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Medicare Advantage vs. Medigap policies aka Medicare Supplement plans

momeason

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MEDICARE ADVANTAGE- SIMPLE, INEXPENSIVE to ENROLL
Complicated and Costly to Use

Medicare Advantage Plans are a very popular choice for many over 65 consumers. The plans are aggressively marketed for 3 reasons

1. These plans remove risk and lower costs to the federal government, risks are absorbed by the insurance carriers.

2. Insurance carriers are in the business of making money. Medicare Advantage Plans must be approved by the Centers for Medicare Services, however, all insurance plans (Health, Life, Homeowners, Auto) are designed to make money for the insurance company offering the plan. Risks versus rewards for each plan offered have been carefully researched by the insurance carrier.

3. Sales agents push Medicare Advantage because the commission rates for Medicare Advantage plans are double the commission rates for Medicare Supplement policies, also known as Medigap policies.

Original Medicare offers 80/20 coverage to Medicare beneficiaries. There is no maximum or cap that Medicare will pay annually for any one beneficiary. In other words, the cost per beneficiary has no limit. When a Medicare beneficiary enrolls in a Medicare Advantage Plan, that beneficiary is now fully insured by United Healthcare, BCBSNC, Humana or any other approved insurance carrier. The government limits risk by paying a fixed amount per enrollee in a Medicare Advantage Plan. This allows the government to reduce their costs and more effectively budget each year. The risk for the individual Medicare beneficiary is also not capped; there is no out of pocket maximum for the Medicare beneficiaries in Original Medicare. Medicare Advantage Plans and Medigap policies do offer the protection of out of pocket maximums. This why it is important to have either a Medicare Advantage Plan or a Medigap policy. I recommend Medigap plans as a preferred choice for many reasons.

All Insurance Carriers play a game of averages. Each Medicare Advantage Plan has been carefully designed with the goal of providing service to each enrollee at a profit. Each Medicare Plan offered must meet strict guidelines and be approved by CMS, the Center for Medicare Services. However when a plan ceases to make a profit for the insurance company, the plan is terminated by the insurance company. Remember, CMS pays a fixed amount for each member of a plan. If a plan, over time, enrolls too many members who have a high need for medical services, the plan may no longer be profitable. Since the insurance company only receives a fixed amount for each enrolled member the incentive is to limit care, especially expensive care from specialists. Medicare Advantage Plans, like Medicare, are also 80/20 plans. The out of pocket maximum is still relatively high in most MA plans, usually between $4500-$6700 per year. Other disadvantages of Medicare Advantage Plans include limited networks that may drop a favorite doctor or hospital, high copays and limited access to Specialists as well as coverage which is only local or regional. Many MA plans require a referral from a designated Primary Care Physician (PCP) before the plan will pay for the member to visit a Specialist. If the member is allowed to visit a Specialist, the Specialist is chosen by the PCP not by the member. As stated above, commission rates are much higher for Medicare Advantage Plans providing a large incentive for agents to promote these plans rather than Medigap policies.
Medicare Advantage Plans are marketed as having everything you need in one simple plan. The policies operate very similarly to the major medical plans offered to under 65 consumers. Offering low premiums, these health plans are attractive and seem familiar to enrollees. However, many beneficiaries do not understand the richer benefits of Medigap policies. Although the premiums for many Medigap policies are higher than many Medicare Advantage Plans, there are many superior benefits. Any doctor who accepts Medicare will accept any Medigap policy; there are no network restrictions. The plans are good nationwide and several plans even include Foreign Travel insurance. There are currently 10 levels of Medicare Supplements. The benefits of each level are established by CMS and are the same from each insurance carrier. Plan F, for example, will pay all the beneficiary’s portion of the costs of any Medicare approved service from a doctor or facility which accepts Medicare in the USA for the rest of one’s life. Plan F even covers 80% of most foreign travel emmegencies. All Medigap policies are guaranteed renewable if premiums continue to be paid. Original Medicare pays the first 80%, these supplemental policies fill in the gaps of Medicare. Medigap policies are surprising affordable ($37-$211/month) for the amount of coverage offered. Even the lower level Medigap offer richer benefits including lower annual out of pocket costs, ease of use and nationwide coverage rather than local or regional coverage compared to Medicare Advantage plans with similar premiums. Medicare Supplement Plans offer a great way to budget for future medical needs at a reasonable monthly cost.
Advice from a respected independent agent is invaluable in helping a Medicare beneficiary choose the best plan at the lowest cost. An independent agent can also offer advice on purchasing a prescription plan that offers the prescriptions needed at the lowest annual cost. Many new Medicare beneficiaries make the mistake of calling or visiting an exclusive agent who sells plans from only one company, believing the name of the insurance carrier is an important consideration. Actually, because the benefits of Medigap plans are established and regulated by the government, the brand name of the Medigap carrier should be only a minor factor in choosing a Medigap policy. It is best to shop around or visit a trusted advisor, rather than an exclusive sales agent representing only one insurance company.
The optimal time to purchase a Medigap Policy is during the period just before or after one’s 65th birthday or the date one qualifies for Medicare Part B. When purchased in the 6 month window immediately after enrolling in Medicare, no health questions are asked. Acceptance is guaranteed.
There is another guaranteed issue period of 63 days following the termination of an enrollee’s Medicare Advantage Plan. Again, in this period, no health questions will be asked. This is a great opportunity to move into a Medicare Supplement. Currently, NC (where I live) has the 3rd highest number of Medicare beneficiaries affected by Medicare Advantage Plan terminations. Other guaranteed issue periods may be triggered by specific events. Send me a private message or call Sherry Eason at 910-750-2605 if you have further questions. (This time of year, I am not on the BBS much at all.):hi:
 

cissy

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Thank you for explaining the difference. I currently have an Advantage plan which has gotten very expensive, so I'm looking to switch.
 

WinniWoman

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Thank you! I have always suspected that the Medigap plans are the best. (I used to work in Health Insurance commercial lines).

I guess then, if you are enrolled in an employer plan with an HSA you should still apply for the Medicare and Medigap policy then, even though you will no longer be able to contribute to the HSA?

I know in some instances it can be beneficial to delay enrolling in medicare if you have an employer plan with an HSA so you can keep contributing.

But it seems, considering the pre-existing condition clause, in most cases one should apply for Medicare and the Medigap plan as well when one turns 65, even though still working?
 

WinniWoman

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PS I heard the G plan is just as good as the F plan, but less expensive?

And- can't people just enroll on-line for these plans? Why would they need an agent at all?
 

bogey21

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This year I am paying about $600 a month for a Medicare Supplement and a Prescription Plan. For next year I switched to Medicare Advantage at $0 per month. Thus I am getting rid of $7,200 in annual premiums in exchange for a $4,900 maximum Out of Pocket with the Advantage Plan.

I know, limited Doctor and Hospital selection, more hassle, co-pays, etc. My mistake was taking the HMO version of the Advantage Plan for $0 per month. I should have taken the PPO version for $32 per month. Hopefully I will not need to use it this year for other than prescriptions, annual check-up, etc. and will change next year to the PPO version.

George
 

momeason

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Thank you! I have always suspected that the Medigap plans are the best. (I used to work in Health Insurance commercial lines).

I guess then, if you are enrolled in an employer plan with an HSA you should still apply for the Medicare and Medigap policy then, even though you will no longer be able to contribute to the HSA?

I know in some instances it can be beneficial to delay enrolling in medicare if you have an employer plan with an HSA so you can keep contributing.

But it seems, considering the pre-existing condition clause, in most cases one should apply for Medicare and the Medigap plan as well when one turns 65, even though still working?

Not necessary. You can wait until you stop working and lose your employer plan if you wish. You will have 63 days of guaranteed issue to buy a Medigap policy and a Prescription plan. One of the things that can be better with traditional insurance is a longer list of prescription drugs available. Thank heavens in about 6 years, the Donut hole will disappear. It gets smaller each year now as part of the ACA.
It pays to re-evaluate your Medicare Prescription Plan every year as the drug formulary lists constantly change within plans and so may your needs.

There are 2 ways to get great Medigap coverage at a low cost. One is Plan G as you mentioned. The consumer will pay the Part B deductible only. In 2015, that is $147. The other is to sign up for the high Deductible Plan F. The out of pocket max for High Deductible Plan F is currently $2180, much lower than most under 65 plans. There is one carrier who even adds "Silver Sneakers" to their plans. This is a membership in 9000 gyms across the country. I am independent, I just give people the facts to help others make an informed choice.

P.S. You can pay your Part B Medicare Premiums with any leftover funds in your HSA.
 
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momeason

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This year I am paying about $600 a month for a Medicare Supplement and a Prescription Plan. For next year I switched to Medicare Advantage at $0 per month. Thus I am getting rid of $7,200 in annual premiums in exchange for a $4,900 maximum Out of Pocket with the Advantage Plan.

I know, limited Doctor and Hospital selection, more hassle, co-pays, etc. My mistake was taking the HMO version of the Advantage Plan for $0 per month. I should have taken the PPO version for $32 per month. Hopefully I will not need to use it this year for other than prescriptions, annual check-up, etc. and will change next year to the PPO version.

George

I do not know what you are paying for. I do not know of any Medigap plan over $211/mo for those over age 65. That is Plan F from one of the most expensive carriers. Most prescription plans run about between $20-$40/mo. If you are under age 65 and are receiving Medicare as the result of a disability the plans could be that expensive. I would not usually recommend a supplement policy until some one reaches 65. Even if you receive Medicare early, you will have an Open Enrollment period to buy a supplement policy without medical underwriting for the 6 months after you turn age 65. I was not directly addressing people under 65.
 
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momeason

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This year I am paying about $600 a month for a Medicare Supplement and a Prescription Plan. For next year I switched to Medicare Advantage at $0 per month. Thus I am getting rid of $7,200 in annual premiums in exchange for a $4,900 maximum Out of Pocket with the Advantage Plan.

I know, limited Doctor and Hospital selection, more hassle, co-pays, etc. My mistake was taking the HMO version of the Advantage Plan for $0 per month. I should have taken the PPO version for $32 per month. Hopefully I will not need to use it this year for other than prescriptions, annual check-up, etc. and will change next year to the PPO version.

George

You can still fix your mistake. It is open season right now and you have a 30 day return and there is also a Disenrollment period in January. You have lots of options. HMOs suck!!
:confused:
 

bogey21

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I do not know what you are paying for. I do not know of any Medigap plan over $211/mo for those over age 65.

It isn't really a Medigap Policy. Out of inertia (my bad) I just kept what my ex-employer was providing.

George
 

isisdave

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Alas, most of the people who need to read this thread, won't.

The most serious disadvantage to HMO-type MA plans is the limited network and the difficulty in obtaining a referral to a specialist. This will be worse if you don't live in or near a big city, because, for some reason, the best doctors don't live in East Nowhere. DW, a psychotherapist, had several clients during her career who died (or whose relative/friend died) because of such delays, mostly because it took months to get an appointment with the specialist that correctly diagnosed them.

You might take a look at PPO-type MA plans, but they are rare. There is only one serving my zipcode.

One non-obvious thing about Medigap plans was mentioned in the original post and bears repeating: any doctor who takes Medicare also takes any Medigap policy. So if you buy it from Blue Shield, that doesn't mean you have to find a doctor on a Blue Shield network. After a lifetime of qualifying your doctors to match your insurance, this is a surprise to many.

Another is that Medicare, after paying its part, automatically forwards the claim to your Medigap company. Neither you nor your doctor have to track and handle this. Aren't computers great?
 

momeason

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Alas, most of the people who need to read this thread, won't.

The most serious disadvantage to HMO-type MA plans is the limited network and the difficulty in obtaining a referral to a specialist. This will be worse if you don't live in or near a big city, because, for some reason, the best doctors don't live in East Nowhere. DW, a psychotherapist, had several clients during her career who died (or whose relative/friend died) because of such delays, mostly because it took months to get an appointment with the specialist that correctly diagnosed them.

You might take a look at PPO-type MA plans, but they are rare. There is only one serving my zipcode.

One non-obvious thing about Medigap plans was mentioned in the original post and bears repeating: any doctor who takes Medicare also takes any Medigap policy. So if you buy it from Blue Shield, that doesn't mean you have to find a doctor on a Blue Shield network. After a lifetime of qualifying your doctors to match your insurance, this is a surprise to many.

Another is that Medicare, after paying its part, automatically forwards the claim to your Medigap company. Neither you nor your doctor have to track and handle this. Aren't computers great?

Yes Dave, You have this right!:whoopie:

I have a lot of difficulty getting people to understand the concept of No Networks. BTW, BCBS is one of the most expensive providers. There are many Life Insurance Companies offering the exact same benefits for a much lower price. One in my area is a Berkshire Hathaway company backed by Warren Buffet.
 
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bogey21

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The most serious disadvantage to HMO-type MA plans is the limited network and the difficulty in obtaining a referral to a specialist.

First, is any Doctor who is not your Primary Care Physician considered a specialist? For example if one sees a Cardiologist for for an annual check-up, is he considered a specialist? Or is a specialist only a Cardiologist one sees for a major procedure? Another example might be an Opthamologist one sees for an eye exam. Or is an Opthamologist one visits for cataract surgery considered a specialist? Assume for the sake of this question that all are in the HMO Network. Second, do all HMOs look at this the same way?

George
 

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I started with an advantage plan, but when we started travelling more I went with the supplement,

Its mice knowing I should have no "budget buster" health care issues, no deductables and no co pays... Just one (high) premium a month built into mu budget. Its also nice that I dont have to worry when I travel.. any doctor, anywhere (as long as they participate in Medicare) will be covered.
 

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First, is any Doctor who is not your Primary Care Physician considered a specialist? For example if one sees a Cardiologist for for an annual check-up, is he considered a specialist? Or is a specialist only a Cardiologist one sees for a major procedure? Another example might be an Opthamologist one sees for an eye exam. Or is an Opthamologist one visits for cataract surgery considered a specialist? Assume for the sake of this question that all are in the HMO Network. Second, do all HMOs look at this the same way?

George

First: No.
Though why one would see a cardiologist for an annual checkup is a mystery. s/he might give you an annual HEART checkup, but you wouldn't see him/her if you had a suspicious mole or your knee swelled up.
Many plans will cover your annual visit to an ophthalmologist for cataract or glaucoma (medical screening) but not for a refraction for glasses- mine throws this in gratis but the eyeglass prescription isn't written by the (MD) ophthalmologist.

Second: No. All HMOs are governed by their own rules and capabilities. One has to read their prospectuses to know exactly what is covered and to what extent. Just like each insurer for prescription drug coverages has their own 'formulary' of preferred meds, and one has to carefully check to see that what you are prescribed is covered by your insurer.

For instance, where I live there is just one pretty-much all encompassing healthcare provider. It didn't make a lot of sense to have to get a referral to every specialist, so for 2016 it looks like every Medicare supplement insurer removed PCP referral from he requirements. We'll just call the specialist of our choice and pay the $65 co-pay.

Jim
 

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momeason, the other Big Thing No One Understands on MA is whether the policy is community-rated (everyone pays the same), issue-age-rated (cost is based on age at signup), or attained-age-rated (just what it sounds like). Where I live, almost all are the last type. But AARP's UHC plan is community rated. This is explained well here.

I have Blue Shield because I'm 66, it's age-rated here, and they offer a discount for the first 5 years. At some point, it will no longer be the cheapest game in town ... but most folks won't notice and will just pay the new price.

I think my first-five-year discount is flat 10%; the age-rated premium goes up some percentage every two years. And of course the whole premium schedule goes up all the time!

To compare, start here.
 

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Having recently (May) had a health crisis where it became suddenly necessary to see the best people I could see, I'd caution against signing up for any plan that limits your choices. I went to Mayo Clinic and M.D. Anderson in Houston. The advice I got from the two--both at the top of the heap of providers--was totally different.

You don't know you're going to need a particular specialist......until you do.

I'd also point out to anyone reading that Medicare pays for 2nd opinions, and there's no cost for getting one. My charges from M.D. Anderson were $0.00.
 

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With an Advantage Plan, the networks are often very small with few good MDs in that system. That means a visit to your preferred MD would be an "out-of-network provider" thus a high co-pay. Those co-pays really add up and become a deal buster.

If you are in an HMO, then you are really limited to MD choices.
 

WinniWoman

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momeason, the other Big Thing No One Understands on MA is whether the policy is community-rated (everyone pays the same), issue-age-rated (cost is based on age at signup), or attained-age-rated (just what it sounds like). Where I live, almost all are the last type. But AARP's UHC plan is community rated. This is explained well here.

I have Blue Shield because I'm 66, it's age-rated here, and they offer a discount for the first 5 years. At some point, it will no longer be the cheapest game in town ... but most folks won't notice and will just pay the new price.

I think my first-five-year discount is flat 10%; the age-rated premium goes up some percentage every two years. And of course the whole premium schedule goes up all the time!

To compare, start here.

I agree these are better plans than the Advantage plans, but from the looks of the premiums you have to be pretty well off to afford them, especially with no salary coming in anymore. $12,000 per year for a couple?! Yikes! What's the point of even having Medicare? Scary stuff. Between just these kinds of premiums in retirement and our school and property taxes it would be like $24,000 per year!I am dreading this when the time comes.
 

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I agree these are better plans than the Advantage plans, but from the looks of the premiums you have to be pretty well off to afford them, especially with no salary coming in anymore. $12,000 per year for a couple?! Yikes! What's the point of even having Medicare? Scary stuff. Between just these kinds of premiums in retirement and our school and property taxes it would be like $24,000 per year!I am dreading this when the time comes.

Look, if you can't afford a supplement, just take basic Medicare after age 65. $104 pp a month, withdrawn from your SS. If you are reasonably healthy and don't take a lot of meds, you can save a lot of money. And no one forces you to live in a jurisdiction with expensive schools and high property taxes. Move to 'tax haven' New Hampshire.
 

WinniWoman

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Look, if you can't afford a supplement, just take basic Medicare after age 65. $104 pp a month, withdrawn from your SS. If you are reasonably healthy and don't take a lot of meds, you can save a lot of money. And no one forces you to live in a jurisdiction with expensive schools and high property taxes. Move to 'tax haven' New Hampshire.

You know that is my plan, Jim- I mean the New Hampshire thing. Unless something changes. As I have mentioned in other posts, a lot will depend on whether or not we CAN sell our home then. Homes are sitting for sale for years around here, so might not have the choice of moving. No one else wants to buy homes with high taxes either.

I have quite a few years yet until Medicare. Who knows what it will be like by then? You know the story I posted about my 80 year old friend with the high deductible Medicare supplement and how she is thinking of doing exactly what you have stated here. But the overwhelming opinion about that is that it is a stupid idea. I don't think I would feel comfortable without a supplemental plan. But- again- we shall see. I am collecting a lot of info. so I can learn about SS and Medicare. My husband takes absolutely no interest, so it all falls on me to understand it.
 
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Luanne

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Look, if you can't afford a supplement, just take basic Medicare after age 65. $104 pp a month, withdrawn from your SS. If you are reasonably healthy and don't take a lot of meds, you can save a lot of money.

Maybe I have completely misunderstood, but I have "basic" Medicare, which for me is a bit more than $104/month withdrawn from SS. I also have a Medicare supplement (Medigap) plan since Medicare might not cover everything. For that I'm paying another just over $100/month. The advice I was given by several people was to pick the "cheapest" supplement plan. What that meant was that if I picked plan F, which I did, all insurers have to offer the same coverage since it's regulated by the government.
 

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I have had a Medicare Advantage Plan with Healthnet for 10 years. My wife has the same policy and has had hers for 3 years.

We are very happy with ours. We do NOT pay any premiums, Zero copays for any Doctor, prescription drugs are covered and it also included dental insurance. Both my wife and I have been to many specialists and received special services. We have never had a problem seeing a specialist or getting CT Scans, MRIs, etc. Trust me, I have been to several different specialists. I have been in the hospital 3 times in the last 2 years and it never cost me a dime. Tomorrow, I am having a hip injection and MRI. They can use out of network Doctors if your network doctor doesn't work for you and there is no cost. My Orthopedic surgeon is not in our network. I switched to him 10 months ago because I wasn't happy with the network Orthopedic surgeon.

Most referrals do not require authorization by the insurance company. For example, authorization is not required to be referred to an Orthopedic Surgeon, Cardiologist, and several others.

It all depends on choosing the right Medicare Advantage plan and choosing the right primary care doctor. We are fortunate in having many different plans to choose from so there is a lot of competition. A lot depends on where you live.
 

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With an Advantage Plan, the networks are often very small with few good MDs in that system. That means a visit to your preferred MD would be an "out-of-network provider" thus a high co-pay. Those co-pays really add up and become a deal buster.

If you are in an HMO, then you are really limited to MD choices.

That depends on the HMO and where you live. There are over 5,000 providers in my MA's network.
 

Luanne

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John, how do you have coveage without paying any premiums? How is your plan paid for?
 

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John, how do you have coveage without paying any premiums? How is your plan paid for?

The government pays the insurance company so much per month for each subscriber. In other words the government pays the premium. For this the Insurance company takes over paying the providers. Medicare requires that the insurance company meets their standards That is how the Medicare Advantage plans works. If you really think about it, the Medicare Advantage plans are very much like a voucher system. In each case, you choose your insurance company and the government pays for it. The only difference is in a voucher system, the government pays you via a voucher and then you pay the insurance company.
 
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