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Old 01-24-2011, 06:46 PM
Status: "Much too young to feel this damn old" (set 3 days ago)
Location: Coast of Somewhere Beautiful
2,226 posts, read 4,413,665 times
Reputation: 5356


My wife and I are fast approaching the magic "65". Our current health insurance situation is a trainwreck, so I have been working hard to acquaint myself with Medicare, including reading every page of "Medicare & You - 2011". My god, this is worse than dealing with the IRS. I'm surprised there's not a huge industry of "certified Medicare advisors", like tax accountants or financial advisors. At this point, I'd gladly pay to have an "expert" guide me thru this mess.

OK, forgive my rant. I've got a few get-started questions for anyone who wouldn't mind chiming in. I understand there are a number of Medigap (Supplement Insurance) plans, and there are a number of Medicare Advantage (Part C) plans, and I realize I'm the only one who can decide which specific plan is best for me. That's fine.

What I don't understand is why is it necessary to further complicate the process by having two different types of plans - Medigap and Medicare Advantage? Before I can pick which specific plan is best for me, how do I go about deciding whether to go with Medigap or Medicare Advantage? Obviously, I'm missing something fundamental here, but it is eluding me. If anybody truly understands all of this stuff, please enlighten me. Thanks.
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Old 01-24-2011, 07:17 PM
Location: Los Angeles area
14,022 posts, read 16,943,481 times
Reputation: 32174
Let me try, as far as the Medicare Advantage Plans are concerned. These are a completely different way to receive your Medicare coverage and (great joy!) they do away with most of the complications of that manual you just read (which I agree is incomprehensible). In a Medicare Advantage Plan, you essentially sign over your Medicare to the plan, and the plan takes care of you and includes a Part D drug benefit. Medicare pays the plan so much per month (and it's a substantial amount) on your behalf, so the plan doesn't need to charge you very much, although the plan charges do vary quite a bit depending on the area of the country. Most of the plans are HMO-like (or just plain HMO's), so you have to use their doctors, which I know some people don't like. Here in Los Angeles, I have the Kaiser Medicare Advantage Plan. Co-pays are $5 for doctor (including specialist) visits, $20 for lab work, and $50 for emergency room visits. I had hernia surgery in August for a total of $75 in co-pays which included the pain pills. You still have to pay your Medicare Part B premiums directly to Medicare. You can go online to Medicare and check out the plans in your area (www.medicare.gov). You must enroll in a Medicare Advantage Plan (if you choose this route) which is authorized to operate in the county in which you reside.

Medigap policies, about which I know very little, are designed to literally close some of the "gaps", or items you would pay out of pocket for under the traditional (or "original") Medicare. You can have traditional Medicare (which most of that complicated manual is about) without buying a Medigap policy if you want to, but someone else will have to weigh in on the merits/demerits of that, as I have direct experience (and positive experience) only with Medicare Advantage Plans, and I believe you get more bang for your buck with the latter. (You sure get less paperwork!)

Please keep coming with more specific questions. I was attempting a brief overview here. Others will doubtless post with more details and different opinions. A suggestion: find some retirees whom you know personally and who are 65 or over and ask them about their Medicare experiences.
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Old 01-24-2011, 07:34 PM
Location: Location: Location
6,220 posts, read 7,398,023 times
Reputation: 17862
At age 65, I signed on to Medicare, (the traditional plan). Medicare Part A is the hospital part. Medicare Part B is the part that pays for testing - i.e., blood work, CT MRI scans, x-rays etc. and for doctor's office visits. The payment for Part B is deducted from your monthly Social Security check. There are deductibles involved and a 20% copay on all services UNLESS you opt for a Medigap policy which is a supplement to your traditional Medicare plan. In that case, in addition to the deduction from your SS check, you will also pay a monthly premium to the supplemental insuror. This is the set-up I had when I was admitted to the hospital for open heart surgery. The entire cost to me for the surgery and hospitalization and doctors was $120.00
As time wore on, the monthly cost of the supplemental increased to $135.00/mo. There was still the matter of the annual deductible which was around $120.00. (And still paying the $90+ for the
Medicare Part B premium. Haven't yet taken into consideration the Medicare Part D premium for prescription coverage. (Believe me, our Government did us NO favors with that boondoggle).
I looked into the Medicare Advantage plan, and decided to change. Still obligated to pay the Medicare Part B monthly premium, but a greatly reduced monthly premium for the new coverage which meant I'm not responsible for the annual deductible which has gone up. I also have the Part D coverage included in this premium. There is also a $100.00 deductible for hospitalization, but if you pay two of these a year, you won't have to pay further deductibles. There is also coverage for eyeglasses, hearing aids, podiatry care if medically necessary, Silver Sneakers exercise and fitness plan to maintain good health, and while I have physician office visit co-pays, it still costs me less than I was paying under the traditional/supplement plans.
Of course, plans differ, and there are different levels available under those plans, but thus far I am satisfied. This after having colon cancer surgery, blood transfusions, 11 iron infusions, chemotherapy. The hospitalization cost me $100.00. The chemotherapy, which retailed at $1,237.00 a round, for eight rounds, ended up costing me $25.00 a round. I'm still not sure if the chemo coverage was because of the Advantage plan or because some merciful being was looking out for me, but I thank whatever entity was responsible.
My plan is a preferred provider plan, which means I can pick my doctors, as long as they participate in my plan. (My plan is with an off-shoot of Blue Cross/Blue Shield, so most of the doctors/hospitals in my area are participating.
Although the monthly premium has gone up over the past four years, it is still cost-effective FOR ME. YMMV
Bless you in your decision-making.
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Old 01-24-2011, 07:53 PM
Location: Florida
3,832 posts, read 3,134,627 times
Reputation: 3404
Good thing the Goverment is getting envolved and making it easier to get insurance and currting costs.
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Old 01-24-2011, 08:04 PM
Status: "Much too young to feel this damn old" (set 3 days ago)
Location: Coast of Somewhere Beautiful
2,226 posts, read 4,413,665 times
Reputation: 5356
Thank you very much for both responses. Your comments are very helpful and tend to support the impressions I came away with from reading the book. I tried to avoid biasing my initial posting, but the book gave me a distinct impression that Medicare Advantage is probably a better choice for most folks than Medigap, and the monthly premiums I saw during a quick browse of my state's plans are amazingly low, at least compared to my current insurance. I realize I also have to pay for Plan B, but it will still be a blessing compared to my current costs. Plus, most of 'em seem to offer an upper ceiling on annual out of pocket expenses. Given all of that, why would I want to choose Medigap, instead? I felt like I was missing something, but couldn't find it.

Theatregypsy, I can already tell you're right about the Plan D options. That alone looks like it makes choosing a Medicare Advantage plan more difficult, since each seems to incorporate its own Plan D. My sister is a pharmacist, and she's promised to help me with the D part.

Anyway, back to where I started, are there situations where Medigap is a better choice over Medicare Advantage? Thanks again, and I'm sure I'll be back with more questions.
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Old 01-24-2011, 09:51 PM
Location: SW Missouri
33 posts, read 68,881 times
Reputation: 42
One thing to keep in mind, if the new Health Care Law stays in effect as is, there will be big changes to Medicare Advantage. Predictions by many in the "know" is higher premiums and less benefits. The elimination of Plans, and some Insurance Companies pulling out of the market all together. My opinion, is that one would be better off with Medicare and Supplement, and Drug Plan if that would be affordable. If you are on Medicare Advantage and wish to switch back to Medicare, You may do so, but the Supplement Plan would be the problem if it is more than 1 year. Some States give 2 years. If you switch within the 1st year you have the right to any Supplement Plan Sold by any Insurance C0 that sells them in your State. This is called "Guarantee Issue" and this is very important if you have any pre existing health conditions.
I was able to go back this year with Medicare and Supplement and stand alone Drug Plan for this year because I done it within the first year. If things were to stay the way they were before the new Heath Care Law, I would have stayed with my Medicare Advantage Plan.
Some things you may ask yourself. Will you be happy with the restrictions of their plan Doctors and Hospitals, or do you travel a lot. Medicare Advantage can get real expensive if you have to have Chemotherapy, or some of the big ticket treatments……..Just my 2cents
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Old 01-25-2011, 07:45 AM
48,519 posts, read 81,013,914 times
Reputation: 17978
The real difference from what I saw with my parnets and my wifes parents is that advanatge plans limit chocie as to providers. Often the best doctors and hospitlaa etc are often not part of the plan. It alos can be the case that the hpospital is on the plan but not all providers theyuse which menas your sent out to get that done. Basically it just a difference in choice and the fact that often they assig a doctor f their chocie who actauly manages your care instead of the one you chose.mOst times they work fine until you have a serious problem where choice makes so much difference. If you can afford it choice is always better;especailly for serius problems.
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Old 01-25-2011, 08:33 AM
88 posts, read 192,461 times
Reputation: 99
I am also in the same situation of helping someone decide which to choose Regular Medicare or Advantage. So far I am leaning towards Regular Medicare because she wants to choose her own providers with no Primary Care Referrals to Specialists. She also travels around quite a bit. I have no personal experience with either type of Medicare myself. My mother & grandmother had the traditional & seemed happy with it. My husband just chose an Advantage plan & is not too happy with the doctor choice on his particular plan. He has to drive distance to be treated & doctors are leaving the plan.

I have heard that some people have trouble with getting referrals on the Advantage Plans & of being denied coverage too with those.

If you choose Regular Medicare & don't choose a drug plan within the 7 mth window there is a 1% penalty for every mth without drug coverage. Also, you have the time period to choose medigap, if you want it, or there might be required underwriting for it.

Hopefully, others will continue posting with their experiences with Medicare Regular or Advantage.

Last edited by CAM2; 01-25-2011 at 09:11 AM..
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Old 01-25-2011, 11:26 AM
Status: "Much too young to feel this damn old" (set 3 days ago)
Location: Coast of Somewhere Beautiful
2,226 posts, read 4,413,665 times
Reputation: 5356
Originally Posted by dhuntz View Post
...If you are on Medicare Advantage and wish to switch back to Medicare, You may do so, but the Supplement Plan would be the problem if it is more than 1 year...
So, if I understand, when enrolling in Medicare, I am required to make decisions that may not be reversible, or perhaps reversible only with a penalty, and yet the private insurers have free rein to make changes to plans and premiums after I enroll in 'em? I guess I need better lobbyists...

I know I need to be concerned about limited choice of doctors, but I've been in a PPO for so long, it's begun to feel natural. Fortunately, we've rarely run into any problems, but I'm sure that depends upon the specific network of available doctors.

Does anyone feel up to expanding on the issue of pre-existing conditions? I assume that when I turn 65, pre-existing conditions are not an issue with original Medicare, is that correct? How about with private insurers providing MediGap or Medicare Advantage? Are they allowed to exclude coverage for medical conditions that existed prior to turning 65?

Thanks for all the great responses. This is very helpful info.
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Old 01-25-2011, 01:17 PM
Location: Location: Location
6,220 posts, read 7,398,023 times
Reputation: 17862

I have been in both plans, traditional Medicare with a Supplemental Provider, and a Medicare Advantage Plan. I have been able to choose my doctor in BOTH circumstances. I have the same Primary Care Provider that I have had for over 20 years - before either Medicare choice was an issue.

With Traditional Medicare, I had open-heart surgery. There was no question as to MY choice of Cardiologist and of Surgeon. I picked both. They both participated. Now bear in mind, we are in Pennsylvania, and doctors are required to participate in Medicare. Given the number of elderly, they'd be foolish not to participate.

When I opted to switch to Medicare Advantage, I researched the two plans that were sending me information on an almost-daily basis. On one of them, I would have been required to submit my bills to them, since there were very few doctors in this area participating. It was a no-brainer to select Freedom Blue, which is a subsidiary of Blue Cross/Blue Shield. I was able to keep my own doctors and hospitals since they were all participating.

Came time to pick a surgeon for cancer surgery, there was no problem. Most of the local surgeons participate in the plan in which I am enrolled.

Also no worries regarding Part D (prescription drug coverage) since my Advantage plan includes the coverage.

You would be well-served to attend the informational seminars that most of the Advantage plans hold to answer any questions you have. And other attendees often ask questions that you hadn't thought of, but that add to your store of information.

It isn't as easy as you'd like, but not as complicated as you think. Good luck.
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