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Old 10-11-2018, 01:52 PM
 
Location: Wisconsin
23,578 posts, read 50,266,725 times
Reputation: 18237

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Quote:
Originally Posted by FiveLoaves View Post
I'm not sure I described my situation correctly, but I don't think the above is correct either.

I have Traditional Medicare Part A & B, Hospital & Doctor premium deducted from my SS check, about $134 per month. Instead of a Medigap Supplement, I have a Medicare Advantage PPO plan that covers my doctor visits and generic drugs. At this stage of the game, I only go to my Primary every 6 months ($5 co-pay) and get a Sunscreen checkup once a year, and maybe a Colonoscopy every other year......all fully covered. The scripts I take are both Tier 1 generics and also fully covered.

At some future date, I may move into a Medigap Plan G or whatever, but for now.....I find this is sufficient.
Mathjak is correct. Your gatekeeper is now the private for-profit Advantage insurer, not Medicare.

You may want to read this:
Quote:
Originally Posted by Ariadne22 View Post
We've had many discussions on this forum on the pros and cons of either a Medigap + Part D, or an Advantage plan which includes drugs. A quick search should turn up many threads.

You need to evaluate these four criteria -
  1. your health
  2. your need/desire for doctor/provider flexibility
  3. your ability to pay Medigap (and Part D) premiums
  4. carrier reliability (especially true for Advantage and some Part D plans)
If you have a lot of chronic health issues or foresee serious issues - and can afford it - then a Medigap G or F - provides the most flexible, worry-free, and trouble-free choice. You can see any provider anywhere in the country who accepts Medicare, no gatekeepers on treatment approval, no provider networks. Bills go to Medicare and your Medigap.

Generally, with a Medigap F/G, your Medicare-approved expenses will be paid 100%. For the most part, medical expenses are pretty much limited to Medigap premium (and Part D premium and copays if you take medication).

There are less expensive (premium) cost-sharing Medigap plans available, as well, but often these prove to be a false economy when managing chronic illness or worse. Copays and hospital deductibles can eat up any premium savings in short order.

If you are reasonably healthy and can afford some premium and the very low 20% not paid by Medicare the few times you doctor - then a high-deductible Medigap F, which, again, provides the most provider flexibility and caps your annual max out-of-pocket (your 20%) at $2,180, worst case scenario, all at one-half to one-third the cost of a regular Medigap F. Bills go to Medicare and your Medigap. Medicare pays its 80%, you pay 20% up to a maximum of $2,240. Thereafter, the Medigap pays 100%.

If you're healthy, over a period of years, you'll probably be much further ahead financially with an hd-F. (If you haven't done so, as yet, strongly recommend you read this: //www.city-data.com/forum/health-insurance/2129000-help-texas-thinking-original-medicare-hi-2.html)

If you are cost-conscious, then an Advantage (aka Medicare health plan) (if you're healthy - or, even if you're sick - depending on plan) can be an appropriate choice, as it bundles docs and drugs, for a low or zero premium. Pay close attention to:
  1. copays and max out-of-pockets, especially if you're sick or anticipate health issues.
  2. restricted networks - an issue if you need specialty care or if you travel a lot.
  3. drug formulary (tiers and copays).
For the chronically ill, annual Advantage copays could exceed twice the cost of a Medigap F, as max out-of-pockets can be set at $5-$7k, or more.

If you travel a lot or snowbird, unless it is a PPO with out-of-network coverage, Advantage is not an appropriate choice.

If you choose Advantage, know that you are divorcing yourself from Medicare and putting the decisions for treatments, benefits, and payment in the hands of the PRIVATE (this means for-profit) Advantage insurer. Some are good actors, others are not. Common bad behaviors by MA's are denials of mandated Medicare benefits, onerous oversight on long-term therapies and preapprovals, etc., slow pays, denials they've received the provider claims, customer-service run-around, and more.

Check with network providers and providers' billing people on ease of use, timely payment, preapprovals, insistence on use of generic drugs, verify with the provider that provider is, in fact, in that network - insurance reps and websites often are wrong - and talk to people you know who have the same plan.

Unless you are in a guaranteed issue state, know that once past the Initial Open Enrollment, you will not be able to switch to a Medigap without undergoing health underwriting, although you can move from one Advantage plan to another Advantage plan during Annual Open Enrollment.

So, choose carefully, because there may not be a do-over if you decide later you prefer a Medigap.

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Old 10-11-2018, 02:12 PM
 
86,028 posts, read 83,554,208 times
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That is such a great write up. I am copying it , it is a great explanation of things when ever someone needs know the differences
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Old 10-11-2018, 02:17 PM
 
Location: Charleston, SC
2,077 posts, read 1,186,027 times
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Thanks Ariadne. That's all good information.

I may switch over to a Medigap plan during next year's enrollment. This year, my Primary Doc is in the PPO network ($5 co-pay), and all my scripts are free. It's been pretty good for me over the last 4 years.

I just thought the gist of this tread was -- you shouldn't pay for Traditional Medicare if you're using Advantage.

Last edited by FiveLoaves; 10-11-2018 at 02:38 PM..
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Old 10-11-2018, 04:33 PM
 
Location: Wisconsin
23,578 posts, read 50,266,725 times
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Quote:
Originally Posted by FiveLoaves View Post
I just thought the gist of this tread was -- you shouldn't pay for Traditional Medicare if you're using Advantage.
Probably whoever posted that meant you don't need a Medigap if you are enrolled in Advantage. Both plans require enrollment in Medicare Parts A & B. Interestingly, it is illegal for a Medigap insurer to sell you a policy if you are enrolled in an Advantage plan. However, if you have a Medigap and then decide to enroll in Advantage, you can keep the Medigap. Of course, it won't pay - because all claims are now administered by the Advantage plan. But, you would avoid health underwriting for reenrollment in the Medigap if you later decided you wanted to leave Advantage.
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Old 10-11-2018, 04:58 PM
 
Location: Boca Raton, FL
5,813 posts, read 9,447,833 times
Reputation: 7805
Smile Very informative thread

Too bad it got moved.
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Old 10-11-2018, 05:19 PM
 
86,028 posts, read 83,554,208 times
Reputation: 61785
Quote:
Originally Posted by FiveLoaves View Post
Thanks Ariadne. That's all good information.

I may switch over to a Medigap plan during next year's enrollment. This year, my Primary Doc is in the PPO network ($5 co-pay), and all my scripts are free. It's been pretty good for me over the last 4 years.

I just thought the gist of this tread was -- you shouldn't pay for Traditional Medicare if you're using Advantage.
You may have health underwriting if you switch to medigap and can be refused
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Old 10-11-2018, 05:45 PM
 
Location: Charleston, SC
2,077 posts, read 1,186,027 times
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Quote:
Originally Posted by Ariadne22 View Post
Probably whoever posted that meant you don't need a Medigap if you are enrolled in Advantage. Both plans require enrollment in Medicare Parts A & B. Interestingly, it is illegal for a Medigap insurer to sell you a policy if you are enrolled in an Advantage plan. However, if you have a Medigap and then decide to enroll in Advantage, you can keep the Medigap. Of course, it won't pay - because all claims are now administered by the Advantage plan. But, you would avoid health underwriting for reenrollment in the Medigap if you later decided you wanted to leave Advantage.

I believe it was this post that caused me to ask the question. It was worded in a somewhat confusing way.....

Originally Posted by BBCjunkie
You either have traditional Medicare + a Part D policy, and then an extra Supplement plan if you want, OR you have an Advantage plan. It's an either/or thing on the consumer end.

Technically the Advantage plans are just a bundling of the three separate Medicare coverages (Part A, Part B, and Part D) under a single premium and with the difference that once the basic coverages are factored in, the bells and whistles (and restrictions) are up to the Advantage plan's insurance carrier.

In other words someone wouldn't be able to enroll in traditional Medicare and then "add" an Advantage plan on top of it.
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Old 10-11-2018, 07:06 PM
 
2,759 posts, read 1,244,074 times
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Sorry about that. :-( I didn't mean to muddy the waters. :-)

My use of the word "coverages" may have been the culprit. Back in the day I worked in the insurance industry, first as an underwriter and then in claims, and so I differentiate between "coverage" and "policy" out of habit. When I wrote "Medicare coverages" what I meant was that Advantage policy cannot offer less benefits than traditional Medicare does -- for example, if traditional Medicare covers a colonoscopy every X years, an Advantage plan must cover it that often as well. But the Advantage policy CAN put restrictions on where you can go to get that colonoscopy in order for them to pay for it.

I probably should have written it like this:

"You can have any one of the following combinations:

* Traditional Medicare Parts A and B; and a Part D drug plan
or
* Traditional Medicare Parts A and B; a Part D drug plan; and a Medigap supplement policy
or
* an Advantage plan"

But those are your only choices (for most people anyway.)
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Old 10-11-2018, 10:21 PM
 
Location: Paradise CA, that place on fire
1,329 posts, read 768,191 times
Reputation: 3666
My Humana Part D drug plan will jump next January from $ 20.40 to $ 29.90. That is a 46% increase. $ 358.80 a year. In addition, every time I get some pills there is a $ 8.00 copayment.
I added up my three medications, Atorvastatin, Atenolol and Tamsulosin at the HealthWarehouse.com website. My yearly total came to $ 186 including shipping. That is a fraction of the cost what I pay with Medicare and Humana.
HealthWarehouse is highly recommended by Consumer Reports. They operate in Kentucky and they don't need my Medicare number or Humana membership number, just a credit card or a check.

Point is, I can spend my own $ 186 or use Medicare and Humana and pay near $ 400; more than twice as much.
As much as I love our country, our health care, at least the insurance and billing part of it, is despicable.

I will cancel Humana, but it is a big hassle, and unless I get it done before the 7th of December, 2018, I will be forced to pay the $ 358 for the year 2019, even if I don't request a single pill from them.
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Old 10-11-2018, 11:29 PM
 
Location: Wisconsin
23,578 posts, read 50,266,725 times
Reputation: 18237
Have you used the Medicare tool to determine which plan is most cost-effective for you next year? No one should automatically renew their Part D plan without doing this homework. This decision needs to be revisited each year during Open Enrollment as insurers change formularies and copays often.

If there still is no good choice for you and if you want to keep minimal coverage in place to avoid a future penalty should you really need Part D coverage, switch to the lowest-cost Part D plan. If you do that on medicare.gov, you won't need to be calling Humana at all. You will be automatically disenrolled and enrolled in the new plan of your choice. Meanwhile, you can still buy your medication direct from whomever you choose.
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