IBM Medicare Via Benefits Extend Health IBM Life Planning Benefit Terminates November 2019

This post has nothing to do with Medicare but I am posting it in case people don't read a recent letter IBM sent out about benefits dated October 11, 2019. 

There was (notice I say "was") a retiree benefit available to some "older" retirees called "Life Planning".  It was a modest program implemented to mostly encourage employees and retirees to stay healthy and also to do financial planning by reimbursing up to $250/year for service fees related to those activities. The recipient had to file a claim every year to get the money.

Buried on page 5 of the October Legal Notice mailing  which is mostly about legal notices related to health benefits is a statement of the Life Planning Program termination.  When they say terminate, they mean terminate!  If you don't file a claim by the end of November 2019 for 2019, you cannot get the $250 benefit.  It is terminated as of January 1, 2020.

It's not a big deal, but a little unnerving because IBM can do the same with the HRA program.  Take full advantage of your HRA money while you can!

IBM Medicare Via Benefits Extend Health Medicare Hospital Days Coverage

Medicare's hospital inpatient coverage is probably the least talked about topic in private insurance marketing campaigns.  That statement is true whether an insurance company is pitching a Medicare Supplement plan (aka medigap) or a Medicare Advantage plan.  Maybe it is not advertised because it is easier to understand copays for a doctor visit.  Mostly, it is too complex to describe in a 30 second ad or a flyer.

Nonetheless, it is the part of Medicare coverage that is the most expensive and if a Medicare consumer doesn't understand the structure it can have both financial and health treatment impacts that are life altering.

The Medicare agency government rules for hospital coverage are straight forward and all Medicare insurance must cover these benefits.  By law, the basic amount of hospital stay coverage is the same irrespective of what type of Medicare insurance:
   

1. There are 90 days of coverage in each benefit period.
         
2. A benefit period begins when the patient is admitted as an inpatient (so "observation" doesn't count as a hospital day).
        
3. A benefit period ends 60 days after the patient leaves the hospital.
         
4. If the patient needs more than 90 days in a hospital in a benefit period, they have an addition 60 "lifetime" days that they can use to extend the 90 day stay.  The "lifetime" number is 190 days if it is a psychiatric hospital.
         
5. If a patient is discharged from a hospital and not readmitted until 61 or more days later, the patient begins a new benefit period.
       

Here is what is not straight forward.  How much do you pay when admitted to the hospital as an inpatient and for hospital days?  What happens if you need more than 150 contiguous days (in the same benefit period) in the hospital because of a dire condition?  What happens if you are hospitalized 3 times in a given year and each time a new benefit period started because you were "out" more than 60 days before being readmitted?

The cost of a hospital stay very much depends on the kind of insurance you have.  It can actually be zero or many thousands of dollars. This is where it gets complicated.  But it's important to understand it. 

The only way to compare original Medicare with Medicare Advantage is to compare costs. To properly compare costs, original Medicare with a Medicare Supplement (aka medigap) are used in the table below.  I used a premium price that is typical for an "N" medigap plan and picked a real Medicare Advantage plan that had a $0 premium. Without a medigap, there is no cap on the annual cost a person can incur in original Medicare.  Medicare Advantage plans do have a cost cap (in 2019 the max can be as much as $6,700 for "in network" services and is the cap for the MA plan I picked).  That $6,700 can buy a very nifty medigap  which is why I am including medigap in this comparison. Also, whether you use original Medicare or a Medicare Advantage plan, you MUST always pay the "part B" fee (currently $135.50/mo). What follows are 2019 numbers:    

Phase	Original Medicare +  Medigap N at $150/mo	Sample MA plan $0 premium
Hospital Benefit period  (Every 60 days if discharged and out of hospital for 60 days)	$1364 deductible Medigap N pays deductible	$0 deductible
Hospital day copay per benefit period	$0 days 1-60  $341 days 61-90  $692 for 60 lifetime days Medigap N pays all the copays	$465 days 1-4 $0 days 5-90 $0 for 60 lifetime days
If exceed 150 days in hospital	All Medigaps provide the extra days benefit of 365 days at $0 copay	No Medicare Advantage plan has extra days benefit, must pay full day cost for days over 150
Maximum hospital  cost in 2019	Medigap premium x 12 (approx. $1800 for 2019)	$6,700 for 2019 (if do not exceed 150 days)

 

    

                                                                                                                            

  

IBM Medicare Via Benefits Extend Health Re-evaluate your part D or MA plan for 2020

Did you get the 2020 brochure for your current part D drug insurance or Medicare Advantage plan?  More importantly, DID YOU READ IT?
 
Actually, all you need to do is glance at it to decide if you need to read more.  I received my part D brochure last week.  Here's what I quickly saw for my plan - wow, the premium when down a few dollars.  But why?  I read on.
 
Let me count the ways:

1. The plan added a deductible.  For me, that's bad news because I would never meet the deductible based on my current drug use.  That means the only benefit I get from the plan is their "negotiated price" for the drug.  I'll have to pay full negotiated price in 2020 for my drugs unless I get new prescriptions.
       
2. The copays, once the deductible is met, increased for brand name drugs.  Again, it's bad news for me because, right now, I don't use generics for the drug I take.
       
3. It looks like the "network pharmacies" have also changed.  A local pharmacy is no longer on the list so I would need to remember to stay away from that pharmacy.
       
4. The brand name drug I take is only covered in the generic version.  I cannot use the generic version.  For some reason, the fillers cause it to work less well for me.
        

So, during open enrollment, I will pick a new plan for 2020.  Since Via Benefits sells a subset of the plans available in my zip code (typically, it is about half of the plans I could buy) I'll look on medicare.gov to pick the new plan and then see if Via Benefits sells it.  If not, just by enrolling in the new plan through medicare.gov, I'll be dis-enrolled from my current part D plan.  Then, I need to remember to file for reimbursement of premiums for that new part D plan in 2020.  

The reason I am easily able to change my part D without engaging Via Benefits is that I buy a Medicare Supplement through them.  Reminder - you only need to buy one medical policy from them to qualify for the HRA/FHA.

Changing a Medicare Advantage plan is more complicated.  If you want to change to a new MA plan for 2020, you have to do it through Via Benefit to continue to have access to your HRA/FHA.  Be sure you check with your doctors before changing to a new MA plan to be sure they will take the plan.

  

IBM Medicare Via Benefits Medicare Fall Enrollment for 2020

This is the time of year when you are being inundated with sales literature from private insurance companies trying to sell you Medicare Advantage plans and part D prescription drug insurance plans.  It is also the time of year when you receive plan updates from companies currently providing your Medicare insurance.  Sometimes it's hard to differentiate.  Usually, your current insurance providers send "thick" booklets to describe changes in premiums, copays, and changes in drug lists (known as their formulary).  You have to look at your mail! You have to keep the booklets about your current policies!

I cannot emphasize it enough. It is really, really important to not throw away the literature from your current insurance companies. You MUST read those "thick brochures" not only to look for changes to your existing policies but also because this is also the time of year insurance companies terminate plans and switch people automatically to another plan if the customer doesn't "take action" to actively pick a new insurance plan.

I have not had the experience, but my guess is that if you have an insurance policy purchased by using Via Benefits, they will tell you that you need to pick another plan. If it is the only plan you have with them, then you must pick a new medical plan that they sell (Medicare Advantage plan or part D drug insurance or Medicare Supplement plan) to have access to your HRA. Vision and Dental plans DO NOT qualify you for HRA access.

Reminder, if you have original/traditional Medicare and a Medicare Supplement through Via Benefits, you can buy any part D prescription drug insurance plan available in your zip code.  It doesn't have to be through Via Benefits.  There is a wide variation in the prices and formularies for part D plans.  Make sure you either use plan finder on www.medicare.gov to see if there is a better plan or call 1-800-MEDICARE and ask them for help to pick the best plan.

Given this is so complex, as we age, it is also really important to have someone else understand this process who can provide help if it becomes overwhelming.  Educate that person now because initially they will also be totally confused by the process.

Medicare (as in the federal government agency) schedules open enrollment every year to allow Medicare recipients to make insurance changes. It is akin to IBM's annual insurance enrollment when you were employed. This year the Medicare Open Enrollment (which is what the federal government calls it although sometimes it is referred to as Fall Enrollment) begins on October 15th and ends on December 7th and the changes are effective January 2020.  Reminder, this federal Medicare insurance change window only applies for Medicare Advantage plans and part D prescription drug insurance plans. 

Medicare Supplement plans (which are for people who have original/traditional Medicare) have completely different "change" rules and schedules.  In some states, you cannot change the insurance - NOT EVER - because insurance companies are allowed to deny policies to people with preexisting conditions or can charge whatever they want for the premium. At this age, it is rare for someone to not have preexisting aliments.  In some states, there are specific times of year (such as your birthday month) when you can change Supplement insurance but the premiums might be higher for a new policy if you have preexisting conditions.  In a few states, you can change the policy whenever you want and it must be sold at the same price that everyone else in the zip code pays plus you cannot be denied.  You have to check with your state to find out these rules.  There are state organizations that will help.  It is the State Health Insurance Assistance Program.  Each state has one.  To find your go to  https://www.shiptacenter.org/

IBM Medicare Via Benefits Extend Health "About Your Benefits Post Retirement" PDF

It is not easy to find a document that IBM publishes for retirees called "About Your Benefits Post Retirement".  It is on the NetBenefits site in the digital library.  A kind reader provided a link to the document in a reader comment.  Thank you! 

This document describes a wide range of topics for more than just health benefits for retirees.  It is particularly useful for people who have retired and are under 65 years old. There is some information about health benefits for retirees on Medicare.  The most important information for people using Via Benefits is how to complain to the Plan Administrator if you are having trouble dealing with Via Benefits.  It is buried in the back of the manual. It has been my experience that if you call the IBM Employee Service Center, they won't give you that information.  They will redirect you to file the complaint with Via Benefits. 

You must log on to the NetBenefits site to gain access to the most current version of the PDF before you use this link:  http://bit.ly/2UnEQxA

In case you want to read it, but don't want to log into NetBenefits, what follows is a link to a downloaded copy of the January 2019 version. IBM republishes this document from time to time.  If you need the most current version, log onto NetBenefits and use the above link. In this version, the description of how to complain about Via Benefits is on page 216:

https://drive.google.com/file/d/1j1OX3l3l_0xsnXYDtCDCjBcE4p3bfWlP/view?usp=sharing

To access this file you might have to download it.

IBM Medicare Via Benefits Extend Health Medicare.gov Plan search changes

The federal government has released a new version of the plan search function for open enrollment on www.medicare.gov.  This is the function that helps users decide which plan (part D or Medicare Advantage) to choose during open enrollment for 2020. The function is known as "plan finder". The federal government has said because of contractual problems with the company that maintained the previous version, the previous version will not be available after the end of September.  That is hard to believe. I think they just want to get rid of the old application because it doesn't push Medicare Advantage plans.

It is is the opinion of many people (including me) that the government is doing everything it can to push Medicare eligible recipients into Medicare Advantage plans using this new plan finder.  The new plan finder function also is pushing hard on users to "register" and use their Medicare account to store their prescription drug information to do plan searches.  That means the federal government will be able to collect even more data about Medicare recipients when it is stored in their personalized accounts.  The federal government has been notoriously bad about protecting user privacy, which means as users load their Medicare account with drug data, they increase exposure to hackers and/or scammers who, if successful in hacking, will know more about the drugs seniors take and be better able to convince seniors they are legitimate for whatever scam they are perpetrating. It might also be used by the government for other purposes, such as seeking geographic trends of drug usage to compare prescriptions for brand name versus generic and put pressure on insurance companies or even state legislatures to push generics (even if they don't work as well, aren't they good enough for old people?). Decide for yourself the amount of data you want to share. I will continue to use medicare.gov anonymously but found it took a lot of effort to get around the website incessant demands to log in.  Don't be intimidated by it!!  More importantly, use feedback to complain about it if you find it highly irritating.

The new plan finder function appears to require the use of a Medicare account but it doesn't.  If you don't want to use you account, just provide a random birth date when prompted for your birthday and don't log into your account. Also, since the drug list you enter will not be saved, be sure to print it out before you leave the site.  Unfortunately you will have to reenter you drug list each time you want to do a plan search.

The most egregious aspect of this new function is the blatant push of users to Medicare Advantage plans.  There is a comparison of "costs" between original Medicare and Medicare Advantage.  How do I put this politely --- it is BS. The Medicare Advantage plans always show as cheaper!  Nor is the comparison showing a provider network comparison, prosthetic devices available, durable medical equipment restrictions, skilled nursing cost differentials and so on.  Reminder, Medicare is health insurance.  The operative word is insurance.  You get what you pay for whether it is house insurance, car insurance or Medicare insurance.

I recently talked to someone who is on a Medicare Advantage plan and had been happy for several years - when they were well.  However, the person was horrified at the cost of care when they got a diagnosis of cancer.  Suddenly, instead of a low cost copay of $35 to see a specialist, they had to pay $100 every time they went to the chemo treatment center.  They also had to pay a 20% coinsurance for the cost of an expensive chemo drug. This is a level of cost comparison that is not available in the plan finder function. The only way to know this level of detail is to look at the plan itself.  It is not easy to find but it can be done.  State health insurance assistance organizations (https://www.shiptacenter.org/) can help you ferret out those details.  For this person, they hadn't known to do it. The person was not exactly low income but couldn't afford their medical bills.  They also did not realize the plan's maximum out of pocket for the year is $5500 and that it would reset in January. They were desperate to find financial assistance and turned to local charities for help.  Just as a reminder, there are no hidden costs in original/traditional Medicare and no network restrictions.  It is very straight forward and, with a Medicare Supplement the maximum cost is very predictable.

The new plan finder is now available on medicare.gov but it is for 2019 plans, 2020 plans won't be loaded until the beginning of October.  Test it out and give CMS your feedback on it.

I do not know whether or how Via Benefits will modify their plan comparison function.  Reminder, their plan comparison function is only for the plans they sell.  If you want to look at all the plans available in your zip code you must use medicare.gov.

IBM Medicare Via Benefits Extend Health Medicare Advantage Plan Problems

This month the New Yorker  published an article about whistle blowing which featured what happened to two people who, as employees, exposed how Medicare Advantage insurers were manipulating both policy holders and the federal government to maximize corporate profits.  Although it was a profile of the whistle blowers, the author did an excellent job of explaining how some insurers are costing taxpayers billions of dollars and reducing the ability of seniors to get adequate healthcare.

The New Yorker article closely paralleled a PBS broadcast several months ago in the area of explaining how insurers are manipulating costs to maximize profits but the PBS broadcast did not include much about what happens to whistle blowers (that alone is worth the read). It's no wonder employees don't whistle blow on corporations. It ruins people's lives.

Here is a link to the New Yorker article:
https://www.newyorker.com/magazine/2019/02/04/the-personal-toll-of-whistle-blowing

Here is a link to the PBS program:
 https://www.pbs.org/video/medicare-advantage-taking-advantage-aldeae/

Some of how the fraudulent actions affect policy holders is buried in the New Yorker article.  There was a description of a practice called "lemon dropping" which is a practice these insurers use to get rid of the sickest policy holders. They were doing it by paying incentives to insurance sales agents to convince people to switch to a different insurance company if they noticed the claim payout was high.

Based on recent counseling sessions, I suspect the "lemon dropping" strategy is being practiced a new way.  Medicare Advantage insurers seem to more frequently deny seniors access to healthcare procedures and  rehabilitation, particular after a hospital stay, by denying coverage for procedures the insurer say are not medically necessary.  Rehabilitation is a costly payout benefit to the insurers.  If denied, a policy holder has to go through a arduous process of appealing the denial and some just don't have the wherewithal to do it after being hospitalized. If they don't have relatives or friends who will vigorously fight the claim denial, they end up being discharged in a compromised condition.  It is likely intended to make the lemon (aka expensive reimbursement) policy holder angry enough to get them to switch to a different insurer, but if the policy holder dies the lemon also drops.

Once again, I urge anyone considering a Medicare Advantage plan to do it "eyes wide open".

Update May 2019:

Kaiser Foundation did an analysis of doctor networks for Medicare Advantage plans.  It is the first time such a study has been done.

https://www.kff.org/report-section/medicare-advantage-how-robust-are-plans-physician-networks-report/

IBM Medicare Via Benefits Part D 2019 Drug Insurance Cost Structure

The dreaded doughnut hole has closed for brand name drugs!  I wrote a long blog post about part D's cost structure in April 2018.  I got most of it right but there were several errors. Mostly, when I reread it last week it was a rambling mess that I had a hard time following .... and I wrote it!

I decided to try to simplify and skip the history lesson by using a series of bullets.  It's still a complicated description, but the whole structure is very complicated.

• Prescription Drug Prices Vary from part D plan to part D plan
  
  That's because each plan negotiates prices with pharmaceutical companies and/or distributors (the middle men) and/or retail pharmacies.  It is important to always fill prescriptions at preferred pharmacies for your insurance policy to get the lowest price for a prescription. The insurer also puts brand name drugs in a tier of their choosing, so a drug might be more or less expensive because of tier placement.  There is no government negotiation with pharmaceutical companies on drug prices and no requirements for drug tier placement for brand name drugs.  Generic drugs are usually in cheaper tiers.  If a drug company puts a generic drug in tier 1 then the policy holder has no copay.  That is a Medicare rule.  Drug prices can (and do) change during the year because insurance companies negotiate prices with pharmaceutical companies throughout the year.
            
• Prescription Drug Insurance Plans might have deductibles
  
  If there is a deductible it cannot be higher than the Medicare dictate. In 2019 the deductible maximum is $415. That means a policy holder has to pay the full (negotiated) price for drugs until the policy deductible is met.  Then, insurance policy co-pays start. Until the deductible is met, the only benefit from Rx insurance is the negotiated price. If a drug is generic and in tier 1 there is no payment for the drug so the deductible does not apply.  However, deductibles are not as important to consider as the total annual insurance plan cost. That's the total annual cost to you for the premium + deductible + co-payments.  Usually, pick a plan that provides the lowest annual cost. Plans with no deductibles can have higher  co-pays to make up for the lack of a deductible or place brand name drugs in higher co-pay tiers. Reminder, the insurers are in the business of making money and structure their plans accordingly. 
     
  There are two reasons (I can think of) to buy a plan with no deductible beyond picking it because it provides the lowest annual cost.  First, the policy holder doesn't have recurring prescriptions.  The policy holder will likely not meet the deductible so the benefits they get from drug insurance is the negotiated drug price (if they need a prescription filled) and avoiding the Medicare penalty for not having part D insurance. If so, it might be more cost effective to buy the cheapest premium part D and try other ways to fill a prescription before using insurance, such as asking the pharmacy what the cost is without insurance.  For example, Costco sometimes sells drugs at a "better price" than using an insurance plan and you do not need to be a member to use their pharmacy. The second reason to have a no deductible plan is if the person has serious cash flow problems - ergo they don't have a cash reserve to be able to meet the up front deductible.  Although the total annual cost might be higher, some people simply do not have a cash reserve to pay for their drugs in the "deductible phase".
      
• Prescription Drug Insurance has 3 phases of payment
     
  The first stage is the initial stage of payment.  After the deductible (if there is one), the policy holder pays a copay determined by the drug tier assignment. On average, for a brand name drug, the policy holder pays 25% of the cost of the drug.  However, the plan decides the tier placement so that percentage can be higher or lower.  The copay amount the policy holder pays for generic drugs depends on the tier too.  In tier 1, as mentioned, the copay is always $0 whether or not there is a deductible. The policy holder stays in the initial stage of co-payments until the total cost of their drugs is $3,820 in 2019. That includes both what you and the plan paid for the drugs.
  
  The second stage of payment is called the coverage gap or the doughnut hole. The structure of this stage has changed over time.  In 2019, in the coverage gap, the policy holder pays (based on negotiated prices)  a 25% copay for a brand name drug and about a 37% copay for a generic drug that is not in tier 1.  (In 2020 the generic percentage will drop to 25%.)  Therefore, the cost of your co-pays might change in the second stage and go down for brand name drugs and increase for some generics.  In this stage, the pharmaceutical companies are required to discount the negotiated cost of brand name drugs by 70%. Medicare pays the 63% cost of generic drugs.
  
  The third stage of payment is called the catastrophic stage.  The policy holder enters the catastrophic phase when policy holder deductible + co-payments + pharmaceutical company discounts in stage 2 = $5,100 in 2019.  The amount Medicare pays for generics is not added into the total.  Also, the copay amount in the second stage will not be counted at 100%.  There will be a 50 cent deduction each time a drug is dispensed in the this phase. Ergo, if you filled a prescription 10 times the total copay will be $5 less than what you actually paid.  In catastrophic coverage, the policy holder pays 5% of the cost of a brand name drug or $8.50 (whichever is greater) and 5% or $3.50 (whichever is greater) for a generic drug.
  
  
  I hope this is a better explanation. 

IBM Medicare Via Benefits versus OneExchange lament

It's been about a year that Towers Watson changed the name and it's obvious they did more than change the name, they changed the subcontracted provider that provides the customer interface.  Time to give feedback on observations about it but my overall assessment is they are not good.

I did not have much interaction with the new services provider because most of my reimbursement are automatic.  However, the few times I did submit claims, if they were routine, it worked.  The two times I tried to submit claims that were "not routine" were not successful.  They seem to not know how to handle claims from doctors who do not accept Medicare nor do they know how to accept claims for procedures that are not covered by Medicare (such as annual physical). In both cases I decided to not go on the war path because I knew I would be using up my HSA on other stuff.  It wasn't worth the fight.

I truly hate the statements they send when they do a reimbursement.  They are unintelligible.  However, if I get the money, that's what really matters.

I also did not spend a lot of time on the website, given I don't need to make changes.  I did call to change my medigap insurance in October and when I spoke to them, the agent tried to say I could not do it without underwriting until I reminded her I could do it whenever I want without consequence because I live in New York.  She apologized for her mistake, but if I had not known I would have believed her. The quality of the service representatives seems to have degraded.

My next encounter happened when a friend told me he was advised, when he called,  he could not file claims for part D IRMAA.  For those that don't know, it is a Medicare income based assessment (don't call it a tax) imposed by Medicare for people with high incomes.  He was told by Via Benefits it was not eligible for reimbursement.  Of course, that was wrong.  It is part of the part D premium but it is paid out of social security benefits or as a separate bill from Medicare.

I double checked it with Via Benefits via an inquiry on their site.  The representative confirmed it was a legitimate recurring expense.  Then he told me how to get a recurring expense form.  Shock of shocks, he gave me the wrong information on how to find the form and I had to troll through the website until I figured it out. He directly sent me that answer to my email address.  I do recommend putting inquiries in writing because it is less likely you will get a wrong answer. They don't want to have hard evidence of wrong answers.

Finally, I complained to Via Benefits via an inquiry message on their site that I no longer get email confirmations when I submit claims and could no longer find the setting on the website to double check it was still activated.  This time, I got an email back telling me they had answered my question and it was posted on the site.  It took me about 10 minutes to find where it was posted.  I had to go to the reimbursements function and dig around until I found the message.  There was no indication in the home screen that a message was pending.  When I read the message, it said I could get a text, but no email confirmation.  That's nuts twice.  They could have put that in the email they sent to me telling me they had answered the question AND not everyone wants to give out their cell phone numbers so they can be texted!

Anyway, I guess we are lucky we still get HRA/FHA money.  However, good luck figuring out all the Via Benefit quirks to be able to access that money to pay claims.

I wish you all a wonderful 2019 and a lot of patience and success getting claims paid.  Complain, complain, complain if you have problems.  It's the only way they will fix it.

IBM Medicare Via Benefits Medicare Advantage Maximum Out of Pocket Cost

I write a lot about Medicare Advantage plans because they are complex but are presented as a comprehensive and simple one-stop shopping alternative to original Medicare.

This post is focusing on the MAXIMUM out of pocket (MOOP) cost you might pay using a Medicare Advantage plan if you are seriously ill.  MOOP is an accumulation of all your payments, excluding premium payments, for a given year.

It is rare that this aspect of Medicare Advantage plans is mentioned or truly explained by the company or an insurance agent.  It is often referred to as a cap and not MOOP. It needs to be an important part of your selection criteria if you are considering one of these plans.

The federal government determines the maximum MOOP number and it is current set at $6,700. However, your actual maximum can go as high as $13,400 a year.  It is up to the insurance company where to set the MOOP but it never can be higher that $6,700 for in-network providers. To be fair, there are plans where the MOOP is $0.  They are more restrictive plans such as HMOs where you cannot go out of network and in-network is a small set of doctors.

It is important to realize that if  your plan does include an in-network and out-of-network option and you go to an out-of-network provider, your payment to the provider might not count toward an in-network MOOP.  It depends on the insurance plan.  Some plans have two numbers, meaning there is an in-network MOOP and an out-of-network MOOP.

I just saw a plan yesterday that had two categories and each category was set at $5000.  That means if the policy holder was very sick, they could end up paying a whooping $10,000 out of pocket in 2019 plus pay a premium of $103/mo.  Ergo, the MOOPs + premium cost could top out at $11,236/year!!!

How the blazes does that happen?  When you are seriously ill, the cost sharing in Medicare Advantage plans changes.  For example, your copay might be significantly higher than in original Medicare if you need home care. Insurance companies never talk about that.

Here is my bottom line on all of this.

A Medicare Advantage plan can be significantly more expensive than original Medicare if you get sick and has the potential of costing $13,400 in 2019 and you cannot buy a secondary insurance policy to cover that cost. There is no regulated MOOP for out-of-network services - see update below.
 
Original Medicare with my current F high deductible plan ($93/mo in my zip code) guarantees I will never pay more than $1116 in premiums and $2300 in F HD deductible in 2019.  So my Original Medicare + FHD policy premium + FHD "MOOP" is $3,416.  AND I can go to any Medicare doctor anywhere in the USA without needing a referral or worrying about networks.

I think that says it all.

Updated 5/31/2019

Today I helped someone who's parent had a Medicare Advantage PPO plan, was scheduled for cataract surgery as a hospital outpatient and was informed they had to pay a $1000 deductible and a $350 fee prior to receiving treatment. 

The plan was structured to have very low cost (in copays and no monthly premium) as long as the person had minimal health issues.  The parent didn't realize there was a $1000 deductible if she needed to use the hospital as an outpatient.  When I looked at a more detailed description, there was a $675 deductible for inpatient admission (and nothing said about how often that deductible had to be paid such as one a year, once a quarter, for every admission and a $500/day copay after day 20.  There was also a $6,700 in-network MOOP and a $10,000 out-of-network MOOP.  Ergo the parent might face an annual cap of $16,700 because apparently the out-of-network MOOP is not regulated!

It's a pathetic decimation of  the promise of Medicare insurance to protect the elderly from overwhelming medical cost and the federal government is enabling this by actively "pushing" Medicare Advantage plans.