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I'm having to make a change in insurance plans, as my doctor no longer accepts my current Medicare advantage plan. I'm debating on getting another advantage plan that she will accept (zero premium, so I would pay only the cost of Medicare B of $135/month, plus a small co-pay), or going with original Medicare A&B plus Plan G plus a drug plan (cost would be $340/month total for this), which would mean finding a new doctor, as my current doctor also doesn't accept original Medicare. I don't really want to have to find a new doctor, but I do want to check out other options, and I have some questions.
1.) Is not accepting original Medicare becoming a trend with doctors, or is my doctor unusual?
2.) I'm not sure why more people don't use an advantage plan over original Medicare, especially when many advantage plans have zero premium--is it because you have to use an in-network doctor (which I don't mind doing) ? Or is it because it only covers 80% of costs?
The new zero-premium advantage plan I'm considering has an out-of-pocket limit of $6500, and the rest is covered 100%. With this advantage plan, my drugs are generic tier 1 and are free, and my doctor co-pay is $5, with a $45 specialist co-pay. I don't mind using an in-network doctor, so I'm wondering why I should pay $340/month total for original Medicare coverage plus Plan G plus a drug plan, rather than paying zero (just $135 total for Medicare B) for an advantage plan.
3.) I've heard that advantage plans are "good until they're not good" what does that mean? They are required to cover the same things that original Medicare covers, with some co-pays and such, which don't seem to add up to much in my particular case, at least at this point in time.
So, my choices are to pay $340/month for 100% coverage, or pay $135/month with a small co-pay and an out-of-pocket limit of $6500.
We've had many discussions on this forum on the pros and cons of either a Medigap + Part D, or an Advantage plan which includes drugs. A quick search should turn up many threads.
You need to evaluate these four criteria -
your health
your need/desire for doctor/provider flexibility
your ability to pay Medigap (and Part D) premiums
carrier reliability (especially true for Advantage and some Part D plans)
If you have a lot of chronic health issues or foresee serious issues - and can afford it - then a Medigap G or F - provides the most flexible, worry-free, and trouble-free choice. You can see any provider anywhere in the country who accepts Medicare, no gatekeepers on treatment approval, no provider networks. Bills go to Medicare and your Medigap.
Generally, with a Medigap F/G, your Medicare-approved expenses will be paid 100%. For the most part, medical expenses are pretty much limited to Medigap premium (and Part D premium and copays if you take medication).
There are less expensive (premium) cost-sharing Medigap plans available, as well, but often these prove to be a false economy when managing chronic illness or worse. Copays and hospital deductibles can eat up any premium savings in short order.
If you are reasonably healthy and can afford some premium and the very low 20% not paid by Medicare the few times you doctor - then a high-deductible Medigap F, which, again, provides the most provider flexibility and caps your annual max out-of-pocket (your 20%) at $2,300 (2019) worst case scenario, all at one-half to one-third the cost of a regular Medigap F. Bills go to Medicare and your Medigap. Medicare pays its 80%, you pay 20% up to a maximum of $2,300 (2019). Thereafter, the Medigap pays 100%.
If you are cost-conscious, then an Advantage (aka Medicare health plan) (if you're healthy - or, even if you're sick - depending on plan) can be an appropriate choice, as it bundles docs and drugs, for a low or zero premium. Pay close attention to:
copays and max out-of-pockets, especially if you're sick or anticipate health issues.
restricted networks - an issue if you need specialty care or if you travel a lot.
drug formulary (tiers and copays).
For the chronically ill, annual Advantage copays could exceed twice the cost of a Medigap F, as max out-of-pockets can be set at $5-$7k, or more.
If you travel a lot or snowbird, unless it is a PPO with out-of-network coverage, Advantage is not an appropriate choice.
If you choose Advantage, know that you are divorcing yourself from Medicare and putting the decisions for treatments, benefits, and payment in the hands of the PRIVATE (this means for-profit) Advantage insurer. Some are good actors, others are not. Common bad behaviors by MA's are denials of mandated Medicare benefits, onerous oversight on long-term therapies and preapprovals, etc., slow pays, denials they've received the provider claims, customer-service run-around, and more.
Check with network providers and providers' billing people on ease of use, timely payment, preapprovals, insistence on use of generic drugs, verify with the provider that provider is, in fact, in that network - insurance reps and websites often are wrong - and talk to people you know who have the same plan.
Unless you are in a guaranteed issue state, know that once past the Initial Open Enrollment, you will not be able to switch to a Medigap without undergoing health underwriting, although you can move from one Advantage plan to another Advantage plan during Annual Open Enrollment.
So, choose carefully, because there may not be a do-over if you decide later you prefer a Medigap.
Biggest issue for me and others re Advantage is restricted provider networks - and, if you're sick - onerous oversight which can restrict common sense medical solutions. Mathjak has cited on the other thread one such ridiculous instance.
If you are healthy, I would go with a high-deductible F plus Part D. Many here have chosen the hd-F. Otherwise, the AARP UHC Plan G which, because of its community rating, will mitigate premium increases.
Advantage would be my last choice - unless it is a PPO plan offered by a local Medical provider such as the one offered by our local Froedtert Hospital & Medical College which is part owner of Network Health - not a private, for-profit insurer such as UHC, Humana, etc.
Fyi - Advantage plans offered in rural areas of WI by local medical providers - such as Security (Marshfield Clinic), Gundersen, and Dean Health are the most highly-rated (92%) Advantage plans in the state. Their local facilities along with in-state customer service are the reason. All the others are in the low-mid 80's.
even with a ppo advantage plan you can find yourself in a world of financial trouble .
don't forget while you can go out of network they only pay these doctors based on the deals they have with preferred providers .
so they don't pay based on what is billed to you by a non provider doctor , they only pay based on what they would pay a provider that they have a special deal with as a provider and you pay the rest . so yes while there is a higher co-pay with the ppo's there is also the issue the co--pay does not include anything over the preferred provider rate so you actually can end up paying the copay and the overage .
madman of bethesda summed it up well .
" If you go to a preferred provider, BCBS pays 85% of the doctor's charges and if you go to a non-participating provider, BCBS pays 65%, but that's not the whole story. The preferred providers have already agreed to be reimbursed a certain price from BCBS, but the non-participating providers haven't, so they can charge you anything they want. BCBS will only pay 65% of the UCR (usual, customary, & reasonable) charges. For example, a surgeon or an anesthesiologist charges $2,000, but the contracted price with BCBS knocks it down to $1,000. BCBS pays $850 (85%) and your copayment is $150. However, if the surgeon or anesthesiologist is a non-participating provider and he charges the same $2,000, BCBS will only pay $650, which is 65% of the $1,000 UCR. You are then responsible for paying not only the $350 difference between BCBS's payment and the UCR, but also the other $1,000 that the anesthesiologist billed.
So the bottom line is that your copay with the "in-network" doctor is $150, but you're copay for the out-of-network doctor is $1,350. So you see, just because BCBS will reimburse you for any doctor you see, the amount you have to pay can be quite different."
even with a ppo advantage plan you can find yourself in a world of financial trouble .
don't forget while you can go out of network they only pay these doctors based on the deals they have with preferred providers .
so they don't pay based on what is billed to you by a non provider doctor , they only pay based on what they would pay a provider that they have a special deal with as a provider and you pay the rest.
...However, if the surgeon or anesthesiologist is a non-participating provider and he charges the same $2,000, BCBS will only pay $650, which is 65% of the $1,000 UCR. You are then responsible for paying not only the $350 difference between BCBS's payment and the UCR, but also the other $1,000 that the anesthesiologist billed.
Out-of-Network providers are not allowed to balance bill Medicare Advantage PPO members. The MA plan, not the member, pays the balance up to Medicare's 115% limiting charge. The provider must write off the difference between the billed charge and limiting charge.
Quote:
Medicare Managed Care Manual
Chapter 6 - Relationships With Providers
Section 100 - Special Rules for Services Furnished by Non-Contract Providers
Consistent with §1852(a)(2) and §1852(k)(1) of the Social Security Act, non-contract providers must accept as payment in full payment amounts applicable in Original Medicare. Thus, this provision of law imposes a cap on payment to non-contract providers of provider payment amounts plus beneficiary cost-sharing amounts applicable in Original Medicare, and ensures that non-contract providers not balance bill MA plan enrollees for other than MA plan cost-sharing amounts.
In addition, under Federal law, non-contract providers are subject to penalties if they accept more than Original Medicare amounts.
Medicare Managed Care Manual
Ch.4 - Benefits and Beneficiary Protections
Section 50.1 – Guidance on Acceptable Cost-sharing
Maximum Out-of-Pocket (MOOP) and Combined (Catastrophic) Limits on cost-sharing:
To ensure that MAO cost-sharing does not discourage enrollment of higher cost
individuals, and to provide for transparent plan benefit designs that permit beneficiaries to better predict their out-of-pocket costs, all local MA plans (employer and non-employer) – including HMOs, HMOPOS, local PPO (LPPO), Regional PPO (RPPO) and PFFS plans – are subject to a mandatory maximum out-of-pocket (MOOP) limit on enrollee cost-sharing for all Part A and Part B services. In addition, both RPPO and LPPO plans are required to have a combined limit on cost-sharing that is inclusive of both in- and out-of-network cost-sharing for all Part A and Part B services.
Section 50.5 – Guidance on Other Enrollee Out-of-Pocket Liability
No balance billing: As indicated in section 170 below, an enrollee is responsible for paying non-contracted providers only the plan-allowed cost-sharing for covered services. The MA plan, not the enrollee, is obligated to pay balance billing when it is allowed under Medicare rules. Furthermore, if an enrollee inadvertently paid balance billing which is the plan’s responsibility, the plan must refund the balance billing amount to the enrollee.
Section 170 – Balance Billing
The guidance in this section applies to HMOs (Health Maintenance Organizations), HMOPOS (HMO Point of Service), PPOs (Preferred Provider Organizations), and RPPOs (Regional PPOs).
When enrollees obtain plan-covered services in an HMO, PPO, or RPPO, they may not be charged or held liable for more than plan-allowed cost-sharing. Providers who are permitted to ‘balance bill’ must obtain the amount in excess of the enrollee’s cost-sharing (the balance) for services, directly from the MAO and not from the enrollee.
Section 170.2 – Balance Billing by Provider Type
* Contracted provider: There is no balance billing paid by either the plan or the enrollee.
• Non-contracting, original Medicare participating provider: There is no balance billing paid by either the plan or the enrollee.
• Non-contracting, non-participating (Medicare) provider: The MAO must pay the non-contracting, non-participating (non-par) provider the difference between the enrollee’s cost-sharing and the original Medicare limiting charge, which is the maximum amount that original Medicare requires an MAO to reimburse a provider. The enrollee only pays plan-allowed cost-sharing.
42 CFR 422.214 - Special rules for services furnished by noncontract providers.
Any provider that does not have in effect a contract establishing payment amounts for services furnished to a beneficiary enrolled in an MA coordinated care plan, an MSA plan, or an MA private fee-for-service plan must accept, as payment in full, the amounts that the provider could collect if the beneficiary were enrolled in original Medicare.
Looking into Medicare for my dad as he is eligible effective 12/01/19. I would but him in the serious health issues categories. He has only been to the doctors a couple times this year but has already had a heart attack and a stroke in the last 10 years and he still smokes.
Came here because Medicare advantage seemed too good to be true. Covers drugs as well and the premiums for the plans I looked at were $0 or $39. The OP above said he had to pay 20% until he met his deductible. The plans I look at show $0 deductible and an out of pocket maximum of $5500. It's would be hard to reach that maximum on $10 doctor copays and $25 specialist copays. Outpatient hospital services are $350 being the most expensive copay. This is a Blue Shield trio Medicare HMO/ and Anthem Blue Cross HMO I'm looking at.
So how would this plan ever be more expensive than purchasing Medicare B, D, and possibly a medigap policy? Is the only thing I need to be weary of is out of network services as was referenced above in the surgeon/anesthesiologist example? Thanks.
You don't understand deductible apparently. There is no payment until the deductible is met, the things you list that they pay are assuming you've met your deductible. One drug (for instance) or test alone could be thousands of dollars.
You don't understand deductible apparently. There is no payment until the deductible is met, the things you list that they pay are assuming you've met your deductible. One drug (for instance) or test alone could be thousands of dollars.
I'm quite familiar with deductibles and have had PPO's my whole life with deductibles. I'm familiar with plans and their deductibles and out of pocket maximums.
Typically under a plans cost it will list the following items:
Premium: the monthly cost
Deductible: amount you must pay before any coverage is paid by the insurance
Coinsurance: the % of in network cost you must pay once the deductible is met
Out of pocket maximum: self explanatory.
This plan I'm looking at shows no coinsurance for any service. Every service has a copay, as most HMO's do. It shows the health insurance deductible as $0. I was expecting these to be similar to ACA plans with $1800 deductibles and 80/20 coinsurance until the OOP maximum.
So I may not be reading the costs correctly but I'm not misinformed as to what a deductible is. Thanks for any clarification you may be able to provide.
Last edited by UntilTheNDofTimE; 09-30-2019 at 06:19 PM..
So how would this plan ever be more expensive than purchasing Medicare B, D, and possibly a medigap policy? Is the only thing I need to be weary of is out of network services as was referenced above in the surgeon/anesthesiologist example? Thanks.
No, what you need to be wary of are onerous oversight/approvals and never-ending copays should your dad become chronically ill. Which is why Advantage plans have maximum out-of-pockets ranging from $5K-$8K.
Advantage is NOT Medicare. Advantage is a private for-profit insurer dispensing Medicare benefits. So, beware.
We've had a number of posts over the years from people who found Advantage plans twice as expensive than a Medigap would have been when disaster struck. Others who didn't like network restrictions and oversight on services.
I had a neighbor who had Advantage. The copays were killing her because she required a lot of home health services for wound care.
A nurse in NJ moved her mother from PA to NJ and immediately put her on a Medigap. When mom was in PA, Advantage would not approve some SNF therapy and rehab and the copays ran to over $7k. She considers Medigap a bargain.
On oversight, one ridiculous case cited by mathjak of a friend's experience, an Advantage plan would approve removal of only half a cancerous pituitary gland when Medicare would have paid for removal of the entire gland.
A regular Medigap G, worst case, at age 65 may cost $2k year, and will cover all Medicare allowed services with no copay after payment of the Medicare Part B $185 deductible. Your doctors decide what services you need, not the Advantage plan. No preapprovals necessary for Medicare. No HMO. Complete provider flexibility. See any doctor who accepts Medicare patients anywhere in the US.
Part D plan should be chosen on basis of your dad's formulary. Part D plans have deductibles and copays.
Know that if you choose Advantage now, assuming he is age 65, under Medicare Trial Right #4, your father has one year to change his mind and return to Original Medicare and purchase a Medigap without health underwriting.
After that, unless he is in a guaranteed issue state or moves out of his Advantage plan's service area, should his health issues worsen he might find it very difficult to switch to a Medigap.
Depending on your carrier, Advantage can work very well or be a nightmare. Given his health issues which will only get worse, if he can afford a Medigap that's what you should be focusing on. Life is so much easier with a Medigap when dealing with chronic illness.
I agree that Original Medicare plus a Part D prescription plan and a medigap HD-F or G is the way to go! You can get all three if you are around 65 years of age for around $210 a month (depending on your income level) if you shop around. That $2,200 deductible you may have to pay could be divided and possibly paid over 12 months at around $180 more per month (worst case scenario). Other than you might have to pay it in one lump sum if you have a castastrophic illness or injury.
Points to consider --
1. Most, not all, but most physicians participate in original Medicare
2. High Deductible Medigap policies F and G provide insurance when traveling outside the US if you do that in retirement it is a benefit that other policies typically do not have.
3. No networks to consider, so no worries outside your normal home area and dr visits, appts, emergencies etc.
4. 20% copays are VERY inexpensive on original medicare for dr. visits. Typically around $9 for general practitioners, $15 to $25 for specialists. Takes a very long time/and lots of visits to meet that $2,200 out of pocket with dr. visits alone.
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