Medigap or Medicare Advantage Plan?

Dudewho said:
With an HMO your primary care physician ascts as your health care Cordinator. Not the insurance company. That's why you pick them with an HMO
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It's the Insurance company that decides what it will pay for.. and what medical care you can have... not your primary care physician.. With traditional Medicare.. it's your doctor that makes that decision. This is why HMO's are inferior to Medicare.
 

My wife was hospitalized for two months in three different facilities, including hospice in the hospital. Had every test you could think of. We had AARP Medi-Gap, and never paid a dime except for ambulance bills.
 
My medicare Advantage plan pays for anything Medicare covers. Medicare decides what it will cover -- your doctor does not. For Medicare to cover, it has to be medically necessary, also. Medicare doesn't just give you a blank check, it decides what it will cover and what it will not. So it acts as your insurance company.

My Advantage plan (for which I pay nothing in addition to the regular Medicare premium) also pays for prescriptions, vision, etc., and several things Medicare does not. The HMO I am in is huge, and most of the doctors here either accept it, or the other major Advantage plan here, or both. My sister and I both had hip surgeries, and we used the same surgeon. She had one Advantage plan, and I had the other. Here, at least, the restrictions on doctors you can choose is not a problem.

As to the out of pocket caps -- I had two hip replacements in 2013, for which I paid a grand total of $100 to the surgeon (for all the visits together, and the surgeries) and about $600 in hospital co-pays (for both surgeries together). I paid nothing to the anesthesiologist, or for diagnostic tests, or home PT, or anything else. And I had no Advantage premiums. My sister had the same scenario, but her payments were a little different (negligible difference) because she was on the other plan.

I saved a heck of a lot of money for two VERY expensive operative procedures and a total of 5 days in the best hospital in the region.

They all work differently.
 

Butterfly said:
My medicare Advantage plan pays for anything Medicare covers. Medicare decides what it will cover -- your doctor does not. For Medicare to cover, it has to be medically necessary, also. Medicare doesn't just give you a blank check, it decides what it will cover and what it will not. So it acts as your insurance company.

My Advantage plan (for which I pay nothing in addition to the regular Medicare premium) also pays for prescriptions, vision, etc., and several things Medicare does not. The HMO I am in is huge, and most of the doctors here either accept it, or the other major Advantage plan here, or both. My sister and I both had hip surgeries, and we used the same surgeon. She had one Advantage plan, and I had the other. Here, at least, the restrictions on doctors you can choose is not a problem.

As to the out of pocket caps -- I had two hip replacements in 2013, for which I paid a grand total of $100 to the surgeon (for all the visits together, and the surgeries) and about $600 in hospital co-pays (for both surgeries together). I paid nothing to the anesthesiologist, or for diagnostic tests, or home PT, or anything else. And I had no Advantage premiums. My sister had the same scenario, but her payments were a little different (negligible difference) because she was on the other plan.

I saved a heck of a lot of money for two VERY expensive operative procedures and a total of 5 days in the best hospital in the region.

They all work differently.
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Unfortunately Butterfly... Medicare does NOT decide what it will pay for.. or what tests you are allowed to have.. There is no pre-certification necessary. If your doctor orders a test.. medicare pays for it. unlike insurance companies. Now.. of course there are things that Medicare will not pay for... like for example cosmetic surgery or breast augmentation. But isn't that understandable.. Ask me how I know... I work with medicare every day and have for 15 years. My only advise to people... DO NOT GIVE UP YOUR MEDICARE for and Advantage Plan..
 
QuickSilver said:
Unfortunately Butterfly... Medicare does NOT decide what it will pay for.. or what tests you are allowed to have.. There is no pre-certification necessary. If your doctor orders a test.. medicare pays for it. unlike insurance companies. Now.. of course there are things that Medicare will not pay for... like for example cosmetic surgery or breast augmentation. But isn't that understandable.. Ask me how I know... I work with medicare every day and have for 15 years. My only advise to people... DO NOT GIVE UP YOUR MEDICARE for and Advantage Plan..
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What if you can't pass underwriting or afford a Supplement?
What caps does Medicare have caps on spending?
Does Medicare promote Wellness with Health memberships and OTC coverage for vitamins?
Do I need a three day stay in the Hospital to go into a Skilled Nursing facility with Medicare, I don't with my Advantage Plan?
Will Medicare cover my prescriptions? My Advantage does.
I get my teeth cleaned, will Medicare cover that?
I wear glasses Medicare help cover them?
I wear hearing aids will Medicare help with them?
I have a chronic condition will Medicare help me with meals?
My Advantage Plan gives me diabetic shoes for free will Medicare?
I get rewards from my Advantage Plan for having my preventive services done will Medicare?
 
Dudewho said:
What if you can't pass underwriting or afford a Supplement?
What caps does Medicare have caps on spending?
Does Medicare promote Wellness with Health memberships and OTC coverage for vitamins?
Do I need a three day stay in the Hospital to go into a Skilled Nursing facility with Medicare, I don't with my Advantage Plan?
Will Medicare cover my prescriptions? My Advantage does.
I get my teeth cleaned, will Medicare cover that?
I wear glasses Medicare help cover them?
I wear hearing aids will Medicare help with them?
I have a chronic condition will Medicare help me with meals?
My Advantage Plan gives me diabetic shoes for free will Medicare?
I get rewards from my Advantage Plan for having my preventive services done will Medicare?
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Well that's the beauty of living in a free country... You do and buy what you like.. I'll keep my Medicare thanks very much.
 
Thorn said:
With Advantage plans, do you still have the part B cost deducted from your social security checks? I can't seem to find the answer to that. Thanks.
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your premiums for your part B are sent to your advantage plan.. As your advantage plan will be covering both hopspitalizations and out patient services. So the answer is yes.
 
QuickSilver said:
Unfortunately Butterfly... Medicare does NOT decide what it will pay for.. or what tests you are allowed to have.. There is no pre-certification necessary. If your doctor orders a test.. medicare pays for it. unlike insurance companies. Now.. of course there are things that Medicare will not pay for... like for example cosmetic surgery or breast augmentation. But isn't that understandable.. Ask me how I know... I work with medicare every day and have for 15 years. My only advise to people... DO NOT GIVE UP YOUR MEDICARE for and Advantage Plan..
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this is something those with advantage plans don't realize until it is to late . nothing is ever a problem with these advantage plans-until it is a problem .

while it sounds great that your for profit insurer is supposed to pay for everything a non profit like medicare would cover that is only true until they don't .

the private for profit insurer can deny certain procedures that medicare typically would say go ahead but you don't have medicare so you have no way of ever saying what medicare would have done when your advantage plan denies you .

this is something you run in to far more often then anyone thinks .

we know someone going through this now with their advantage plan . the surgeons want both sides of a cancerous pituitary gland removed . the for profit advantage plan said they will approve only the cancerous half and the other half which is in bad shape will have to wait until it too is cancerous .

the surgeons are blown away by this as medicare always approves this , but without having medicare you can't document what medicare would have done and the insurers know this fact . it is done all the time where these hmo's can save money at your expense .
 
Butterfly said:
My medicare Advantage plan pays for anything Medicare covers. Medicare decides what it will cover -- your doctor does not. For Medicare to cover, it has to be medically necessary, also. Medicare doesn't just give you a blank check, it decides what it will cover and what it will not. So it acts as your insurance company.

.
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if only this was true but it isn't . in theory advantage plans are SUPPOSED to cover what medicare does but in practice they do not because you can never prove what medicare would have covered once the procedures are not black and white . you would actually need medicare , which you don't have , in order to prove what medicare would have done in your specific case . advantage plans are all to well aware of this fact
 
Dudewho said:
Check for a PPO. It has IN and OUT of network benefits.
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those out of network benefits in advantage plans can kill you financially and most people do not understand how they work .once again you learn way to late the disadvantages in an advantage plan .

i mentioned this warning in another thread .

as an example , 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.
 
I have a Medicare Advantage Plan and live it. $1900 cap on out of pocket costs per year. Free Doctor visits and between my wife and myself spend less than $200 a year out of pocket. Check out the AARP plans. They are good.
 
Vinny said:
I have a Medicare Advantage Plan and live it. $1900 cap on out of pocket costs per year. Free Doctor visits and between my wife and myself spend less than $200 a year out of pocket. Check out the AARP plans. They are good.
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I started out (10 years ago) with AARP United Healthcare, after the first year they wanted a $100 a month more!!! Cancelled!!!
 
Vinny said:
I have a Medicare Advantage Plan and live it. $1900 cap on out of pocket costs per year. Free Doctor visits and between my wife and myself spend less than $200 a year out of pocket. Check out the AARP plans. They are good.
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advantage plans are always good , that is until they are not .then you wish you had medicare and a comprehensive supplement . it turns out that way more often then not. those who rave about their advantage plans usually do so because they have not bumped the issues -yet.

if you are lucky you won't have any issues .
 
FYI, I got Plan G at 65 and Plan D with Medicare A&B . I retired the first of this year and 2 months later was diagnosed with Cancer. Just took my 3rd Cemo ( glad I signed up as some on here said to do ) .
 
my co-worker used to brag all the time about how little his advantage plan cost . that was until his wife got breast cancer . each chemo was 4500 bucks and his out of pocket was 6500 . it happened towards year end so he got hit for 13k with her and later in the year he was in the hospital and it cost him even more .

they both switched to medicare. they were lucky because ny is one of the few states you can do that . most states you can switch advantage plans but without underwriting you can't go advantage plan to medicare
 
mathjak107 said:
my co-worker used to brag all the time about how little his advantage plan cost . that was until his wife got breast cancer . each chemo was 4500 bucks and his out of pocket was 6500 . it happened towards year end so he got hit for 13k with her and later in the year he was in the hospital and it cost him even more .

they both switched to medicare. they were lucky because ny is one of the few states you can do that . most states you can switch advantage plans but without underwriting you can't go advantage plan to medicare
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FYI, my 1st cemo $38,000 total as outpatiant.
 
the irony is these advantage plans are used by those generally who are trying to save on the premiums because they do not have the assets to pay for medicare and a supplement . so when these gray areas hit and you reach these very high outof pockets , this 13k in the instance above is an insane amount in proportion to their assets and savings . it is usually these very people who can afford the least to roll the dice with their health coverage .
 
mathjak107 said:
the irony is these advantage plans are used by those generally who are trying to save on the premiums because they do not have the assets to pay for medicare and a supplement . so when these gray areas hit and you reach these very high outof pockets , this 13k in the instance above is an insane amount in proportion to their assets and savings . it is usually these very people who can afford the least to roll the dice with their health coverage .
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Ditto, I like to gamble but I enjoy the lottery or slots!!
 
Could be the medicare insurance carrier that makes a difference, I really don't know. What I do know is 2 ambulance transports, emergency room charges, surgical hospital room & operation, semi private hospital room, surgeon fees, private room at the rehab facility, medications, and 24 therapy sessions totalling over $700,000.00 my total out of pocket cost $680.00. The higest cost in that was the copay for the 2 ambulance transport.


AARP advantage insurance has contracts and didn't pay that amount. We quit traveling because we've gone to every place we ever wanted to go. We have no reason to go out of network so it's not about saving money it's about knowing what our advantage plan pays for. Other than the unexpected surgery that was needed our health is excellent.


To each their own when it comes to what to choose.
 
lots of people have no issues with their advantage plans . but all it takes is that one time or have an emergency while traveling and it can turn it in to another outcome . it certainly will never be as secure as you are with medicare and a supplement but that is why it cost more.here in ny you have way more going from advantage plans to medicare when they can then the other way around .
 
Butterfly said:
Well here where I live, there are two medicare advantage plans that cost nothing additional over the $104 that we pay for Medicare. I have one of them, pay NOTHING in addition to the medicare premium, and I am extremely pleased with the plan. Both the plans available here are local and tied to large hospitals and medical groups in the area. I don't know where else to look, as I never tried looking for anything else because this is such a good deal for me.
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Don’t you have copays and large total out of pocket you were to suddenly have major health problem?
 

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