How does Medicare Advantage plan differ from the Original Medicare i.e. Part A and Part B? (medical, hospital)
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We live in Arizona, and one of the insurance companies that was referred to me is edited out URL.As I'm planning to buy a Medicare Insurance plan for my Dad next month and I need to clear few of the basics. I am on with the research work but still confused which one will be best for him.
What is Medicare or as we call it Original Medicare? Could someone please me with the various services covered in Medicare Part A and Part B?
Last edited by in_newengland; 11-16-2018 at 08:26 PM..
Reason: Grammar Error
Medicare Advantage plans are managed plans, you go to docs and hospitals only in the plan and there are gatekeepers. My moms plan tried to cut her after a week of rehab and we had to appeal, got two more weeks approved and she still had thousands in copays. It wouldn’t even pay for her ambulance we had to pay $500 for that.
Regular Medicare allows you to see any doc that accepts Medicare. They pay 100% of the first 20 days of rehab and 80% of days 21-100 if you need them. That’s where the supplemental comes in. They pick up the 20% Medicare doesn’t. With both you won’t have copays for anything. Advantage plans sound cheaper but only till you get sick. Then you will be billed a lot.i switched my mom as soon as open enrollment came.
I’ve worked in skilled nursing home rehab for 20 years. I’ve treated stroke patients with traditional Medicare who walk out after 85 days of rehab, and we’ve sent other stroke patients home at a wheelchair level because their Advantage plan cut them after 21 days. If you can swing g the supplemental, traditional is much better.
Medicare B covers outpatient services, home therapy if you didn’t have the three day hospital stay required for Med A services, and will cover more therapy if you use up your 100 days (happens sometimes, person uses up days, goes home and breaks a hip a week later). It won’t pay for your room though only therapy. B also pays for equipment such as commode, walker, wheelchair, hospital bed.
Some of the above is true, some is not.
Go to www.medicare.gov and put in your Dad's zip code to see all the plans available to him in his area. I have an advantage plan and always have. (I am in AZ). There are many choices depending on where you live in AZ.
Some of the above is true, some is not.
Go to www.medicare.gov and put in your Dad's zip code to see all the plans available to him in his area. I have an advantage plan and always have. (I am in AZ). There are many choices depending on where you live in AZ.
What is not true? ocnjgirl recited her personal experience on the East Coast. Mom was originally in PA, I believe, had BCBS Advantage, moved to NJ and was able to get a supplement. Normally, that could be problematic for someone w/preexisting conditions but mom did move out of her plan's service area so was eligible for a Medigap without health underwriting. See #1:
Your personal experience with your particular Advantage insurer in Arizona may have not been problematic, but there are enough reports over the years, including in my local newspaper and lawsuits filed in MN b/c Humana didn't perform, that not all Advantage plans perform ethically, copays can become a real burden, treatment approval problematic, provider networks an issue.
Another case cited numerous time by Mathjak:
Quote:
in the case above i mentioned the doctors said medicare always pays to remove both haves of the pituitary gland if one side is cancerous . the advantage plan gate keepers denied both halves and only approved the 1/2 .
That said for some reason area of country matters. Many in AZ do have Advantage and have reported they are satisfied. Otoh, we have a NY poster who left Advantage in favor of a Medigap because she developed issues and the Advantage ended up being far more expensive. Fortunately, in NY, a guaranteed-issue state, one can switch from one to the other without health underwriting. Her health has improved and she's now back on Advantage, I believe.
In the end, Advantage plans are all about their bottom line. They are for-profit insurers. Advantage plans are huge cash cows for the insurers. The profit motive provides a strong incentive to "manage" care.
If OP's dad has ailments, or the prospect of chronic ailments, a Medigap G is best if he can afford it. He can then see any Medicare provider anywhere, no gatekeepers on treatment other than Medicare itself which is a whole lot less problematic than an Advantage plan.
My summary on this issue:
Quote:
Originally Posted by Ariadne22
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 -
your health
your need/desire for doctor/provider flexibility
your ability to pay Medigap (and Part D) premiums
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 $2,300 in 2019, 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 $2,300. Thereafter, the Medigap pays 100%.
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:
copays and max out-of-pockets, especially if you're sick or anticipate health issues.
restricted networks - an issue if you need specialty care or if you travel a lot.
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.
Last edited by Ariadne22; 11-16-2018 at 05:05 PM..
What is not true? ocnjgirl recited her personal experience on the East Coast. Mom was originally in PA, I believe, had BCBS Advantage, moved to NJ and was able to get a supplement. Normally, that could be problematic for someone w/preexisting conditions but mom did move out of her plan's service area so was eligible for a Medigap without health underwriting. See #1:
Your personal experience with your particular Advantage insurer in Arizona may have not been problematic, but there are enough reports over the years, including in my local newspaper and lawsuits filed in MN b/c Humana didn't perform, that not all Advantage plans perform ethically, copays can become a real burden, treatment approval problematic, provider networks an issue.
Another case cited numerous time by Mathjak:
That said for some reason area of country matters. Many in AZ do have Advantage and have reported they are satisfied. Otoh, we have a NY poster who left Advantage in favor of a Medigap because she developed issues and the Advantage ended up being far more expensive. Fortunately, in NY, a guaranteed-issue state, one can switch from one to the other without health underwriting. Her health has improved and she's now back on Advantage, I believe.
In the end, Advantage plans are all about their bottom line. They are for-profit insurers. Advantage plans are huge cash cows for the insurers. The profit motive provides a strong incentive to "manage" care.
If OP's dad has ailments, or the prospect of chronic ailments, a Medigap G is best if he can afford it. He can then see any Medicare provider anywhere, no gatekeepers on treatment other than Medicare itself which is a whole lot less problematic than an Advantage plan.
My summary on this issue:
I’m glad you brought up the State issue, I had forgotten that! Advantage plans are all state-specific. If you live in NJ and get sick in Michigan, only ER will be covered.
I had to rescue my mom without much notice when she was in rehab. She got cut on Friday and I had to go get her Saturday. She was not good enough on stairs to go home so I took her to Jersey with me. My plan was to get her into a respite room at the ALF I worked in while we looked for a permanent solution (I lived in a second story one bedroom apartment). I couldn’t get her in until she got a physical and a Dr cert that she was okay for ALF.
I called Blue Cross thinking I could just switch her to a NJ Blue Cross Plan, but they all operate separately. They said I had to disenrolll her from PA Blue Cross and then call NJ Blue Cross and apply. So we had a nerve wracking few weeks with no plan, then a plan but no card, and I ended up private paying for her ALF exam.
We live in Arizona, and one of the insurance companies that was referred to me is . As I'm planning to buy a Medicare Insurance plan for my Dad next month and I need to clear few of the basics. I am on with the research work but still confused which one will be best for him.
What is Medicare or as we call it Original Medicare? Could someone please me with the various services covered in Medicare Part A and Part B?
FYI I just bought Medicare 2019 for Dummies from Amazon...
Last edited by in_newengland; 11-16-2018 at 08:28 PM..
FYI I just bought Medicare 2019 for Dummies from Amazon...
The Dummies books are great, thanks for mentioning this one!
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