Switching from a Medicare Advantage plan to regular Medicare plan - has anyone had any experience with this for their parent? Pros and cons?

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Switching from a Medicare Advantage plan to regular Medicare plan - has anyone had any experience with this for their parent? Pros and cons?

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My 94yo mother, who is still of sound mind (short of forgetfulness) insists on aging in place and is house bound. I'm her long-distance caregiver (two hours away and FT job). I travel every other weekend to care for her and her large home. She developed edema and last year was hospitalized twice for cellulitis in her legs. She has had a home health nurse to wrap her legs since, as with her back issues she has trouble keeping her legs elevated; thus, it is difficult to keep the swelling from occurring. The leg wraps are the only solution for her as she can't get compression stockings on, nor can others get them on her because she has little strength in her legs. Recently, continuation of her insurance coverage for this was denied as the nurse's assessment indicated her legs were healed. However, her legs began weeping within 12 hours of the removal of the wraps. After many phone calls to the nursing agency, a re-assessment was completed and the insurance company authorized 8 more weeks of visits through the first week in December. The nursing agency suggested we switch from my mother's current Medicare Advantage plan to regular Medicare, as a regular Medicare plan usually does not require prior authorizations. Has anyone had this experience and how did it work out? Did switching to regular Medicare prove to be a better choice? Thanks for any insight.

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Yes, do it now. You will not regret it. My mom fell and shattered her pelvis in April 2022 while she had Medicare Advantage. They stopped coverage of her rehab stay two weeks after her fall stating the rehab facility had determined she was ready to be released. The call came in while I was in the office of the rehab director discussing how my mom was having issues that concerned them and they wanted her to go back to the ortho to be checked. It was shocking, the bold faced lie I was being told. That rehab director told me to switch to traditional Medicare ASAP. Ask any professional who works with Medicare patients, they will tell you the same thing. Traditional Medicare A&B plus a supplement. You can switch during the year, too. I called Medicare loaded for bear. When I explained the situation the rep agreed to switch her back. I did not have to fight for that. Every call I’ve made to Medicare has been easy. Until you make the switch know this, if your Medicare advantage plan wants to stop something such as the wraps on your mom’s legs you can appeal. I believe for 48 hours. I did that with my moms rehab situation and the Medicare advantage rep threatened me and my mom, said it would cause her financial ruin. It is disgusting how low those companies will go. Call Medicare and don’t look back. BTW my moms Medicare advantage plan was through AARP

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Reply to CaregiverNat

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After having read all the answers and having made some suggestions myself, I have 2 thoughts. First, separate from the Medicare plan, there ARE options for compression hose other than those you pull on all the way. I wear them myself, and there are at least 2 additional options. First, as another poster has mentioned, you can purchase hose that zip on instead of being pulled up. Second, you can purchase hose which are 2-part, one part for the foot (if needed) and another part for the calf. The hardest part about putting on and taking off hose is going over the heel. The 2-part hose makes this part easier. Regarding the hose themselves, I would also add that they come in several different compression levels. My physician could not tell me what level of compression to purchase! The higher the compression, the greater the difficulty in putting on the hose and taking them off. It might be worth seeing if a lower level of compression would do the job, at least for now. I forgot to mention also that there are inexpensive tools you can purchase to assist with putting on the hose. It would certainly be easier and less demanding for all if compression hose could be worn!

Second I want to emphasize again--and you should be able to check on this--that I don't believe. Medicare, regardless of the kind of plan, will pay indefinitely for someone to come into the home to wrap a person's legs. There are other pros and cons of the different kinds of plans, but the deal-breaker should not be whether or not pre-authorization is required for someone to come in to do the wraps. The result in this situation will probably be pretty much the same.

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Reply to Igloocar

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Thank you for your suggestions, very helpful!

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Please talk to a SHIP counselor in your area .
(SHIP = Senior Health Insurance Plan)
These are trained counselors and they do not work for any insurance plan so are not beholden to any of them They will look at all the medications, the current plan and compare and find a plan that will work best.
The service is free.
Just do a search for "SHIP counselor in my area" Many Senior Service Centers have one or more but you will have to make an appointment....pretty busy this time of year.

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Reply to Grandma1954

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My Aunt uses zip-up compression socks. You can find them on amazon.

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Reply to Geaton777

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Olddude, the problem is it is unlikely at this point that she can get a good supplement plan that will cover her edema. She would have needed to be on the supplement plan before the edema treatment began.

AlvaDeer's point is also good. If her mother had Medicare + Supplement right along, she wouldn't usually have needed preauthorizations, but that doesn't mean treatment would have been continued indefinitely if there was no improvement. Some limits are imposed by Medicare itself; for example, limits on PT and OT treatments for a condition.

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Reply to Igloocar

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Igloocar
Of course we know about our on experiences and not all experiences but if a person needs therapy to maintain a level of ability they can indeed continue with PT and OT as my mom had OT until her death due to not being able to use her right arm w/o it.

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I just went to a lecture by an independent agent and this topic came up. The plan will be underwritten based on her medical needs. You should see an agent to assist in filing for the supplemental to find out the added costs. You can decide once you get that estimate. Don't wait too long because those agents are working many hours right now.

Keep another thing in mind. In either plan, CMS will still dictate the number of treatment coverage since the diagnosis code will not change.

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Reply to MACinCT

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Multipass: Perhaps she can switch to Medicare AND Medicare Supplemental, i.e. United Health Care/AARP.

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Reply to Llamalover47

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Llama, this is what OP's Mom already has. She's asking about going with Medicare only and no supplement.

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Your best option is to consult a Medicare Specialist who can show you "options" and what each option costs. If you switch to Standard Medicare, you will need a Medigap Policy to cover the 20% not covered by Medicare. An Insurance Underwriter may be needed to determine a Medigap eligibility situation. Traditional Medicare gives more choices and with no list of preapproved Providers...BUT: Can the Medigap Policy that is essential to cover the 20% NOT covered by Standard Medicare: be afforded? + Plan D for Prescriptions?

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Reply to fluffy1966

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I have a Medigap plan: BCBS MedicareBlue. In 2024 tt cost an extra $267.85 per person/ per month. I have access to a huge network in my state, including the Mayo Clinic, and no pre-approvals required. I also have a Part D drug plan through BCBS ($20.20 per/month per person), as well as Vision ($198 family plan, single annual payment in full) and Dental ("Freedom" family plan $108 p/mo). The Vision paid for 50% of itself through my first contact lens purchase discount. The dental is pretty much the same coverage as my former Delta Dental insurance that I had for years.

Advantage Plans are only useful when you 100% healthy. It gives you lower co-pays and sends you free bandaids and acetamenophin, and gives you health club access (and so does my gap plan). But IMHO when the rubber meets the road you don't want to only have an Advantage plan if you become seriously ill or injured. You'll pay more in office visit co-pays, but it'll cover a lot more of your medical expenses. I don't need any pre-approval for anything with my gap plan.

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Edema. Not medical advice - only what has worked for me. My mother has had edema in her left leg and foot. A diuretic did not help at all. So I began to apply a liquid Magnesium to her leg and foot on a cotton ball - or you can spray it on - and the edema has mostly resolved. Most people are terribly deficient in magnesium. The brand I use is "EASE". You can get it on Amazon. Here's the link:

https://a.co/d/dn9lhx5

There are also other magnesium supplements that she could take orally as well.

Medicare: My mother has been on original Medicare since she was 65 and is now 97. She also has a supplemental plan G. Since I have been handling her medical issues, including hospitalizations, surgeries, doctor visits, and now hospice care, she has not paid one penny in medical bills. Not one penny.

Last May I turned 65 and am now also on Medicare. Before deciding on an advantage vs traditional medicare, I did my due diligence and it became clear to me that original Medicare with a supplemental plan is the way to go.

Even though people think that an advantage plan is "free", it's not. You still pay the $174.00 every month - it just goes to an insurance company. And now you've brought another entity who can reject your claims into your medical issues. No thanks. Doctors and hospitals don't have to take Advantage plans from what I understand, but they do have to take Medicare unless they want to pay a penalty.

So I went the same route as my mother with original Medicare and a supplemental plan G through Mutual of Omaha. I am assuming that I will have the same level of payments as my mother if and when I begin to need medical treatment.

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Reply to southiebella

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An interesting question. I just went on Medicare with a supplement in July. Now I have to decide to keep it or change. So many changes. Will it ever end. About 2 years ago my wife was on advantage when she went on hospice. The coverage and care were great. It saved me from going broke. I avoided that plan because at that time most of my doctors were not covered. So now that the gov has screwed up everything. My question is have people switched between advantage and regular and back every year as the rules change. Seems like a rigged system.

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Reply to Sample

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Medicare Advantage plans were created by private insurance companies to compete with Medicare. They use the Medicare Advantage name to confuse people into thinking that it is the same or better than regular government insurance provided to people 65 and older under Medicare. In my opinion, Medicare Advantage plans are a private insurance industry rip off that will bite you in the butt if you ever have a serious health issue. If anyone is screwing people it is these private insurance companies who lure customers with the promise of lower costs and “free” dental and vision benefits. We should all understand by now that nothing is free. The private insurers control their costs - and you - by limiting the doctors and facilities available under your plan as well as controlling approved procedures and medicines. Medicare exercises some of that control too, but not to the extent of private insurance companies. Medicare does not require prior authorizations to see specialists as long as they accept Medicare patients and payment caps and Medicare goes after providers who try to over-bill patients by charging more than the Medicare contract allows. So make sure when you are bashing the government that uses tax dollars to fund the cost of providing everyone 65 or older with coverage for Part A hospital benefits and low premium cost Part B secondary benefits that you ponder what life would be like without Medicare. And, be careful to not confuse the lack of choices and poor administration under the private Medicare Advantage plans with what is available from the government under Medicare. No plan is perfect - but regular Medicare gives you the choice of doctors that Medicare Advantage plans do not.

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My mom went into Hospice care recently. Her supplemental was $452 a month. My mom was in and out of hospitals and had so many ailments, so her plan covered everything. As her guardian, I switched her to a plan that is $27 a month. Medicare covers Hospice. No regrets.

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Reply to Onlychild2024

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Wow. What plan is that?

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Sorry you are dealing with this. It sound like a lot given the travel and your FT job.

As others have suggested, time to work through some plans for the future now as it will get worse/harder. And, I would advise getting with a licensed elder care attorney in the State where your mom resides as each State law/regs are different.

There are many "moving parts" to figuring out what is best. But so-called regular Medicare is better overall as it does not have so many impediments to coverage. That said, it will be more expensive. Medicare Part A (inpatient hospital care, and post acute care such as a limited home care or SNF option) does NOT have a premium, but there is a deductible.

Your mom will need Medicare Part B, which covers things like doctor visits and some "B, physician administered drugs such as an infusion." Medicare Part B has a monthly premium. I believe the standard Part B premium is about $175 for 2025. That said, if you mom's adjusted gross income is above a certain amount, the premium might be more. There may also be a "late" Part B premium if one did NOT sign up for Part B when first eligible. This is the Part B Late Enrollment Penalty." Part B has a deductible and a 20% cost sharing, more money.

Your mom will need Medicare Part D for outpatient drug coverage as original Medicare does NOT cover drugs other than those administered in the hospital, in a post acute care facility or in a doctor's office, vaccines too. The premiums for Part D depend on the plan one chooses. First, make sure the outpatient drugs she takes ARE covered by the D plan you are considering. Just do not choose based on the premium.

Medigap (another premium) may cover some of the out of pocket costs and cap out of pocket costs. There are different plans to look at and compare.

You said your mom is "homebound." If she meets the Medicare definition of "home bound" she may be entitled to other regular/traditional Medicare benefits.

If she has other issues -- has end stage renal disease/kidney failure, for example -- she may be entitled to other benefits.

If she meets the definition of "disabled" for Social Security, again she may be entitled to other benefits.

Some states have so-called PACE programs that cover more things and she may be entitled to that.

Lastly, there are various Medicaid-related (for low income folks) possible options if she "spends down."

This is very complex and difficult without proper legal advice. Yes, that too will cost money, but it may give you and her a better understanding to make the right decisions so she gets the best care possible.

Good luck with this

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Reply to Sohenc

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The "extra" coverage for end-stage renal disease and disability is not extra when you already are on Medicare. The "extra" part is that you can get Medicare before you are age-eligible if you are in one of those 2 situations. I was and so did get Medicare early.

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Yes, but it comes with cost. Contact a healthcare advisor. This service is free and they can help you navigate the process. The pros to this is that she isn’t as limited as to who she can see for care.

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Reply to RealMary

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But what about the physicians and groups who either don’t accept Medicare or who limit the number of Medicare patients they will accept to their practice?? It does happen

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Traditional Medicare with a Medigap plan provides the most flexible coverage. There are no networks that limit where the person may go for care, or with whom, and there is no requirement for referral. The person also needs to sign up for a prescription drug plan ("part D") if the Advantage plan had been covering prescriptions. However, as others have pointed out here, in many states it's very difficult to switch from Advantage plans to traditional Medicare+ medigap plan because there is "underwriting," i.e., the person's pre-exisiting health conditions are taken into account, which means paying a much higher premium or being rejected outright. That said, there are 12 states that provide guaranteed issue protections at least once per year to switch to Medigap or change Medigap plans: California, Connecticut, Idaho, Illinois, Maine, Massachusetts, Missouri, Nevada, New York, Oregon, Rhode Island and Washington.

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Reply to newbiewife

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Calling and speaking with the SHIP counselor is a good idea. also there are probably some insurance brokers in your area that can help.

I tried one time to check on how to get my friends changed. A broker told me the problem was when you go on Medicare it is extremely important that you make the choice for the right one the first time you sign up.

Part A no problem. Part B should be no problem. The problem is the MediGap plan doesn’t have to take you after the initial opportunity to sign up when you first registered. You must put down all the preexisting conditions and they will charge more than if you had just signed up when the preexisting didn’t count against you. Also each year as you get older, it will go up. There are about a dozen plans to choose from in my area for the medigap. You put in your zip code on the Medicare site and all will appear. You can see the prices there for the first time applicants.

I have a good friend whose sister has an advantage plan. She has just been diagnosed with bladder cancer. First of all she had two cultures (supposedly) for an UTI and had been on antibiotics. My friend just happened to call and found that her sister sounded so bad that she called 911 from several states away. She needed 6 pints of blood. Then the hospital experience was a nightmare then she went to a rehab, 1 of 3 that the advantage plan would cover. On the Medicare site there was a red hand meaning no don’t go there, abuse, on two of the three.
There she was thought to be not doing so well in therapy when what the problem was (discovered by my friend when she arrived) she had low oxygen. Back to the hospital to have blood clots treated in her lungs. The orig surgeon had taken her off blood thinners because she was bleeding. Next she learned she couldn’t go for the best cancer treatment because they wouldn’t take her plan. So my friend wants to change her sisters plan but I don’t know what she has found out. She wants to get her to better care than she can find in her sisters small rural town with the advantage plan.

Here is a link to an article recently posted on JIMMO. I posted one there as well regarding appealing advantage plans when they deny coverage. This might help inform you on helping your mom get services.

Let us know what you find out. We learn from one another.

https://www.agingcare.com/discussions/jimmo-settlement-490035.htm?orderby=recent

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Reply to 97yroldmom

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Call her County Office of Aging. They can help you pick the correct Insurance plans for Mom. They know which companies are allowed to write policies in your State. Its open enrollment and this is the time to switch over.

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Reply to JoAnn29

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Government offices are prohibited from making recommendations.

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My mother had both, Medicare Advantage and regular Medicare with BC/BS supplement . There is NO advantage to the Medicare Advantage plan and PERA ditched it altogether for every single one of their members in Colorado after 1 long, miserable year of dealing with It! Just trying to find a SNF for rehab that had beds available for Advantage Plan members was nearly impossible. Think of it as the McDonald's of health care plans, when you're looking for Ruth Chris Steakhouse.

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Reply to lealonnie1

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Lealonnie, many Advantage PPO plans allow out-of-network coverage with a higher co-pay (it's called co-insurance, because it's a percentage of the cost rather than a fixed amount). Medicare Advantage HMOs do not always have that option. Also, Advantage plans often have a maximum annual limit. In 2025, mine will be $3800 in-network; don't remember out-of-network.

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Multi,
See also this question today, and it's answers. This medicare coverage mentioned available apparently only to patients without advantage plans:

Does medicare cover in-home care for patient with cancer? - AgingCare.com.

This could pertain to mom's care for sure, I would think.
I couldn't copy paste the link, but that is the title of the question and it is in todays threads. You will find it by going up to timeline in blue, finding magnifying glass, typing question into the search bar. Good luck.

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Reply to AlvaDeer

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Your mothers situation will only get worse. It’s time to figure out next steps. What are you going to do when you get that phone call? This arrangement will not work over the long term.

By the way my father had leg swelling and he had an electronic compression device that helped a lot. His vein doctor prescribed it. We used the device a half hour each day and it really kept the swelling at bay.

I really can’t answer your insurance question.

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Reply to Hothouseflower

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The nurse means regular Medicare WITH supplemental policy, I assume. My brother was on Medicare with AARP recommended United Health Care. Not their advantage program, but regular policy. VERY EXPENSIVE. And the only difference I could find in it and their advantage was that he could use any doctor/any hospital.
It cost twice what my Kaiser Advantage did. At the time of his death 5 years ago it was 250.00 a month, so I can only imagine cost today. So one comparison is that the non-advantage program is almost always more costly.

I don't know that home care would have provided him more than had he been on an advantage, with it's limitations. BUT, I do know that most insurance will not continue to cover in home services for this forever.

I really cannot "guess" what would be covered by a "not-advantage care" policy in terms of a need for ongoing in home visits daily; most insurance will not cover this.
With no one there to assist your mom when she can no longer care for herself or even manage, because of other factors, to keep her legs elevated, this will go on and will be a constant which requires, in all truth, daily management.
You may be looking at a situation that requires daily care. Will your mother be able to manage that? Or does she need someone with her to keep her legs elevated, wrapped, monitored daily?

I can't find an answer now, for mom's daily needs, in an "insurance supplement". I do not believe that any will pay for daily management by medical. And without her legs staying elevated I am afraid this is chronic and ongoing for her. The time when she can manage alone at home is almost over, I am afraid is my best guess.

I wish you good luck. You might consider checking on any policy how long they would care in home for such a condition, because this is chronic and ongoing.

I am by the way assuming that this is "dependent edema" by diagnosis and not Congestive Heart Failure which in the case of right sided failure would cause edema, require diuretics and their emergency trips to the bathroom and monitoring for potassium depletion and etc. I know you are hoping your mom can remain at home and die as home (the hope of all us oldsters). But you are skating close to the edge of what's safe, I am fearing.

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Reply to AlvaDeer

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The reason why Medicare Advantage plans are so cheap is because they don't cover anything. There is a reason why most people on this site consider MA plans to be scams.

Get on Medicare, find a good supplemental plan, and stop having your treatments being denied.

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I used the SHIP program in my state when my husband became Medicare eligible because of ESRD. The counselor was so helpful!! She talked with me for over an hour. I cannot recommend the SHIP program enough! It's free of cost too.

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Reply to Wrenee5111

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Please do a search in your area for a SHIP Counselor.
SHIP is Senior Health Insurance Program.
They are people that have been trained to help you navigate the various Health Plans and they can help find the one that is best suited for the least cost.
They are not paid by any Insurance Plan so they are not beholden to any of them and they will give you unbiased information.

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Reply to Grandma1954

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Switching from a Medicare Advantage plan to regular Medicare plan - has anyone had any experience with this for their parent? Pros and cons?

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