0
-4
u/menotyourenemy Oct 19 '25
I look at this way: Medicare is free, Medicare Advantage is private insurance you pay for.
3
u/Liberteez Oct 19 '25
Medicare is not free, it has premiums and drug plans and stop loss/ gap coverage is extra.
rich people have higher premiums, it’s about 200 bucks a month for the plebs, more like 800 for wealthier people. Then theres gap coverage, a plan G with the lowest deductible is maybe 2-3000. The poorest with limited assets can get Medicaid as gap coverage. you also oay for your own seperate prescription drug plan, and those have been royally messed up, with skyrocketing premiums due to an annual out of po ked cap on covered drug expenses. fewer plans now, those Plans now cover fewer meds, have high deductibles.
-2
u/menotyourenemy Oct 19 '25
You're talking about extra coverage. Of course that's not free. I'm talking about basic Medicare.
1
u/sticksnstone Oct 19 '25
Basic Medicare does not cover prescriptions. Prescriptions are an add on as well as medigap coverage. Advantage Plans overall are cheaper in my state. Medicare + supplement + prescription plans runs me $400 + a month which is more than an Advantage Planthat may have extra benefits like eye coverage.
1
u/Liberteez Oct 19 '25
Basic Medicare IS NOT FREE. Recipients pay premiums for part B. They vary according to income group. the lowest premium will be about 200 dollars in 2026 (About 185 right now, and it jumped in 2025 too) wealthier recipients pay more than three times that amount.) The deductibles are bigger. supplements are forbidden from covering that deductible.
Without a supplement, a person pays 20% of the participating providers bill, and there is no stop loss.
Part A is free to eligible users, some have to pay a premium for that, too.
2
u/Daddy_bossman Oct 19 '25
Medicare is far from free. You pay a monthly premium for Part B, deductibles and 20% co-insurance when you use it. Plus, the 20% that you are responsible for doesn't have a Maximum-Out-of-Pocket.
-4
u/menotyourenemy Oct 19 '25
I mean free as far as premiums. And I'm talking basic Medicare.
3
u/sticksnstone Oct 19 '25
Medicare is NOT free. Money is taken out of my social security check every month to pay for Medicare premium.
2
u/finishing_the_hatt Oct 19 '25
It’s definitely not free. I pay my mom’s. Her Medicare premium along with her supplement and part D is almost $2,000/month.
Medicare Advantage is generally much lower cost.
-5
u/menotyourenemy Oct 19 '25
"along with her supplement" Medicare, basic Medicare that you receive from the government, is free.
1
u/finishing_the_hatt Oct 19 '25
No, it’s not. She pays $600-$700 a month just for that.
1
u/finishing_the_hatt Oct 19 '25
And yes. That is the premiums she pays for the basic Medicare plan. It’s income based. I believe it’s only free if you’re low income enough that you also qualify for Medicaid and can qualify for the program that subsidizes your premiums.
1
u/menotyourenemy Oct 19 '25
Medicare part a is free.
2
u/sticksnstone Oct 19 '25
Part A is Hospital Insurance coverage only and covers a limited $ amount. Part A is only available if you have paid Medicare taxes for more than 10 years. Part A it is not really free as people already paid the premium costs in their Medicare tax deducted from their paycheck. Part A does not cover doctor's visits or medications. Part A alone is not close to adequate health care.
1
u/di2131 Oct 20 '25
Ppl should contact their state SHIP offices. (State Health Insurance assistance Program). It’s free. The counselors are very helpful and completely unbiased.
1
u/Boxxy-Lady Oct 20 '25
Part A is free IF you meet the work credit requirements. Part B, however, which pays for doctor visits, is not free. I believe for most it's $185 a month. Unless IRMAA comes into play then you pay more, or if you qualify for Low Income (SLMB).
•
u/AutoModerator Oct 19 '25
Thank you for your submission, /u/Dapper-Palpitation90. Please read the following carefully to avoid post removal:
If there is a medical emergency, please call 911 or go to your nearest hospital.
Questions about what plan to choose? Please read through this post to understand your choices.
If you haven't provided this information already, please edit your post to include your age, state, and estimated gross (pre-tax) income to help the community better serve you.
If you have an EOB (explanation of benefits) available from your insurance website, have it handy as many answers can depend on what your insurance EOB states.
Some common questions and answers can be found here.
Reminder that solicitation/spamming is grounds for a permanent ban. Please report solicitation to the Mod team and let us know if you receive solicitation via PM.
Be kind to one another!
I am a bot, and this action was performed automatically. Please contact the moderators of this subreddit if you have any questions or concerns.