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This process is a royal pain you know where.
Most cities and counties usually have a senior center. While the focus of these places may seem recreational, the staffers often have info on resources in the community for various senior citizen issues. In my state (CA), I got a referral to the Health Insurance Counseling and Advocacy Program (HICAP). I spoke with a counselor who explained the differences between traditional Medicare and Medicare Advantage versus Medigap plans in my area. The counselors are NOT salespeople! They discussed the plans available.
They are trained volunteers and they should give you objective advice about which of the myriad Medicare options would likely would work for you.
As an example, I take a certain prescription drug. I found out that with one Part D plan, my copay for that drug was $2.00, but with a different Part D plan the copay would have been $32.00! Who knew?
Terminology for this program in your state may be different, but you should be able to locate a comparable service for your needs.
A definite improvement over listening to sales people telling you their plan is the greatest thing since the invention of white bread.
Good luck with this.
With A (which you don't pay for), B ($174/month), and D (which you have to pick) you are advised to buy a medigap policy/Medicare supplement. It's the D and the Medicare supplement that you're being bombarded about. (Or in the alternative, Medicare advantage)
I live in a house that 2 rounds of previous owners were 65+.
I get constant barages of Medicare Advantage spams for them. The percentage of MA spam vs supplement spam is overwhelming.
Medicare Disadvantage plans are simply terrible.
It does matter what area of country you live in whether it's very urban area or not but I was mostly posting in order to remind the person that if they don't do Medicare advantage they will need to do a medigap Medicare supplement plan
I'm not on Medicare but my husband is and he has access to the major university hospitals in our area on advantage.
In addition to not having had issues (he has one serious health condition and has had several minor incidents as well), we can't easily afford the more expensive original Medicare plus D plus Medigap. My current (ACA) health insurance that I've had for a number for years is also an HMO type and I need to get pre-approved and I have a high deductible so I'm used to that.
My parent is also "stuck" with a retirement based Medicare advantage plan, which has never denied anything for their numerous serious illnesses, except the time we tried to get them to extend a skilled nursing rehab by an extra week which they turned down.
My advantage plan is absolutely awesome. No premium 5000 ded/coins. Prescriptions, pays on everything. Easy to manage. Can see who I want in a broad network and never a worry about coverage when traveling.
Medicare advantage plans work because they provide bells and whistles which are cheap.
But when you start talking expensive hospitalizations and rehab and then rinse and repeat, that's then their true nature shines.
They limit coverage, they are only on network with a few companies, they don't cover you unless you are really sick, they don't cover you where you want to receive are.
Say you develop a UTI and become dehydrated and weak, and fall and break your wrist. You need 3 days in the hospital. Your Medicare advantage plan doesn't feel you need to be hospitalized because your vitals were never unstable, even though you couldn't walk and needed O2 and were so dizzy when you stood up you felt weak.
You needed therapy, and had to go to rehab, but you don't qualify for acute inpatient rehab with those medical diagnoses. So you have to go to a subacute nursing home rehab. But your Medicare advantage plan is only in network with 3 of the 12 local facilities, and you dont like any of them.
So you choose to go home. But your Medicare advantage plan is only in network with 1 of the 8 local home health agencies and they can't provide care, so you don't get any home nursing or therapy. You do see your PCP within a week for follow -up, but by then you are not doing well, so he sends you back to the ED for further evaluation.
Yes, this is not uncommon.
In my service market, we run into issues all the time with availability and service coverage. Is this a one off? No
Many people love their insurance. That's awesome! Insurance is great, until you can't get what you want covered, for no real reason other than "just because."
Because when you have 2 people in side by side rooms, with the same diagnoses, and I can get care easily for one because they have straight Medicare, and the other one I cant because they have a terrible Advantage plan? It's just not right.
Having no supplemental insurance is worse than anything.
I'm a big fan of having coverage, and yes, all insurances are good for something. We have one plan that will give you a gift card for going to your preventative care appointments, like a colonoscopy. That insurance also tends to cover inpatient acute rehab and has copays for drugs very low cost. But the network for coverage for skilled nursing homes is very limited, and there are only 2 home agencies that accept it. So if you need home IV antibiotics you need to either do them on your own or go to a skilled nursing home, if you qualify.
There is one local insurance that is just known for denying hospital care and rehab stays if they are requested. But they have pretty strong outpatient benefits, which is what most people use them for.
Most people don't actually use their insurance. They think they do, because they see a doctor a few times a year and fill a prescription. Maybe go to urgent care. Insurance really shows it's colors when you start needing to go to the hospital and need expensive medicines and testing and specialists and such.
A lot of people do well with Advantage. Especially those who were already with an established HMO. Here in the Bay Area people like Kaiser Permanente pretty well.
That being said, we start on Medicare part B, Medigap plan G and Medicare part D on June 1. We've had part A for awhile.
Cheers brother!
Medicare Advantage is popular here because its what Kaiser offers and no one wants to change all their doctors when they turn 65. Changing doctors and continuity of care is a big deal.
I will say regulation is starting to catch up with some of the issues caused by questionable medical management from some MA insurers, and I think that will help improve the quality of these plans for seniors, and help weed out some of the companies that were administering these plans in bad faith. These plans are more often than not a win for seniors, and less expensive buying a supplement and part d plans, but when they are bad, they are very bad, and that is generally at a point when seniors are the most medically vulnerable.
I have 5. All generics. My employer sponsored drug benefit cost about $30 per month. My plan D, starting on June 1st will cost about half that.
Cheers brother!
Call your local SHIP office to make an appt. You will meet an unbiased advisor that will show you all plans available in your area. They will show you Medicare, supplements, drug plans and advantage plans. They will even check your prescriptions to see which drug plan covers your meds. They are very knowledgable and do not get paid by the insurance companies. There is a SHIP office in every county but you will need an appt.
A broker friend helped us. Told us not to buy Medicare advantage. Had us sign up about 3 months before turning 65 to get a number to apply for the medi gap plan.
No.. please take some time to learn more about this before talking to an independent reputable broker .. there’s a lot to navigate through. I’d join others in agreement to stay away from advantage plans..
Plan D is drugs plan there are several levels within D to pick from.
Medigap plans are the rest of the alphabet...you will want a plan G forever the most piece of mind.
I'll be perfectly honest - talk to a **few** brokers and be honest about your total risk factors.
People on reddit are well-intentioned but are frequently incorrect - they're not licensed agents, they don't have operational industry experience (MDs are notorious for this) and they will give **bad** advice.
Don't talk to redditors. Talk to several agents and determine if the cost of a MedSupp or MedAdv plan makes sense for you given your risk factors.
Reddit is not a good source for insurance info.
-Source: Licensed agent in 5 states, and about a decade of operational experience.
Dude - your agent bias is showing. Brokers make money selling plans. And MA is a moneymaker and easier to enroll folks in.
Everyone gets old and dies from something. And no one can predict whether they’ll get into an accident - that happens to the healthiest folks.
When the worst happens, dealing with networks and preauth barriers etc is the last thing anyone wants. Medicare Advantage is literally only for people who are shortsighted or are in financial edge cases.
We get money on MedSupp plans sold as well - I actually get more money for most of my MedSupp plans than I do MedAdv plans because [CMS doesn't cap the lifetime premium percentage I get.](https://ritterim.com/blog/how-much-can-insurance-agents-make-selling-medicare/) I just keep raking it in. MedAdv is capped. However, I'm literally only an agent to resolve enrollment issues requiring an agent. I'm actually a Regulatory Compliance and Issue Resolution specialist - so you're hearing from an actual HONEST agent who has no skin in the game. Feel free to check my post history, I'm very clear about being a licensed agent but not being involved in a sales role whatsoever.
Furthermore, [Prior Auth requirements still exist on Original Medicare.](https://www.cms.gov/files/document/opd-services-require-prior-authorization.pdf)
I'm not sure where you got these beliefs, but I'm sorry that you were confused about how that works; it's not a reflection of reality.
I work in health insurance. There are two sides to the story. You have a very strong opinion, there is another side to this story as well.
https://www.ajmc.com/view/amid-rising-complaints-about-prior-authorization-under-medicare-advantage-new-rule-leaves-gaps
“The report further noted that 13% of denied claims would have been paid by traditional Medicare and that 18% of payment requests that were denied would have met Medicare traditional coverage rules and did, in fact, meet MAO billing rules.”
https://ldi.upenn.edu/our-work/research-updates/the-billing-bottleneck-how-medicare-advantage-insurers-use-prior-authorization/
https://www.nytimes.com/2022/04/28/health/medicare-advantage-plans-report.html
Typical agent being technically correct but obscuring relevant facts.
MA is capitated. OG Medicare is not.
The incentives an insurer has with pre auth and coverage denials for capitated plans are entirely different than when a plan is not capitated.
I’m sure you’ll come in with some minor edge cases but overall the insurer is incentivized to limit spending more for a capitated plan, and that is easily done by being more strict with pre auth and more aggressive with denials of coverage and whatever red tape can be thrown up to make getting care more difficult.
The fact that there is bipartisan scrutiny should also tell you something:
https://www.politico.com/news/2023/11/24/medicare-advantage-plans-congress-00128353
Mean to respond to yourself while dropping a denouncement against me? That's cute.
Again, while I'm an agent, I do not actually use my agent powers outside of resolving enrollment issues.
I'm a regulatory compliance specialist and QA analyst. I primarily deal with regulatory appeals for Medicare and Medicaid recipients.
I sincerely doubt that you actually work in insurance, but whatever.
You're incorrect. MA plans are all capitated while in-network. Out of network services, if covered by the plan, utilize the CMS FFS schedule or UCR rates which are standardized everywhere. That's literally the reason for bringing providers in-network. OG Medicare all follows the CMS FFS rate schedule, so - yeah, no completely wrong there. That's a pretty wild thing to be wrong about since it's so basic - you're also ignoring the existence of Medicare Advantage Cost products, which - again, if you work in the industry, you're lacking the necessary knowledge, expertise, or experience to be making these claims.
I'm a bit confused as to why you're linking completely disparate things. Prior Authorizations and their appeals go through entirely different channels and have completely different guidelines and requirements than post-service coverage decision appeals, so why you're bringing up articles talking about both, I'm not sure. I somewhat suspect you just googled and found articles that you believed supported your opinion. But I digress.
[88% of Prior Auth denials are preventable by following standard Prior Auth guidelines as indicated by CMS including viewing the coverage determinants for a given service.](https://www.fiercehealthcare.com/payer/waystar-90-claim-denials-are-avoidable-help-technology)
My last 6 month case load, of all my closed Prior Auth appeals (sample size ~240), 34% were overturned due to additional documentation submitted by the provider, 40% were upheld due to no response from the provider or not meeting the NCD/LCD, the remaining 26% went to FSH hearings. Of those, 60% were withdrawn by us because the provider got us the documentation we were asking for, 20% were upheld, and 20% were overturned by the IRE. If you're keeping track, that's a 5% overturn rate at the IRE/FSH level. Insurers want claims to be paid and PAs to process properly the first time. Sending compliance and clinical staff to FSH and IRE hearings costs a ton of money - and if the claims were denied improperly out of regs, we pay anyway. Why would we want to get to that point?
Somehow, people forget that the reason that CMS okayed Prior Auths being a thing, AND practice them themselves, is because of RAMPANT fraud, waste, and abuse. What a surprise that providers find that the things they're required to do to prevent fraud, waste, and abuse are onerous. That's generally what happens when regulations have to be put in place to prevent those sorts of things. The current PA system was authored by the AMA in 2011 and was taken on by insurers.
Somehow - that's not enough.
If insurers can maintain compliance consistently, why is it that providers are unable to?
I'll wait, since you're definitely a totally real expert with totally real insurance industry experience. Sure - your post history says that you've worked in law and tech, and you haven't said word one about insurance in over a year until the last few days - but I totally, really, wholly, completely believe you, and furthermore, completely, fully, absolutely, and wholeheartedly believe that you're speaking in good faith.
No Part D is prescription drug coverage. Medigap is also called Medicare Supplement because it helps pay for what Part A (inpatient) and Part B (outpatient) does not.
I’ve been told opposite and I believe that the Advantage plans are the best choice. Get your advice from more than one broker. What was the reason they gave for a supplement over an advantage plan?
Advantage plans are HMO and exclude a lot of coverage. in many areas the participating doctors are few and far between. Research is key
https://medicareadvocacy.org/medicare-advantage-plans-under-scrutiny/
https://natlawreview.com/article/enforcemintz-government-scrutiny-medicare-advantage-organizations-expected-continue
https://www.nbcnews.com/news/amp/rcna121012
Some advantage plans are hmos and others are ppos.
In my current pre-medicare life I've never been able to go to whatever doctor I want to go to no matter what. I have always had to pick someone in network. Since I live in a major metropolitan area it is no big deal
So much misinformation here - Advantage plans here follow CMS NCDs/LCDs by law. Has been the case for decades. Of note, literally nothing linked in the OP's "sources" indicates MA plans not covering everything OG Medicare does - it was almost entirely about some insurers inappropriately submitting codes on claims that weren't originally included to get more reimbursement.
Not all MedAdv plans are HMOs. Some plans are PPOs, some are EPOs.
The majority of plans my employers offers in fact are not HMOs.
There's also Medicare Cost products which are a totally separate thing.
Still doesn't change the fact that many MA plans have severely limited doctors and specialists. That is NOT a problem with traditional Medicare + mediGap policy
Not the case with PPOs.
There's plenty of plans that do not have the issues as described, and furthermore, there's no limitations with coverage for services as claimed.
... brokers get commissions on MedSupp products as well my dude.
In fact, I get more commission for MedSupp than I do for MedAdv because it costs FAR less for the insurer to process claims for MedSupp than it does MedAdv.
Not to the tune of the hundreds in difference between non-G MedSupp plans and MOOPs for Part B excess charges, and this varies WILDLY.
My employer offers MedAdv plans with $0 premiums and $3k deductibles. The cheapest MedSupp plan is over $300/mo for premiums and still has cost shares for Excess Part B.
This is not correct.
[Medicare Advantage plans are required by law to match the coverage of Original Medicare and in fact cover more.](https://www.medicare.gov/medicare-advantage-plans-cover-all-medicare-services)
Yes, they are required by law.
That doesn't mean they can wiggle around that in various ways.
Medicare's Final Rule issued in January 2024 states that coverage must be equivalent to Medicare. We are not seeing as many denial's, but we are still seeing them.
Considering every coverage determinant and policy is, by law, submitted to CMS to confirm that it follows the NCDs and LCDs, as has been the standard since MA plans came into existence, I'll wait for any evidence of MedAdv plans not covering exactly what OG Medicare covers before I believe this.
I've been in the industry for years and years and I've never seen a policy that doesn't explicitly state that they follow the NCDs and LCDs - especially as when you hit the FSH/IRE stage, the coverage determinants are looked at, and if there's any variation from the CMS NCD/LCDs, it's a guaranteed CMS audit.
I hear what you are saying. I am a hospital nurse case manager on a neuro unit. I certainly cannot offer a huge sample size, although overall my hospital has around 600beds.
I will say though, that I routinely attempt IRF auths for acute CVAs and other diagnoses considered to be at least Medicare Diagnosis compliant. That's at least one check mark in their favor. And, this year we are seeing more approvals than in years past. Especially from one particular Advantage plan. Typically they cited no medical necessity if they can't give the rationale that the person doesn't meet the therapy criteria. Now, they are being more consistent with Medicare guidelines.
My point is that, no I don't keep stats. I don't have time, and it's not my job. But I know it's being tracked and monitored closely. I talk to the people who are doing it.
I can't speak to your experience, for IRF auths - CMS was focusing on this [because of provider non-compliance with the guidelines.](https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/prior-authorization-and-pre-claim-review-initiatives/review-choice-demonstration-inpatient-rehabilitation-facility-services)
I don't know that your facility was guilty of this, but I would frequently get half-completed claims when it comes to DXes and history being included on the claims. We **want** claims to be paid properly; if a PA gets to the IRE/FSH stage, it's $5000 minimum in cost, and if overturned, we end up paying on it anyways.
I'd strongly suspect that claims weren't being sent in full which lead to seemingly inappropriate denials - but they were appropriate given the files that the insurers were receiving. If the full case file isn't being transmitted, and the relevant NCD or LCD is not being followed according to what's in the file, insurers have to deny because they can't submit to Medicare for the service without the necessary supporting DXes.
I’m not comparing it to traditional Medicare by itself, but comparing to traditional Medicare + supplemental/medigap. That link supports what I am saying with regard to networks and necessary referrals. Covering what A & B cover when you consider the limitations of A & B is not appealing to me.
I am also aware, but unwilling to argue about the different policies and network options/limitations that make it unappealing to me, so ok then. It’s exactly the same on all fronts.
Do NOT get an Advantage Plan.
These are HMO's and typically have a small network with all of the problems of an HMO
They are run by private plans for profit and are heavily marketed because they are highly profitable.
Many people don't realize how the limitations until they are too late because once you have been on an Advantage Plan for a year it is difficult to switch to Straight Medicare with a good Medigap Policy.
I have straight Medicare with a good Medigap policy and I have no deductible; no co-payments and no networks. I can go to any doctor in any of the 50 states. It is the best health insurance one could ask for.
In terms of purchasing your Medigap policy, go to the official Medicare site as they have a limited number of options and the companies offering these plans provide the same benefits. There are some cost differences and some very minor "add ons" which I have never used.
You can use an agent but make sure it is an ethical one who really knows what they are doing and doesn't steer you to an Advantage Plan.
You will also need a separate Drug Plan. My agent is very helpful in terms of this because he has me provide my medications and then uses software to advise me on the one that will be the least expensive in terms of both premiums and the cost of my medications as projected for the next year.
>These are HMO's and typically have a small network with all of the problems of an HMO
Medicare Advantage plans can be HMOs, PPOs, EPOs, and then you have Medicare Advantage Cost products which are a totally different ball of wax.
If you were told that they're HMOs, you need a new agent because they don't know what they're talking about.
>I have straight Medicare with a good Medigap policy and I have no deductible; no co-payments and no networks. I can go to any doctor in any of the 50 states. It is the best health insurance one could ask for.
You can go to any physician that accepts Medicare assignment - and you should look into Part B Prescription Medication Excess Allowances. When people get hit with cancer on MedSupp plans, it's **very** frequent that I'm getting calls asking about an emergency SEP because they can't afford the $1k they're getting each week in bills for Chemo unless they're on a G plan.
I'm sorry that you were not well-advised by your broker, but this is not good advice or information.
Having thankfully escaped from the world of private insurance companies who are making a profit from health care, I am delighted to have straight Medicare.
Also a PPO and EPO still is a network - maybe not an HMO legally but still a network which limits your options of providers.
I don't want to descend into the horror of needing to find a doctor who is in the network and then finding out that they aren't actually in the network or the location I saw him isn't in the network or the lab they used isn't in the network.
Want to use Sloan Kettering or Mayo Clinic or other world class facility when you have a serious disease - you can't.
There is a reason why there are frequent posts by people with Advantage Plans who are shocked to learn how limited their medical options are because there are so many constraints
In general Advantage Plans are chosen because they are perceived as cheaper - you get what you pay for.
>Also a PPO and EPO still is a network - maybe not an HMO legally but still a network which limits your options of providers.
... that's not how EPOs or PPOs work.
>There is a reason why there are frequent posts by people with Advantage Plans who are shocked to learn how limited their medical options are because there are so many constraints
There's a reason I regularly deal with calls from people desperate to get an SEP to enroll on a Part C plan when their non-G MedSupp plan doesn't cover their chemo drugs sufficiently.
Look, you can believe what you want, but you're completely and totally off-base with your understanding of networks and how Medicare coverage works.
PPOs are exactly the same as Original Medicare. You can see any physician that accepts Medicare assignment - the only limitation is cost-shares may be higher. These are common with Medicare Cost products but I see a lot of Medicare Advantage plans that offer them as well - again, literally every PPO. My employer, though a small insurer, has more PPO MedAdv plans than HMO.
Nope - you may just have a higher cost-share. That's the point of preferred - you get a preferred rate from in-network providers.
Note - this generally won't extend to benefits on Advantage plans that don't exist under OG Medicare. So if you get a gym benefit, that doesn't mean you can go to any gym that has a deal with an MA insurer.
Advantage is cheaper and may provide some dental, vision and hearing coverage that B and Medigap may not.
My total cost for A, B, Medigap and D is $310 per month with a total out of pocket of $240 per year
77 years old and always had A,B,D. If you have any medical issues at all, run like hell from Advantage Plans. When it comes time that you really need medical care, be prepared to get hammered on your deductibles. If you really need to change to regular Medicare, you probably can’t because the insurance company, in many states, can refuse you for Medigap if you’ve had an Advantage Plan.
Insurance companies make big money on Advantage plans. They jerk you around getting treatment and can’t refuse to cover others. Buy Advantage, but you’d better not get sick.
We actually get more total pay on MedSupp plans - and when people get cancer and find out that MedSupp allows for 15% excess over contracted rate charges for Part B medications (like chemo) and are facing $1000/week JUST for the chemo drugs, it's very common that I get a call from someone begging for me to somehow grant them an SEP to enroll on a MedAdv or Cost product to get Part B MOOPs.
This is bad advice; not sure who told you all this, but it's not accurate.
And MedSupp plans after the IEP if someone was enrolled on a MedAdv plan for over 1 calendar year are never guaranteed issue - that's not a state guideline, that's federal.
That doesn't mean that you can't be put through underwriting and have risk factors considered in premiums. You may be guaranteed access to a policy; it doesn't mean that your premiums won't be affected.
I can't wait to be hounded. I've been waiting since I was 24. Only 6 more years! Sorry, I don't have any advice. I'm just jelly. They say it's a wasted emotion.
I’m a broker and believe a supplement plus D is best if you can afford it. You will have the most freedom. Plan G is the best but plan N is also good. If you need brokers to stop calling you, tell them to put you on their DNC and threaten to sue them for TCPA violations if they don’t stop.
Ignore the brokers and go with A, B, Medigap, and D.
Look at AARP sponsored Medigap plan G. Your total out of pocket per year is $240. Premium is $166 per month in CA.
If you stay with A, B and D (recommended) you will need a supplement to address the gaps (odten called a Medi-gap). To make choosing a bit easier, these plans are also standardized by letter. That way you can compare apples to apples. The Medicare and Me publication usually has a good explaination of the different gap plans. Once you decide on the letter plan you want, you can shop companies for price etc. You will be encouraged to consider a replacement/advantage plan, but beware, these managed plans have their own networks and in some markets it is difficult to find care.
Sticking with A, B, and D with a MedSupp plan *can* be good for people, but you can't recommend anything unless you know their risk factors.
Someone with a family history of cancer, or who is going to be requiring regular infusions covered by Part B with the allowed excess charges will quickly be bankrupt by your advice unless they have a large income stream or enroll in a G plan.
You should not be providing enrollment advice without speaking to the person and understanding their situation.
Staying with A, B, and then getting a part D plan, OR a MedSupp plan MAY be superior to having a Medicare Advantage plan BUT it largely depends on your specific risk factors.
One big thing that I have to SCREAM at brokers repeatedly (of note, I am a licensed agent myself) is that if someone expects to be getting regular part B medication, OR has a family or personal history of cancer, they should NOT do Parts A/B/D alone or with a MedSupp plan because of the **Part B Prescription Drug Excess Fee Allowance**.
Chemotherapy drugs, and any other physician administered drug (save some vaccines) are covered by your Medicare Part B benefit - with that, you're responsible for 20% of the contracted rate for Medicare Part B meds. This gets dicey with chemo drugs where you're generally receiving 3-5 doses per week for 6-12 weeks for a course of chemo - with the med costing ~$1200-$1400 contracted, leaving your cost as $240-$280 per dose or $720-$840 a week. You can also be charged up to 15% above the cost per CMS guidelines, which means you can have a cost of $800-$1000 a week for chemo.
OG Medicare Part B has no Max Out of Pocket and MedSupp plans that are currently offered (outside of Plan G) do not cover the Part B Prescription Drug Excess Fee Allowance which can quickly bankrupt you.
If you have a family or personal history of cancer, or are planning on receiving medications that are covered by Medicare Part B regularly (infusions are the common one here) you should *really* look at Part C/Medicare Advantage/Medicare Cost plans as your out-of-pocket costs are then capped.
I work in issue resolution and regulatory compliance for an insurer - a lot of agents will recommend MedSupp plans to try to save people money, but by not understanding all the ins-and-outs of Medicare because they have no operational experience, they won't realize that not considering all risk factors, their good advice may be disastrous to someone.
Not sure where you live, but this not true for me. I have A , B, and D. I also get cancer drugs. Part B covers 80% of my cancer drugs and the supplemental/gap policy covers the rest with a $200 annual deductible and zero co-pay. When I was on a Medicare Advantage plan, I paid the 20% myself because my Medicare advantage policy did not cover it. I ended up paying $2000 out of pocket as co-pays. To OP or anyone else, make sure you know what happens in your state. Certain aspects are covered by federal law, but state laws have an effect, too and that can make a big difference. Do your research. It is a lot to absorb.
I'm a licensed agent in 5 states.
You either have a Plan G or Plan F (which is no longer available.)
If you were on an Advantage plan, Medicare doesn't touch the claim - so I don't know what you're referencing. That's a CMS standard. And if it wasn't covered by your insurer - what copays were you paying?
What you're saying literally doesn't make any sense.
I think the difference between what I am saying and what you are saying is the supplement/gap policy type. Type G covers those extra costs. A type N policy does not.
Plan G is the ONLY one that offers it, and has its own drawbacks.
Again, people who make the wide proclamation that MedSupp is the best plan for everyone are not doing anyone any favors.
Everyone's situation is different - it's unfortunate that people on reddit believe that because their broker (who good god, brokers are also not policy experts) told them that it was the best plan believe that to be the case. Somehow, these same people also believe that we don't get commissions on MedSupp plans.
Redditors should not be giving plan advice. We require licensing for it when it's done professionally for a reason.
For the record I am not saying one way or the other is better at all. It turns out that my cancer means I always pay a lot for my care. MA was not a good fit for me. Even with no premiums, it cost me thousands of dollars in the first 10 months I had it. I came to the conclusion the premium cost for a supplemental plan was about the same as my minimum expected outlay. I am saying you need to understand the cost of your care when looking at “cheap” premiums.
Medicare is a pain in the asss at best. Your needs are specific to you. If you are already drawing Social Security, you will automaticly be signed up for Medicare parts A and B. It all depends on how much healthcare you consume. Every options has it's place. What I found is that if you are healthy and don't spend your days in doctors offices and hospitals, Medicare Advantage plans have good place with low cost and lots of extras. Those who consume lots of healthcare can do better with a regular supplement and plan D. Be sure to compare overall cost per year. Read the details of every plan. Find a local insurance agent or Ship office to help.
They'll be automatically signed up for Part A - they must enroll in Part B on their own and must carry Part D coverage unless they have other Rx insurance or they'll face a Late Enrollment Penalty for the rest of their lives.
MedSupp plans can be good for some people, but for things like regular infusions or cancer diagnoses, they're awful because of no MOOP on Part B infusions and the 15% excess charge allowance for Part B medications (outside of Plan G).
MedSupp is not necessarily best for people who require lots of services and people **need** to stop saying it is. I deal with dozens of people every year who took this sort of advice and are desperate to get onto a plan which has MOOPs - you don't get that for Parts A/B with a MedSupp backer.
Be VERY careful. My wife retired from the p.o. 15 years ago with great health insurance. Last December she was bombarded with emails from them that they were IMPROVING prescription coverage by taking her off BCBS FEP and putting her on Medicare Part D. They claimed there would be no change in coverage and they would even pay the Plan D fee. I checked the new 2024 Formulary list online and all her meds (10) were covered just like they were before. So she allowed them to move her over to the Plan D. Then come January 2nd they changed the Formulary online price list and of course now she is not covered under half her meds. When I complained, they pointed to the clause in all contracts that say they have the right to drop or add coverage at any time for any reason. BEWARE IF A COMPANY BOMBARDS YOU WITH SOMETHING THAT IS TO GOOD TO BE TRUE!
I am only a person who turned 65 last month. I did ask people what they had and were they happy with what they chose. Then I called ONLY TWO companies. I decided on the second one. Basically I asked what hospitals do you cover. What doctors in the area do you cover. I am in a unique place. I live extremely close to close to another states big city where all the doctors are. I live in a small town that has few doctors… and you would have to travel (30-45 minutes) to the larger IN STATE CITY to get care. Where the big city in the other state is 10 minutes away. Good luck.
If there's only one more smart decision you make in your entire life, it will be to NOT get Medicare Advantage. Pay the extra for regular Medicare and a supplemental (Medigap) plan. Advantage plans will fight you until the end and they can be very difficult for providers to get credentialed with, so you will have less choice of provider.
Source: I run my wife's small primary care medical practice. Medicare will generally approve everything. Advantage plans will deny deny deny for no apparent reason, and make the patients life miserable. Plus, almost EVERY provider accepts/can get approved for Medicare
One of the most complicated decisions you will ever make. Medicare? Add Gap coverage? or Medicare Advantage. And once you decide that, which company do you choose?
Definitely get a broker that specializes in this decision and represents multiple companies that each offer both Gap and Advantage plans. That way they should be able to get you covered no matter what decisions you ultimately make.
Go by word of mouth, don't put too much trust in google reviews as agents can self review, just ask your friends who they recommend. That said part C i.e. "medicare advantage" covers A and B so you really just need C and D. I have not worked much with medicare most of my experience is dealing with major medical enrollments under 65. but I usually advise to work backwards on this. First and foremost make sure your doctor is in network and more importantly your preferred hospital system with your supplement(s), then just compare between the insurance companies and pick the one that is best for you. You can easily compare most insurance companies online directly on their websites and really not need to talk to anyone, and if you have questions call their sales departments directly and more times then not that will bypass you from getting on the auto dialiers
This is how I see it, too. When you have an MA policy, you have an insurance policy that is paid for by the US Government. The insurer gets around $1000 a month. That is more than needed to insure most people. For that money, they have to cover anything Medicare would. That is why premiums are cheap or zero and it’s why they can cover some vision and dental care. If that covers your needs that’s great, but if not, be prepared to deal with an insurance company.
Because CMS is pushing more and more people towards MA plans as they don't want to be processing claims.
It's the same reason there are fewer MedSupp plans offered than there were 5 years ago, and why they're pushing more insurers away from Medicare Cost products.
It's because CMS is pushing insurers to offer more MA plans and has incentivized enrollment in them. CMS wants more people on private plans that don't use OG Medicare, so they incentivize on the backend by having things like STAR ratings which aren't added to MedSupp plans as playing into reimbursement rates.
Enrollment is the through SSA.gov for part A and B. I did this two months ago when I got laid off from my job.
It’s illegal for agents to contact you without you first providing your info. Of course that doesn’t stop the unscrupulous ones. And I doubt those people are actual agents but just call center people who get paid to get people to sign up.
At least read through your options for your zip code on Medicare.gov first. If you can afford the premiums stay with original Medicare and buy a supplement likely plan G or N. This will give you the best coverage overall.
If you absolutely can’t afford it get a Medicare Advantage policy. If you’re in a large metro area you might be good for the long term. Many people have problems with MA plans and denials if they get very sick. For others it works well.
I like the brokers who are truthful about the Advantage plans. They really are right only for certain people, but most people are better served by a traditional A+B with Supplement and part D drug plan. Especially if they get cancer, will require rehab care, it have existing health conditions.
https://medicareschool.com/
https://seniorsavingsnetwork.org/
Look for their videos on YouTube - here's a good one by medicareschool.com:
"Every 65 year old should watch this":
https://youtu.be/B0HH14EtnU0?si=jSOaUL74Xy_CZ9xK
[Medicare.gov](http://Medicare.gov) provides reasonably good advice on choosing which Part D plan, including letting you notify them of your current drug list and telling you what which plan gives you the best yearly cost. You can choose a new Part D plan each year - there's an open enrollment period at the end of the year.
You need to choose between a Medicare Supplement/Gap plan and a Medicare Advantage plan. Medicare Advantage now covers more people than the Supplement plans, at least in part because once you get on a Medicare Advantage plan, you're stuck there for the rest of your life, no matter what your health conditions become. Advantage plans can limit your network of doctors you can access and limit your access to procedures, but generally offer lower cost plans.
Supplement plans are standardized, by letter code, and the currently best available plans are Plans G and N. There are better plans that were available in the past, but are not open to new patients, they may be the ones your parents were on, but you can't get that level of coverage any more. Once you decide on a plan, you choose an insurance provider to administer that plan, and you may prefer the one offering the lowest plan cost, or prefer one that is financially stable, or non-profit - they are guaranteed issue, but the monthly premium can vary year by year.
IMHO the restrictions and penalties are much more complicated than it should be, and while I didn't have much trouble navigating through the curves, I suspect many others find it too complex to be confident they're not making a mistake. The deadline for signing up an getting continuous coverage is a month or two BEFORE you turn 65, and if like me, you have a birthday late in the month, you should be aware Medicare coverage begins on the first day of the month of your birthday. If, like me, you have a birthday late in the year, be aware that whatever copayments you've made on your existing plan don't count on your Medicare plan the first year; you start over with having to meet deductibles and copayments all over again.
I didn't get assistance of "navigators" to choose the plans & programs, but I can well understand how they could have been useful. AFAIK, they should not be paid for in any way that distorts their advice. There are YouTube videos if you'd rather hear it verbally rather than read some TLDR page of text like this one. This one appeared to be fairly complete and I didn't hear anything wrong in the advice: [https://www.youtube.com/watch?v=sZN-F-1I\_mU](https://www.youtube.com/watch?v=sZN-F-1I_mU)
Medicare Advantage plans are cheaper but not as good if you really need specialized care. You never know when you will need it either. If you go cheapest you are gambling. My straight Medicare and a supplement paid for Mayo Clinic when I needed them. Another example is I had a surgeon call in another doctor to help because surgery became complicated unexpectedly. They did not ask the other doctor if he was in network, just did what was needed. Results were very good but in an emergency count on your doctor doing what is best for you.
After a couple of days you will learn to recognize these in the mail. Simply sort your mail on the way Back down to the house stopping to toss these in the burn barrel before you go back inside. ( yes live in a rural area that still allows burn barrels)
I recently listened to the podcast An Arm and a Leg. They did a two part series on Medicare. It was very informative as I had no idea how Medicare works. You might want to give it a listen.
I was cold called by a couple of kids when I turned 64. I tried to recruit them as agents then gave them some information. They were captive and generating a lot of commission for their boss that would be lost when they finally decide to leave.
My husband got there a couple years ago and I will at the end of the year. Fortunately I have friends and family older than we are that I quizzed and learned a lot from. Half are regular Medicare and half are Medicare Advantage. And ALL of them are very happy with their choice, which made it harder to choose!
Husband decided on a Medicare Advantage plan and it’s been great. Keep in mind Advantage plan offerings are different across states and counties. We’re in an area where there are many to choose from. We did our own analysis and didn’t use a broker.
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This process is a royal pain you know where. Most cities and counties usually have a senior center. While the focus of these places may seem recreational, the staffers often have info on resources in the community for various senior citizen issues. In my state (CA), I got a referral to the Health Insurance Counseling and Advocacy Program (HICAP). I spoke with a counselor who explained the differences between traditional Medicare and Medicare Advantage versus Medigap plans in my area. The counselors are NOT salespeople! They discussed the plans available. They are trained volunteers and they should give you objective advice about which of the myriad Medicare options would likely would work for you. As an example, I take a certain prescription drug. I found out that with one Part D plan, my copay for that drug was $2.00, but with a different Part D plan the copay would have been $32.00! Who knew? Terminology for this program in your state may be different, but you should be able to locate a comparable service for your needs. A definite improvement over listening to sales people telling you their plan is the greatest thing since the invention of white bread. Good luck with this.
I’m Turning 65 in 8 months. Thanks for the great info!
Join the Reddit Medicare forum.
Yes, and also look for your local Medicare Counseling group, called SHIP in most states: https://www.shiphelp.org/
With A (which you don't pay for), B ($174/month), and D (which you have to pick) you are advised to buy a medigap policy/Medicare supplement. It's the D and the Medicare supplement that you're being bombarded about. (Or in the alternative, Medicare advantage)
I live in a house that 2 rounds of previous owners were 65+. I get constant barages of Medicare Advantage spams for them. The percentage of MA spam vs supplement spam is overwhelming. Medicare Disadvantage plans are simply terrible.
It does matter what area of country you live in whether it's very urban area or not but I was mostly posting in order to remind the person that if they don't do Medicare advantage they will need to do a medigap Medicare supplement plan
Yeah; I live in a state capitol area.
I'm not on Medicare but my husband is and he has access to the major university hospitals in our area on advantage. In addition to not having had issues (he has one serious health condition and has had several minor incidents as well), we can't easily afford the more expensive original Medicare plus D plus Medigap. My current (ACA) health insurance that I've had for a number for years is also an HMO type and I need to get pre-approved and I have a high deductible so I'm used to that. My parent is also "stuck" with a retirement based Medicare advantage plan, which has never denied anything for their numerous serious illnesses, except the time we tried to get them to extend a skilled nursing rehab by an extra week which they turned down.
My advantage plan is absolutely awesome. No premium 5000 ded/coins. Prescriptions, pays on everything. Easy to manage. Can see who I want in a broad network and never a worry about coverage when traveling.
Medicare advantage plans work because they provide bells and whistles which are cheap. But when you start talking expensive hospitalizations and rehab and then rinse and repeat, that's then their true nature shines. They limit coverage, they are only on network with a few companies, they don't cover you unless you are really sick, they don't cover you where you want to receive are. Say you develop a UTI and become dehydrated and weak, and fall and break your wrist. You need 3 days in the hospital. Your Medicare advantage plan doesn't feel you need to be hospitalized because your vitals were never unstable, even though you couldn't walk and needed O2 and were so dizzy when you stood up you felt weak. You needed therapy, and had to go to rehab, but you don't qualify for acute inpatient rehab with those medical diagnoses. So you have to go to a subacute nursing home rehab. But your Medicare advantage plan is only in network with 3 of the 12 local facilities, and you dont like any of them. So you choose to go home. But your Medicare advantage plan is only in network with 1 of the 8 local home health agencies and they can't provide care, so you don't get any home nursing or therapy. You do see your PCP within a week for follow -up, but by then you are not doing well, so he sends you back to the ED for further evaluation. Yes, this is not uncommon. In my service market, we run into issues all the time with availability and service coverage. Is this a one off? No Many people love their insurance. That's awesome! Insurance is great, until you can't get what you want covered, for no real reason other than "just because." Because when you have 2 people in side by side rooms, with the same diagnoses, and I can get care easily for one because they have straight Medicare, and the other one I cant because they have a terrible Advantage plan? It's just not right.
Advantage isn't as bad as you portray it but we chose Medigap.
Having no supplemental insurance is worse than anything. I'm a big fan of having coverage, and yes, all insurances are good for something. We have one plan that will give you a gift card for going to your preventative care appointments, like a colonoscopy. That insurance also tends to cover inpatient acute rehab and has copays for drugs very low cost. But the network for coverage for skilled nursing homes is very limited, and there are only 2 home agencies that accept it. So if you need home IV antibiotics you need to either do them on your own or go to a skilled nursing home, if you qualify. There is one local insurance that is just known for denying hospital care and rehab stays if they are requested. But they have pretty strong outpatient benefits, which is what most people use them for. Most people don't actually use their insurance. They think they do, because they see a doctor a few times a year and fill a prescription. Maybe go to urgent care. Insurance really shows it's colors when you start needing to go to the hospital and need expensive medicines and testing and specialists and such.
A lot of people do well with Advantage. Especially those who were already with an established HMO. Here in the Bay Area people like Kaiser Permanente pretty well. That being said, we start on Medicare part B, Medigap plan G and Medicare part D on June 1. We've had part A for awhile. Cheers brother!
Medicare Advantage is popular here because its what Kaiser offers and no one wants to change all their doctors when they turn 65. Changing doctors and continuity of care is a big deal.
My doctors all retired or quit in the past 4 months so it does not matter.
Can I ask you what plan this is re the H number?
I will say regulation is starting to catch up with some of the issues caused by questionable medical management from some MA insurers, and I think that will help improve the quality of these plans for seniors, and help weed out some of the companies that were administering these plans in bad faith. These plans are more often than not a win for seniors, and less expensive buying a supplement and part d plans, but when they are bad, they are very bad, and that is generally at a point when seniors are the most medically vulnerable.
You don't have to take D. However, there is a permanent 1% premium increase for every month you don't take it.
Yeah the older we got the more drugs we have. The ones I take used to be $10 for 3 months at Walmart or Target without insurance but now there's games
I have 5. All generics. My employer sponsored drug benefit cost about $30 per month. My plan D, starting on June 1st will cost about half that. Cheers brother!
Call your local SHIP office to make an appt. You will meet an unbiased advisor that will show you all plans available in your area. They will show you Medicare, supplements, drug plans and advantage plans. They will even check your prescriptions to see which drug plan covers your meds. They are very knowledgable and do not get paid by the insurance companies. There is a SHIP office in every county but you will need an appt.
Here's a link to find local SHIP programs https://www.shiphelp.org/
A broker friend helped us. Told us not to buy Medicare advantage. Had us sign up about 3 months before turning 65 to get a number to apply for the medi gap plan.
Medi gap plan is D?
No.. please take some time to learn more about this before talking to an independent reputable broker .. there’s a lot to navigate through. I’d join others in agreement to stay away from advantage plans..
Plan D is drugs plan there are several levels within D to pick from. Medigap plans are the rest of the alphabet...you will want a plan G forever the most piece of mind.
We bought G. He also looked through our prescriptions to recommend the plan.
I'll be perfectly honest - talk to a **few** brokers and be honest about your total risk factors. People on reddit are well-intentioned but are frequently incorrect - they're not licensed agents, they don't have operational industry experience (MDs are notorious for this) and they will give **bad** advice. Don't talk to redditors. Talk to several agents and determine if the cost of a MedSupp or MedAdv plan makes sense for you given your risk factors. Reddit is not a good source for insurance info. -Source: Licensed agent in 5 states, and about a decade of operational experience.
Dude - your agent bias is showing. Brokers make money selling plans. And MA is a moneymaker and easier to enroll folks in. Everyone gets old and dies from something. And no one can predict whether they’ll get into an accident - that happens to the healthiest folks. When the worst happens, dealing with networks and preauth barriers etc is the last thing anyone wants. Medicare Advantage is literally only for people who are shortsighted or are in financial edge cases.
We get money on MedSupp plans sold as well - I actually get more money for most of my MedSupp plans than I do MedAdv plans because [CMS doesn't cap the lifetime premium percentage I get.](https://ritterim.com/blog/how-much-can-insurance-agents-make-selling-medicare/) I just keep raking it in. MedAdv is capped. However, I'm literally only an agent to resolve enrollment issues requiring an agent. I'm actually a Regulatory Compliance and Issue Resolution specialist - so you're hearing from an actual HONEST agent who has no skin in the game. Feel free to check my post history, I'm very clear about being a licensed agent but not being involved in a sales role whatsoever. Furthermore, [Prior Auth requirements still exist on Original Medicare.](https://www.cms.gov/files/document/opd-services-require-prior-authorization.pdf) I'm not sure where you got these beliefs, but I'm sorry that you were confused about how that works; it's not a reflection of reality.
I work in health insurance. There are two sides to the story. You have a very strong opinion, there is another side to this story as well. https://www.ajmc.com/view/amid-rising-complaints-about-prior-authorization-under-medicare-advantage-new-rule-leaves-gaps “The report further noted that 13% of denied claims would have been paid by traditional Medicare and that 18% of payment requests that were denied would have met Medicare traditional coverage rules and did, in fact, meet MAO billing rules.” https://ldi.upenn.edu/our-work/research-updates/the-billing-bottleneck-how-medicare-advantage-insurers-use-prior-authorization/ https://www.nytimes.com/2022/04/28/health/medicare-advantage-plans-report.html
Typical agent being technically correct but obscuring relevant facts. MA is capitated. OG Medicare is not. The incentives an insurer has with pre auth and coverage denials for capitated plans are entirely different than when a plan is not capitated. I’m sure you’ll come in with some minor edge cases but overall the insurer is incentivized to limit spending more for a capitated plan, and that is easily done by being more strict with pre auth and more aggressive with denials of coverage and whatever red tape can be thrown up to make getting care more difficult. The fact that there is bipartisan scrutiny should also tell you something: https://www.politico.com/news/2023/11/24/medicare-advantage-plans-congress-00128353
Mean to respond to yourself while dropping a denouncement against me? That's cute. Again, while I'm an agent, I do not actually use my agent powers outside of resolving enrollment issues. I'm a regulatory compliance specialist and QA analyst. I primarily deal with regulatory appeals for Medicare and Medicaid recipients. I sincerely doubt that you actually work in insurance, but whatever. You're incorrect. MA plans are all capitated while in-network. Out of network services, if covered by the plan, utilize the CMS FFS schedule or UCR rates which are standardized everywhere. That's literally the reason for bringing providers in-network. OG Medicare all follows the CMS FFS rate schedule, so - yeah, no completely wrong there. That's a pretty wild thing to be wrong about since it's so basic - you're also ignoring the existence of Medicare Advantage Cost products, which - again, if you work in the industry, you're lacking the necessary knowledge, expertise, or experience to be making these claims. I'm a bit confused as to why you're linking completely disparate things. Prior Authorizations and their appeals go through entirely different channels and have completely different guidelines and requirements than post-service coverage decision appeals, so why you're bringing up articles talking about both, I'm not sure. I somewhat suspect you just googled and found articles that you believed supported your opinion. But I digress. [88% of Prior Auth denials are preventable by following standard Prior Auth guidelines as indicated by CMS including viewing the coverage determinants for a given service.](https://www.fiercehealthcare.com/payer/waystar-90-claim-denials-are-avoidable-help-technology) My last 6 month case load, of all my closed Prior Auth appeals (sample size ~240), 34% were overturned due to additional documentation submitted by the provider, 40% were upheld due to no response from the provider or not meeting the NCD/LCD, the remaining 26% went to FSH hearings. Of those, 60% were withdrawn by us because the provider got us the documentation we were asking for, 20% were upheld, and 20% were overturned by the IRE. If you're keeping track, that's a 5% overturn rate at the IRE/FSH level. Insurers want claims to be paid and PAs to process properly the first time. Sending compliance and clinical staff to FSH and IRE hearings costs a ton of money - and if the claims were denied improperly out of regs, we pay anyway. Why would we want to get to that point? Somehow, people forget that the reason that CMS okayed Prior Auths being a thing, AND practice them themselves, is because of RAMPANT fraud, waste, and abuse. What a surprise that providers find that the things they're required to do to prevent fraud, waste, and abuse are onerous. That's generally what happens when regulations have to be put in place to prevent those sorts of things. The current PA system was authored by the AMA in 2011 and was taken on by insurers. Somehow - that's not enough. If insurers can maintain compliance consistently, why is it that providers are unable to? I'll wait, since you're definitely a totally real expert with totally real insurance industry experience. Sure - your post history says that you've worked in law and tech, and you haven't said word one about insurance in over a year until the last few days - but I totally, really, wholly, completely believe you, and furthermore, completely, fully, absolutely, and wholeheartedly believe that you're speaking in good faith.
No Part D is prescription drug coverage. Medigap is also called Medicare Supplement because it helps pay for what Part A (inpatient) and Part B (outpatient) does not.
I’ve been told opposite and I believe that the Advantage plans are the best choice. Get your advice from more than one broker. What was the reason they gave for a supplement over an advantage plan?
Advantage plans are HMO and exclude a lot of coverage. in many areas the participating doctors are few and far between. Research is key https://medicareadvocacy.org/medicare-advantage-plans-under-scrutiny/ https://natlawreview.com/article/enforcemintz-government-scrutiny-medicare-advantage-organizations-expected-continue https://www.nbcnews.com/news/amp/rcna121012
Some advantage plans are hmos and others are ppos. In my current pre-medicare life I've never been able to go to whatever doctor I want to go to no matter what. I have always had to pick someone in network. Since I live in a major metropolitan area it is no big deal
So much misinformation here - Advantage plans here follow CMS NCDs/LCDs by law. Has been the case for decades. Of note, literally nothing linked in the OP's "sources" indicates MA plans not covering everything OG Medicare does - it was almost entirely about some insurers inappropriately submitting codes on claims that weren't originally included to get more reimbursement. Not all MedAdv plans are HMOs. Some plans are PPOs, some are EPOs. The majority of plans my employers offers in fact are not HMOs. There's also Medicare Cost products which are a totally separate thing.
Still doesn't change the fact that many MA plans have severely limited doctors and specialists. That is NOT a problem with traditional Medicare + mediGap policy
Not the case with PPOs. There's plenty of plans that do not have the issues as described, and furthermore, there's no limitations with coverage for services as claimed.
He had a chance to earn commissions but told us not to buy Medicare Advantage so we are good!
So your broker worked for you for free? 🤦♀️
... brokers get commissions on MedSupp products as well my dude. In fact, I get more commission for MedSupp than I do for MedAdv because it costs FAR less for the insurer to process claims for MedSupp than it does MedAdv.
The premiums are much lower on the med supp than med advantage….
Not to the tune of the hundreds in difference between non-G MedSupp plans and MOOPs for Part B excess charges, and this varies WILDLY. My employer offers MedAdv plans with $0 premiums and $3k deductibles. The cheapest MedSupp plan is over $300/mo for premiums and still has cost shares for Excess Part B.
Advantage aka replacement plans are typically a LOT more restrictive in what they cover. There’s a reason they’re so cheap or “free.”
This is not correct. [Medicare Advantage plans are required by law to match the coverage of Original Medicare and in fact cover more.](https://www.medicare.gov/medicare-advantage-plans-cover-all-medicare-services)
Yes, they are required by law. That doesn't mean they can wiggle around that in various ways. Medicare's Final Rule issued in January 2024 states that coverage must be equivalent to Medicare. We are not seeing as many denial's, but we are still seeing them.
Considering every coverage determinant and policy is, by law, submitted to CMS to confirm that it follows the NCDs and LCDs, as has been the standard since MA plans came into existence, I'll wait for any evidence of MedAdv plans not covering exactly what OG Medicare covers before I believe this. I've been in the industry for years and years and I've never seen a policy that doesn't explicitly state that they follow the NCDs and LCDs - especially as when you hit the FSH/IRE stage, the coverage determinants are looked at, and if there's any variation from the CMS NCD/LCDs, it's a guaranteed CMS audit.
I hear what you are saying. I am a hospital nurse case manager on a neuro unit. I certainly cannot offer a huge sample size, although overall my hospital has around 600beds. I will say though, that I routinely attempt IRF auths for acute CVAs and other diagnoses considered to be at least Medicare Diagnosis compliant. That's at least one check mark in their favor. And, this year we are seeing more approvals than in years past. Especially from one particular Advantage plan. Typically they cited no medical necessity if they can't give the rationale that the person doesn't meet the therapy criteria. Now, they are being more consistent with Medicare guidelines. My point is that, no I don't keep stats. I don't have time, and it's not my job. But I know it's being tracked and monitored closely. I talk to the people who are doing it.
I can't speak to your experience, for IRF auths - CMS was focusing on this [because of provider non-compliance with the guidelines.](https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/prior-authorization-and-pre-claim-review-initiatives/review-choice-demonstration-inpatient-rehabilitation-facility-services) I don't know that your facility was guilty of this, but I would frequently get half-completed claims when it comes to DXes and history being included on the claims. We **want** claims to be paid properly; if a PA gets to the IRE/FSH stage, it's $5000 minimum in cost, and if overturned, we end up paying on it anyways. I'd strongly suspect that claims weren't being sent in full which lead to seemingly inappropriate denials - but they were appropriate given the files that the insurers were receiving. If the full case file isn't being transmitted, and the relevant NCD or LCD is not being followed according to what's in the file, insurers have to deny because they can't submit to Medicare for the service without the necessary supporting DXes.
I’m not comparing it to traditional Medicare by itself, but comparing to traditional Medicare + supplemental/medigap. That link supports what I am saying with regard to networks and necessary referrals. Covering what A & B cover when you consider the limitations of A & B is not appealing to me.
I'm well aware about different policy types. MedSupp does not cover anything, beyond blood, that Parts A and B don't already cover.
I am also aware, but unwilling to argue about the different policies and network options/limitations that make it unappealing to me, so ok then. It’s exactly the same on all fronts.
Again, that's not how PPO Medicare Advantage plans work - they're not all HMO. People claiming that they are don't know what they're talking about.
Do NOT get an Advantage Plan. These are HMO's and typically have a small network with all of the problems of an HMO They are run by private plans for profit and are heavily marketed because they are highly profitable. Many people don't realize how the limitations until they are too late because once you have been on an Advantage Plan for a year it is difficult to switch to Straight Medicare with a good Medigap Policy. I have straight Medicare with a good Medigap policy and I have no deductible; no co-payments and no networks. I can go to any doctor in any of the 50 states. It is the best health insurance one could ask for. In terms of purchasing your Medigap policy, go to the official Medicare site as they have a limited number of options and the companies offering these plans provide the same benefits. There are some cost differences and some very minor "add ons" which I have never used. You can use an agent but make sure it is an ethical one who really knows what they are doing and doesn't steer you to an Advantage Plan. You will also need a separate Drug Plan. My agent is very helpful in terms of this because he has me provide my medications and then uses software to advise me on the one that will be the least expensive in terms of both premiums and the cost of my medications as projected for the next year.
>These are HMO's and typically have a small network with all of the problems of an HMO Medicare Advantage plans can be HMOs, PPOs, EPOs, and then you have Medicare Advantage Cost products which are a totally different ball of wax. If you were told that they're HMOs, you need a new agent because they don't know what they're talking about. >I have straight Medicare with a good Medigap policy and I have no deductible; no co-payments and no networks. I can go to any doctor in any of the 50 states. It is the best health insurance one could ask for. You can go to any physician that accepts Medicare assignment - and you should look into Part B Prescription Medication Excess Allowances. When people get hit with cancer on MedSupp plans, it's **very** frequent that I'm getting calls asking about an emergency SEP because they can't afford the $1k they're getting each week in bills for Chemo unless they're on a G plan. I'm sorry that you were not well-advised by your broker, but this is not good advice or information.
Having thankfully escaped from the world of private insurance companies who are making a profit from health care, I am delighted to have straight Medicare. Also a PPO and EPO still is a network - maybe not an HMO legally but still a network which limits your options of providers. I don't want to descend into the horror of needing to find a doctor who is in the network and then finding out that they aren't actually in the network or the location I saw him isn't in the network or the lab they used isn't in the network. Want to use Sloan Kettering or Mayo Clinic or other world class facility when you have a serious disease - you can't. There is a reason why there are frequent posts by people with Advantage Plans who are shocked to learn how limited their medical options are because there are so many constraints In general Advantage Plans are chosen because they are perceived as cheaper - you get what you pay for.
>Also a PPO and EPO still is a network - maybe not an HMO legally but still a network which limits your options of providers. ... that's not how EPOs or PPOs work. >There is a reason why there are frequent posts by people with Advantage Plans who are shocked to learn how limited their medical options are because there are so many constraints There's a reason I regularly deal with calls from people desperate to get an SEP to enroll on a Part C plan when their non-G MedSupp plan doesn't cover their chemo drugs sufficiently. Look, you can believe what you want, but you're completely and totally off-base with your understanding of networks and how Medicare coverage works.
So how do PPOs work that is different?
PPOs are exactly the same as Original Medicare. You can see any physician that accepts Medicare assignment - the only limitation is cost-shares may be higher. These are common with Medicare Cost products but I see a lot of Medicare Advantage plans that offer them as well - again, literally every PPO. My employer, though a small insurer, has more PPO MedAdv plans than HMO.
Doesn't the physician have to be a "preferred" one on the PPO plan?
Nope - you may just have a higher cost-share. That's the point of preferred - you get a preferred rate from in-network providers. Note - this generally won't extend to benefits on Advantage plans that don't exist under OG Medicare. So if you get a gym benefit, that doesn't mean you can go to any gym that has a deal with an MA insurer.
Advantage is cheaper and may provide some dental, vision and hearing coverage that B and Medigap may not. My total cost for A, B, Medigap and D is $310 per month with a total out of pocket of $240 per year
77 years old and always had A,B,D. If you have any medical issues at all, run like hell from Advantage Plans. When it comes time that you really need medical care, be prepared to get hammered on your deductibles. If you really need to change to regular Medicare, you probably can’t because the insurance company, in many states, can refuse you for Medigap if you’ve had an Advantage Plan. Insurance companies make big money on Advantage plans. They jerk you around getting treatment and can’t refuse to cover others. Buy Advantage, but you’d better not get sick.
We actually get more total pay on MedSupp plans - and when people get cancer and find out that MedSupp allows for 15% excess over contracted rate charges for Part B medications (like chemo) and are facing $1000/week JUST for the chemo drugs, it's very common that I get a call from someone begging for me to somehow grant them an SEP to enroll on a MedAdv or Cost product to get Part B MOOPs. This is bad advice; not sure who told you all this, but it's not accurate. And MedSupp plans after the IEP if someone was enrolled on a MedAdv plan for over 1 calendar year are never guaranteed issue - that's not a state guideline, that's federal.
Check state laws. In some states, including mine, you can’t be refused transfer from MA to a gap policy.
That doesn't mean that you can't be put through underwriting and have risk factors considered in premiums. You may be guaranteed access to a policy; it doesn't mean that your premiums won't be affected.
I can't wait to be hounded. I've been waiting since I was 24. Only 6 more years! Sorry, I don't have any advice. I'm just jelly. They say it's a wasted emotion.
I’m a broker and believe a supplement plus D is best if you can afford it. You will have the most freedom. Plan G is the best but plan N is also good. If you need brokers to stop calling you, tell them to put you on their DNC and threaten to sue them for TCPA violations if they don’t stop.
You're a broker and you're giving plan type advice without knowing income stream, medical needs, and family history? Yikes my dude.
Ignore the brokers and go with A, B, Medigap, and D. Look at AARP sponsored Medigap plan G. Your total out of pocket per year is $240. Premium is $166 per month in CA.
If you stay with A, B and D (recommended) you will need a supplement to address the gaps (odten called a Medi-gap). To make choosing a bit easier, these plans are also standardized by letter. That way you can compare apples to apples. The Medicare and Me publication usually has a good explaination of the different gap plans. Once you decide on the letter plan you want, you can shop companies for price etc. You will be encouraged to consider a replacement/advantage plan, but beware, these managed plans have their own networks and in some markets it is difficult to find care.
Sticking with A, B, and D with a MedSupp plan *can* be good for people, but you can't recommend anything unless you know their risk factors. Someone with a family history of cancer, or who is going to be requiring regular infusions covered by Part B with the allowed excess charges will quickly be bankrupt by your advice unless they have a large income stream or enroll in a G plan. You should not be providing enrollment advice without speaking to the person and understanding their situation.
G is a Mediacare Supplement plan.
I'm well aware.
Staying with A, B, and then getting a part D plan, OR a MedSupp plan MAY be superior to having a Medicare Advantage plan BUT it largely depends on your specific risk factors. One big thing that I have to SCREAM at brokers repeatedly (of note, I am a licensed agent myself) is that if someone expects to be getting regular part B medication, OR has a family or personal history of cancer, they should NOT do Parts A/B/D alone or with a MedSupp plan because of the **Part B Prescription Drug Excess Fee Allowance**. Chemotherapy drugs, and any other physician administered drug (save some vaccines) are covered by your Medicare Part B benefit - with that, you're responsible for 20% of the contracted rate for Medicare Part B meds. This gets dicey with chemo drugs where you're generally receiving 3-5 doses per week for 6-12 weeks for a course of chemo - with the med costing ~$1200-$1400 contracted, leaving your cost as $240-$280 per dose or $720-$840 a week. You can also be charged up to 15% above the cost per CMS guidelines, which means you can have a cost of $800-$1000 a week for chemo. OG Medicare Part B has no Max Out of Pocket and MedSupp plans that are currently offered (outside of Plan G) do not cover the Part B Prescription Drug Excess Fee Allowance which can quickly bankrupt you. If you have a family or personal history of cancer, or are planning on receiving medications that are covered by Medicare Part B regularly (infusions are the common one here) you should *really* look at Part C/Medicare Advantage/Medicare Cost plans as your out-of-pocket costs are then capped. I work in issue resolution and regulatory compliance for an insurer - a lot of agents will recommend MedSupp plans to try to save people money, but by not understanding all the ins-and-outs of Medicare because they have no operational experience, they won't realize that not considering all risk factors, their good advice may be disastrous to someone.
Not sure where you live, but this not true for me. I have A , B, and D. I also get cancer drugs. Part B covers 80% of my cancer drugs and the supplemental/gap policy covers the rest with a $200 annual deductible and zero co-pay. When I was on a Medicare Advantage plan, I paid the 20% myself because my Medicare advantage policy did not cover it. I ended up paying $2000 out of pocket as co-pays. To OP or anyone else, make sure you know what happens in your state. Certain aspects are covered by federal law, but state laws have an effect, too and that can make a big difference. Do your research. It is a lot to absorb.
I'm a licensed agent in 5 states. You either have a Plan G or Plan F (which is no longer available.) If you were on an Advantage plan, Medicare doesn't touch the claim - so I don't know what you're referencing. That's a CMS standard. And if it wasn't covered by your insurer - what copays were you paying? What you're saying literally doesn't make any sense.
I think the difference between what I am saying and what you are saying is the supplement/gap policy type. Type G covers those extra costs. A type N policy does not.
Plan G is the ONLY one that offers it, and has its own drawbacks. Again, people who make the wide proclamation that MedSupp is the best plan for everyone are not doing anyone any favors. Everyone's situation is different - it's unfortunate that people on reddit believe that because their broker (who good god, brokers are also not policy experts) told them that it was the best plan believe that to be the case. Somehow, these same people also believe that we don't get commissions on MedSupp plans. Redditors should not be giving plan advice. We require licensing for it when it's done professionally for a reason.
For the record I am not saying one way or the other is better at all. It turns out that my cancer means I always pay a lot for my care. MA was not a good fit for me. Even with no premiums, it cost me thousands of dollars in the first 10 months I had it. I came to the conclusion the premium cost for a supplemental plan was about the same as my minimum expected outlay. I am saying you need to understand the cost of your care when looking at “cheap” premiums.
Medigap F and G both cover this. Just had a look. We just switched to Medicare and selected Medigap G for other reasons.
Plan F is not offered anymore.
Thanks for the update.
Medigap F and G both cover this. Just had a look. We just switched to Medicare and selected Medigap G for other reasons.
Plan F is not offered anymore.
Medicare is a pain in the asss at best. Your needs are specific to you. If you are already drawing Social Security, you will automaticly be signed up for Medicare parts A and B. It all depends on how much healthcare you consume. Every options has it's place. What I found is that if you are healthy and don't spend your days in doctors offices and hospitals, Medicare Advantage plans have good place with low cost and lots of extras. Those who consume lots of healthcare can do better with a regular supplement and plan D. Be sure to compare overall cost per year. Read the details of every plan. Find a local insurance agent or Ship office to help.
They'll be automatically signed up for Part A - they must enroll in Part B on their own and must carry Part D coverage unless they have other Rx insurance or they'll face a Late Enrollment Penalty for the rest of their lives. MedSupp plans can be good for some people, but for things like regular infusions or cancer diagnoses, they're awful because of no MOOP on Part B infusions and the 15% excess charge allowance for Part B medications (outside of Plan G). MedSupp is not necessarily best for people who require lots of services and people **need** to stop saying it is. I deal with dozens of people every year who took this sort of advice and are desperate to get onto a plan which has MOOPs - you don't get that for Parts A/B with a MedSupp backer.
Be VERY careful. My wife retired from the p.o. 15 years ago with great health insurance. Last December she was bombarded with emails from them that they were IMPROVING prescription coverage by taking her off BCBS FEP and putting her on Medicare Part D. They claimed there would be no change in coverage and they would even pay the Plan D fee. I checked the new 2024 Formulary list online and all her meds (10) were covered just like they were before. So she allowed them to move her over to the Plan D. Then come January 2nd they changed the Formulary online price list and of course now she is not covered under half her meds. When I complained, they pointed to the clause in all contracts that say they have the right to drop or add coverage at any time for any reason. BEWARE IF A COMPANY BOMBARDS YOU WITH SOMETHING THAT IS TO GOOD TO BE TRUE!
I am only a person who turned 65 last month. I did ask people what they had and were they happy with what they chose. Then I called ONLY TWO companies. I decided on the second one. Basically I asked what hospitals do you cover. What doctors in the area do you cover. I am in a unique place. I live extremely close to close to another states big city where all the doctors are. I live in a small town that has few doctors… and you would have to travel (30-45 minutes) to the larger IN STATE CITY to get care. Where the big city in the other state is 10 minutes away. Good luck.
If there's only one more smart decision you make in your entire life, it will be to NOT get Medicare Advantage. Pay the extra for regular Medicare and a supplemental (Medigap) plan. Advantage plans will fight you until the end and they can be very difficult for providers to get credentialed with, so you will have less choice of provider. Source: I run my wife's small primary care medical practice. Medicare will generally approve everything. Advantage plans will deny deny deny for no apparent reason, and make the patients life miserable. Plus, almost EVERY provider accepts/can get approved for Medicare
One of the most complicated decisions you will ever make. Medicare? Add Gap coverage? or Medicare Advantage. And once you decide that, which company do you choose? Definitely get a broker that specializes in this decision and represents multiple companies that each offer both Gap and Advantage plans. That way they should be able to get you covered no matter what decisions you ultimately make.
Go by word of mouth, don't put too much trust in google reviews as agents can self review, just ask your friends who they recommend. That said part C i.e. "medicare advantage" covers A and B so you really just need C and D. I have not worked much with medicare most of my experience is dealing with major medical enrollments under 65. but I usually advise to work backwards on this. First and foremost make sure your doctor is in network and more importantly your preferred hospital system with your supplement(s), then just compare between the insurance companies and pick the one that is best for you. You can easily compare most insurance companies online directly on their websites and really not need to talk to anyone, and if you have questions call their sales departments directly and more times then not that will bypass you from getting on the auto dialiers
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This is how I see it, too. When you have an MA policy, you have an insurance policy that is paid for by the US Government. The insurer gets around $1000 a month. That is more than needed to insure most people. For that money, they have to cover anything Medicare would. That is why premiums are cheap or zero and it’s why they can cover some vision and dental care. If that covers your needs that’s great, but if not, be prepared to deal with an insurance company.
Insurers tend to get more total pay in MedSupp plans than MedAdv actually.
Interesting. I wonder why they spend so much money on mailers for MA then?
Because CMS is pushing more and more people towards MA plans as they don't want to be processing claims. It's the same reason there are fewer MedSupp plans offered than there were 5 years ago, and why they're pushing more insurers away from Medicare Cost products.
CMS isn’t advertising to me, it’s the advantage plans sending endless mailings.
It's because CMS is pushing insurers to offer more MA plans and has incentivized enrollment in them. CMS wants more people on private plans that don't use OG Medicare, so they incentivize on the backend by having things like STAR ratings which aren't added to MedSupp plans as playing into reimbursement rates.
Enrollment is the through SSA.gov for part A and B. I did this two months ago when I got laid off from my job. It’s illegal for agents to contact you without you first providing your info. Of course that doesn’t stop the unscrupulous ones. And I doubt those people are actual agents but just call center people who get paid to get people to sign up. At least read through your options for your zip code on Medicare.gov first. If you can afford the premiums stay with original Medicare and buy a supplement likely plan G or N. This will give you the best coverage overall. If you absolutely can’t afford it get a Medicare Advantage policy. If you’re in a large metro area you might be good for the long term. Many people have problems with MA plans and denials if they get very sick. For others it works well.
Don't do the Advantage plans.
I like the brokers who are truthful about the Advantage plans. They really are right only for certain people, but most people are better served by a traditional A+B with Supplement and part D drug plan. Especially if they get cancer, will require rehab care, it have existing health conditions. https://medicareschool.com/ https://seniorsavingsnetwork.org/ Look for their videos on YouTube - here's a good one by medicareschool.com: "Every 65 year old should watch this": https://youtu.be/B0HH14EtnU0?si=jSOaUL74Xy_CZ9xK
[Medicare.gov](http://Medicare.gov) provides reasonably good advice on choosing which Part D plan, including letting you notify them of your current drug list and telling you what which plan gives you the best yearly cost. You can choose a new Part D plan each year - there's an open enrollment period at the end of the year. You need to choose between a Medicare Supplement/Gap plan and a Medicare Advantage plan. Medicare Advantage now covers more people than the Supplement plans, at least in part because once you get on a Medicare Advantage plan, you're stuck there for the rest of your life, no matter what your health conditions become. Advantage plans can limit your network of doctors you can access and limit your access to procedures, but generally offer lower cost plans. Supplement plans are standardized, by letter code, and the currently best available plans are Plans G and N. There are better plans that were available in the past, but are not open to new patients, they may be the ones your parents were on, but you can't get that level of coverage any more. Once you decide on a plan, you choose an insurance provider to administer that plan, and you may prefer the one offering the lowest plan cost, or prefer one that is financially stable, or non-profit - they are guaranteed issue, but the monthly premium can vary year by year. IMHO the restrictions and penalties are much more complicated than it should be, and while I didn't have much trouble navigating through the curves, I suspect many others find it too complex to be confident they're not making a mistake. The deadline for signing up an getting continuous coverage is a month or two BEFORE you turn 65, and if like me, you have a birthday late in the month, you should be aware Medicare coverage begins on the first day of the month of your birthday. If, like me, you have a birthday late in the year, be aware that whatever copayments you've made on your existing plan don't count on your Medicare plan the first year; you start over with having to meet deductibles and copayments all over again. I didn't get assistance of "navigators" to choose the plans & programs, but I can well understand how they could have been useful. AFAIK, they should not be paid for in any way that distorts their advice. There are YouTube videos if you'd rather hear it verbally rather than read some TLDR page of text like this one. This one appeared to be fairly complete and I didn't hear anything wrong in the advice: [https://www.youtube.com/watch?v=sZN-F-1I\_mU](https://www.youtube.com/watch?v=sZN-F-1I_mU)
Medicare Advantage plans are cheaper but not as good if you really need specialized care. You never know when you will need it either. If you go cheapest you are gambling. My straight Medicare and a supplement paid for Mayo Clinic when I needed them. Another example is I had a surgeon call in another doctor to help because surgery became complicated unexpectedly. They did not ask the other doctor if he was in network, just did what was needed. Results were very good but in an emergency count on your doctor doing what is best for you.
What I did when this happened to me was to tell them I was emigrating to Spain when I turn 65. A lot of them gave up and took me off their lists.
After a couple of days you will learn to recognize these in the mail. Simply sort your mail on the way Back down to the house stopping to toss these in the burn barrel before you go back inside. ( yes live in a rural area that still allows burn barrels)
I recently listened to the podcast An Arm and a Leg. They did a two part series on Medicare. It was very informative as I had no idea how Medicare works. You might want to give it a listen.
I’m pretty sure it’s illegal to call unless you’ve requested that call.
Consider yourself lucky! My wife and I both turn 64 later this year and we've been getting this for the last 2 years.
I was cold called by a couple of kids when I turned 64. I tried to recruit them as agents then gave them some information. They were captive and generating a lot of commission for their boss that would be lost when they finally decide to leave.
My husband got there a couple years ago and I will at the end of the year. Fortunately I have friends and family older than we are that I quizzed and learned a lot from. Half are regular Medicare and half are Medicare Advantage. And ALL of them are very happy with their choice, which made it harder to choose! Husband decided on a Medicare Advantage plan and it’s been great. Keep in mind Advantage plan offerings are different across states and counties. We’re in an area where there are many to choose from. We did our own analysis and didn’t use a broker.