Medicare Advantage and Medicare Supplement Plans (Medigap)

GreenSky

GreenSky

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Location
Las Vegas
There were a couple of questions about these products in another thread so I thought this subject deserved a thread of its own.

Medicare Advantage Plans replace Original Medicare with a private insurance policy. The benefits must be at least on par with Medicare but copays, coinsurance and other "rules" are based upon the insurance company's plan. As an example, Medicare requires a one-time deductible for in-patient services billed by the hospital with an annual deductible and 20% coinsurance for all other covered benefits. A Medicare Advantage plan could charge as little as zero to many hundreds of dollars a day for the same hospitalization. However, most MA plans includes the Part D drug plan.

As far as premium payment, Medicare pays most if not all the premium for these plans. They generally come in either of two "flavors"; HMO and PPO. The HMO plans are the most restrictive usually requiring referrals for most non-primary services. The network can be quite restrictive. PPO plans will allow for self-referral into a much larger network and usually (at a higher cost) allow the member to go out of network.

Original Medicare has a deductible for Part A (Hospitalization) that is charged for every admission per benefit period of 60 days. Part B has an annual deductible and then covered charges are paid at 80% of the allowable. To protect oneself from these charges a Medicare Supplement can be purchased. There are 10 standardized plans but the most popular are F, G and N. All supplements of the same letter are identical regardless of the insurance company. The only difference is the premium. Don't let anyone tell you their company is the best. They are all the same.

Plan F covers 100% of your costs. Plan G is the same as Plan F except it does not pay the Part B deductible ($183 for 2017). Plan N does not pay the deductible, requires a copay of up to but never more than $20 for office visits (treatment does not raise the cost and various services such as physical therapy, chemo, etc. are not office visits), and up to $50 for emergency room visits that don't result in admission.

Plan N do not pay excess charges. This is when a doctor will not accept the assignment of your claim. The provider still must do all the billing but payments go to the patient. It is then up to the doctor to bill the patient and hope the bill is paid. For all this work the doctor winds up with 9.25% more than he/she would receive if assignment was accepted. It's not worth the trouble and 96% of all physicians accept assignment. I've helped hundreds with their Medicare supplement plans and not one has ever told me their doctor did not accept assignment. It's truly a non issue.

I hope this brief description and comparison helps. I'm always available to talk without obligation nor a sales pitch. I promise!

Rick
insure(at)greenskyins(dot)com
 

we have a high deductible f-plan . it is perfect for us . it cost 2k less and has a 2k deductible . most of our non medicare covered claims are about 400 a year so we save 1600 a year as opposed to just taking a full f-plan .

not only do we save 1600 a year but they pay for our gym directly through silver sneakers saving another 480.00 a year in membership . that makes the high deductible f-plan a real value .
 
mathjak107 said:
we have a high deductible f-plan . it is perfect for us . it cost 2k less and has a 2k deductible . most of our non medicare covered claims are about 400 a year so we save 1600 a year as opposed to just taking a full f-plan .

not only do we save 1600 a year but they pay for our gym directly through silver sneakers saving another 480.00 a year in membership . that makes the high deductible f-plan a real value .
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I completely agree. I'll have Medicare in 2 years and that's the plan I will use. So many people are afraid of the $2,000 out of pocket despite generally saving between $1,000-$1,500 annually in premium.

Rick
 

I plan to retire later this year and looking at the Medigap plans vs. the Advantage plans for my zip code the advantage plans have a lower monthly cost with equal or better coverage than Medigap with part D. Am I missing something? If not then why would anyone want the Medigap plans?
 
Bill4x4 said:
I plan to retire later this year and looking at the Medigap plans vs. the Advantage plans for my zip code the advantage plans have a lower monthly cost with equal or better coverage than Medigap with part D. Am I missing something? If not then why would anyone want the Medigap plans?
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'

1) Not everyone has access to Medicare Advantage;
2) The coverage for MA always is at least as good as Medicare (although copays and deductibles can vary);
3) All Medicare Advantage plans are network based meaning you may not be able to see the doctor of your choice. I'm not talking about primary care doctors but rather specialists. If the specialist you want to see is not in network you cannot see that doctor unless you pay 100% of the cost.

Neither MA nor Medicare+Medigap fits everyone. You have to decide what's best for you, both now and in the future. There is no doubt that MA plans restrict your freedom of choice. And it's usually the case that MA will save the most premium dollars although can be the most expensive (both financially and out of pocket costs) in the event of illness.

Find an independent agent to help you with your choices. And if you don't feel good about that agent, find another.

Rick
 
Bill4x4 said:
I plan to retire later this year and looking at the Medigap plans vs. the Advantage plans for my zip code the advantage plans have a lower monthly cost with equal or better coverage than Medigap with part D. Am I missing something? If not then why would anyone want the Medigap plans?
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Yes.. A Medicare Advantage plan is an HMO... This means the insurance company can deny procedures and hospitalizations.. They can dictate which doctors you can see and which hospitals you may go to..

I will advise sticking to Traditional Medicare with a Plan F or Plan G supplement and a Part D based on your medication needs.
 
QuickSilver said:
Yes.. A Medicare Advantage plan is an HMO... This means the insurance company can deny procedures and hospitalizations.. They can dictate which doctors you can see and which hospitals you may go to..

I will advise sticking to Traditional Medicare with a Plan F or Plan G supplement and a Part D based on your medication needs.
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Actually, MA plans include both PPO and HMO in many areas.

Plan F is going away and will be even less of a value in the future. I agree with Plan G but am partial to Plan N.

Rick
 
My Advantage plan is an HMO, but the HO pool is huge and encompasses most of the specialists in Albuquerque, that is to say most of our specialists take my plan. I have no deductible and my doctor visits are $5, with specialists being more. I think they are $50 now. BUT, when I had my hips replaced, I only paid that $50 once, at the first visit to the orthopedic surgeon. The rest of the visits were considered ongoing care and I didn't have to pay again. Now when I dislocated my shoulder I had to pay the $50 again to the orthopedic group, but that was a different issue. When I initially dislocated the shoulder, I had to pay $65 to the ER, but that was all; no additional for ER docs or X-rays or all the morphine and assorted drugs (thank God for painkillers!!!) I got so they could put the shoulder back in its socket.

With my hips, I paid $0 out of pocket for all the pre-surgery stuff, x-rays, lab stuff, and all that. I paid $0 to the anesthesiologist. I DID pay the hospital the medicare deductible for the couple of days I was in there for each hip, which was a total of about $900. That was ALL I paid. My plan picks up the hospital charges 100% after day 3. I would have paid more than that in premiums if I had a Medigap policy. I have a $3,400 maximum out of pocket yearly; I haven't come anywhere near that, even in the year when I had the hips done.

My plan is affiliated with the largest hospital here and is administered by them. I wouldn't change. I've gotten great care for very little out of pocket cost. I pay nothing additional for the Advantage plan, just the regular Medicare premium.
 
Hi Rick,

Maybe you can help me understand, and shed light for others. I wAs advised to switch to a Plan F from an Advantage plan. I did, feeling relievd I was “fully” covered (as per an agent, and reading material). To my surprise, this is not always the case. I went for a phhysical once, and was billed for my blood panel. I recently had hernia repair, woke up with a support belt for my recovery, and I received a bill for this belt, not from the hospital, but from a third party suplier I never heard off. I refuse to pay, and am now being threatened with legal action, or a collection agency. So, is this the Plan F everyone is raving about? I feel duped, and everyone needs to know about this. Of course, the surgery was over 50K, and had I had a lesser plan I would incure a much greater expense than a $40 bill for a support belt. My concern is that in other circumstances I could wake up with a charge much higher than this. My question is, what can I do, and is there another plan that truly covers it all? BTW, I am still contacting, and awaiting answers from all parties involved, but no one has been able (?) to help me, so far...
 
there is a lot more to this . the first question is did you have a high deductible f-plan ? the second question is did the doctors assigned to you or lab agree to take just what medicare pays them . they may not be accepting medicare. in which case you owe anything above the agreed medicare prices just like an advantage plan .

the labs and doctors have to be part of medicare . if not you pay anything over the medicare agreed prices . was anything considered preexisting in your state when you switched plans ? did medicare cover the belt ? if they don't you get nothing paid by a supplement .remember supplements only pay the difference on what medicare covers . if medicare paid nothing you get nothing from the supplement .medicare must cover the expense first .
 
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maunymuray said:
Hi Rick,

Maybe you can help me understand, and shed light for others. I wAs advised to switch to a Plan F from an Advantage plan. I did, feeling relievd I was “fully” covered (as per an agent, and reading material). To my surprise, this is not always the case. I went for a phhysical once, and was billed for my blood panel. I recently had hernia repair, woke up with a support belt for my recovery, and I received a bill for this belt, not from the hospital, but from a third party suplier I never heard off. I refuse to pay, and am now being threatened with legal action, or a collection agency. So, is this the Plan F everyone is raving about? I feel duped, and everyone needs to know about this. Of course, the surgery was over 50K, and had I had a lesser plan I would incure a much greater expense than a $40 bill for a support belt. My concern is that in other circumstances I could wake up with a charge much higher than this. My question is, what can I do, and is there another plan that truly covers it all? BTW, I am still contacting, and awaiting answers from all parties involved, but no one has been able (?) to help me, so far...
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The support belt may be considered by Medicare to be "durable medical equipment," which Medicare in many, if not most, cases does not cover.
 
Butterfly said:
The support belt may be considered by Medicare to be "durable medical equipment," which Medicare in many, if not most, cases does not cover.
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i think the poster thinks the supplement is supposed to cover everything -period . but that is not how supplements work .they only pay for what medicare covers .if it is something medicare won't pay for a supplement pays nothing . it must be a medicare covered event
 
I have a Humana Medicare Advantage Plan that is a ppo plan with a drug plan. Love it as all of my meds are free. I get a 90 day mail order supply and if I need short term meds I use Walgreens. My pcp, specialists and hospitals are in network. They do the silver sneakers gym and offer a $50.00 health and wellness program each quarter where you can order over the counter things you need. I would never have a HMO plan as they are too restrictive requiring referrals, etc. This PPO plan works for me but its offered only in certain areas. I just ordered the 2019 information to see if there are any changes that might affect me. I hope to keep it so I won't have to buy a supplement and go back to regular Medicare.
 
we use a humana high deductible f-plan and medicare. for the monthly premium i pay the fact it includes silver sneakers and pays for my gym has 1/2 the premium i pay going for what i would pay for the gym .

be careful with that ppo advantage plan. they can be dangerous if you end up with a non participating doctor or lab .

If you go to a preferred provider, they may pay as an example up to 85% of the doctor's charges and if you go to a non-participating provider they pay up to 65%, but that's not the whole story.

The preferred providers have already agreed to be reimbursed a certain price from humana , but the non-participating providers haven't, so they can charge you anything they want. humana 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 humana knocks it down to $1,000. humana 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,humana will only pay $650, which is 65% of the $1,000 UCR. You are then responsible for paying not only the $350 difference between humans payment and the UCR, but also the other $1,000 that the anesthesiologist billed.

So the bottom line is that your copay with the provider " doctor is $150, but you're copay for the non provider doctor is $1,350. So you see, just because humana will reimburse you for any doctor you see, the amount you have to pay can be quite different.
 
As I said before I only use in network providers. Once when my pcp asked another doctor for a consult I told him to remember that I am only going to see a provider in my network. In fact I had a new neuro guy come in and introduced himself and I promptly told him that if he was not a network provider not to come in. He laughed and assured me he was and said he understood. I don't care what anybody thinks, it is my health involved and I know there are qualified providers in my network and I will only use them.
 
you would be amazed how many get stung by this because they think they can see any doctor because it is a ppo . it never hurts to keep reminding everyone.you may be aware but few are aware how it works . that is until the bills come in from seeing a non participating provider .
 
Bill4x4 said:
I plan to retire later this year and looking at the Medigap plans vs. the Advantage plans for my zip code the advantage plans have a lower monthly cost with equal or better coverage than Medigap with part D. Am I missing something? If not then why would anyone want the Medigap plans?
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You need to evaluate these four criteria -

  1. your health
  2. your need/desire for doctor/provider flexibility
  3. your ability to pay Medigap (and Part D) premiums
  4. 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 aMedigap 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 $2,180, 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 $2,180. Thereafter, the Medigap pays 100%.

If you're healthy, over a period of years, you'll probably be much further ahead financially with an hd-F. (If you haven't done so, as yet, strongly recommend you read this: Help - In Texas: Thinking Original Medicare and hi-D Plan F - thoughts?

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:

  1. copays and max out-of-pockets, especially if you're sick or anticipate health issues.
  2. restricted networks - an issue if you need specialty care or if you travel a lot.
  3. 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.

also read my warning above on advantage ppo's .
 
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In my case plan f-n will cost me from 1600 a month to 1300 a month. Yes I said a month. This my be due to my chronic disability.I have congested heart failure.
 
if you have health issues, you should join a plan when you’re first eligible, during your Medigap Open Enrollment Period. This is the period when you have guaranteed-issue rights, and Medigap insurers can’t deny you coverage, require medical underwriting, or charge you a higher premium if you have health problems.

you must be trying to switch plans not first join otherwise they can't count prexisiting .


 
I have an advantage plan, which is currently $134 @ month. Out of pocket expenses have been running about $400 annually, so a total of approximately $2,000 @ year.
My wife has medigap plans, with premiums in the $300 @ month range. Her out of pocket expenses have also been running about $400 annually or about $4,000 @ year.

We have discussed having her switch to an advantage plan, but have never pulled the trigger. Largely due to my retirement included a healthcare reimbursement clause. It covers mine, but comes up a bit short on hers. The end sum is affordable, so why not.

My opinion, is that any health care plan is a shot in the dark. You can save money up front and take a chance on future health problems costing more... or spending money up front on the potential of future health problems that may not come into play. Gaze into the crystal ball and make a choice.
 
there is more to it than money . advantage plans are gate keeper to your treatment and procedures and not everything just flies through unfortunately. nothing is ever a problem until it is a problem .

we have a friend who learned there is a difference to late .

they had pituitary gland cancer and the doctors wanted it out .

her advantage plan said they would only authorize the cancerous side but not the side that was in bad shape at this point .

her doctors thought that was insane . medicare ALWAYS PAYS for the removal of both halves .

but the advantage plans know you can't prove in your case what not for profit medicare would cover so they can pretty much deny anything they like and you can't prove other wise . it was a big learning curve for them about the difference between a for profit insurer and not for profit medicare as a gate keeper to your health


i wish the price was the only difference .
 
My plan is owned and operated by the largest (and not for profit) healthcare system in New Mexico. It covers thousands and thousands of seniors here. Most of the seniors here are on this plan and no one I know has ever had any problem at all with it. My sister had all kinds of trouble getting her care covered by another plan (a nationally known one). She has multiple medical issues and I had an ongoing battle with them over her care. I finally got her to switch to the one I am on and we have had zero problems with it and she gets better care and better hospitals. We each pay about $20 a month for the plan and are extremely pleased with it.
 
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