Medicare Advantage

Former group plan insurance salesman explains Medicare Advantage – and covers all the stuff SHIP(*) is prohibited from telling you.

https://youtu.be/hrkbOjBtBsw

(*) State Health Insurance Program (SHIP) Medicare help for people confused with their choices.
https://www.shiphelp.org/

intercst

10 Likes

That video is from another reality. Factual information is equally weighted with spin and misstatements about original Medicare and Medicare Advantage.

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Well, you have to consider who posted it.

Everybody has to have a hobby-horse, I guess. He has his. Doesn’t mean we have to have the same one.

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When I retired I was in good health and I didn’t give medicare much thought. Hey! Here is a medicare plan that’s FREE! So I signed up with Health Net HMO and everything was just fine. I had my Primary Care Physician, and she would arrange referrals to specialists as needed. As I aged, I started to have a few relatively minor health issues. I had to go to my PCP and say “Mother May I?” before seeing a specialist. I finally got annoyed with the Health Net when they had to review every appointment and they would graciously send me to the Anointed One. So in 2020 I switched to Aetna’s HMO plan. Aetna was worse. They just hired Optum, another company, to handle every case. They have an army of “adjusters” whose job seem to be to delay or deny any service. So last year I switched to their PPO (Preferred Provider) plan. No improvement.

Last Fall I was diagnosed with cancer. It took two months to actually get any treatment. In the meantime, we moved to another county, and found a lot of providers were “Out of Network”, including the hospital at the University of California in Irvine, a serious medical teaching hospital. Guess what! If you are in an HMO you have to get “underwriting” to go to a Medicare Advantage plan. Intercst is right! It’s a roach motel. You can’t get out.

I went to an insurance broker who steered us to a secret back door. For the month of February Blue Shield would waive the underwriting requirement to switch to an advantage plan. I jumped at it. Once you are in an Advantage program there is a possibility to change companies in your birth month. So I will be leaving Blue Shield for a less expensive company soon, but still an Advantage plan. I am happy with this insurance broker.

I have got no bills from UCI for the (very expensive) radiology and chemo treatments I have been receiving. Yes, Blue Shield costs more than the HMO’s.

Intercst’s link is right on. I listened to all of it and it resonates to me.

CNC

16 Likes

CNC writes,

I went to an insurance broker who steered us to a secret back door. For the month of February Blue Shield would waive the underwriting requirement to switch to an advantage plan. I jumped at it. Once you are in an Advantage program there is a possibility to change companies in your birth month. So I will be leaving Blue Shield for a less expensive company soon, but still an Advantage plan. I am happy with this insurance broker.

I don’t know how secret this is. It looks like you got the Special Enrollment Period because you moved to a new area where your existing Medicare Advantage Provider had a substandard or no network of providers. But, of course, you have to move to another Medicare Advantage plan. You can’t get traditional Medicare plus a Medigap Plan without medical underwriting in California. Only CT, MA, ME, and NY allows you to buy a Medigap plan without underwriting after you’ve been in Medicare advantage for more than 12 months.

https://www.medicare.gov/sign-up-change-plans/when-can-i-joi…

https://www.kff.org/medicare/issue-brief/medigap-enrollment-…

intercst

5 Likes

intercst: I don’t know how secret this is. It looks like you got the Special Enrollment Period because you moved to a new area where your existing Medicare Advantage Provider had a substandard or no network of providers.

I don’t think so. Aetna was more than willing to continue my HMO plan in my new abode. Orange County has plenty of HMO’s. Is basically an appendage of LA County.

You can’t get traditional Medicare plus a Medigap Plan without medical underwriting in California.

Normally that’s true. I don’t know all the details, but Blue Shield let me in during the month of February.

I can go to any physician in the US who accepts medicare.

CNC

You can’t get traditional Medicare plus a Medigap Plan without medical underwriting in California.

Normally that’s true. I don’t know all the details, but Blue Shield let me in during the month of February.

You said you switched to a Blue Shield “advantage” plan, not Medigap. There isn’t any medical underwriting for switching from one advantage plan to another during a Special Enrollment Period.

Now if you really got a Medigap plan without underwriting, that would be a “secret deal”.

intercst

1 Like

My Medicare Advantage HMO plan doesn’t require referral to see specialists. Providors are required to obtain any pre-authorization when needed. I can move back to Medicare and get a supplement with the company through which I get my Advantage plan with no underwriting. I am responsible to make sure additional providors are in network, and if the Advantage plan doesn’t offer in network services, they will help me get the service at in-network prices. The video still feels like a con job for supplements
5

1 Like

5imple5 explains,

My Medicare Advantage HMO plan doesn’t require referral to see specialists. Providors are required to obtain any pre-authorization when needed. I can move back to Medicare and get a supplement with the company through which I get my Advantage plan with no underwriting. I am responsible to make sure additional providors are in network, and if the Advantage plan doesn’t offer in network services, they will help me get the service at in-network prices. The video still feels like a con job for supplements
5

That’s what I like about traditional Medicare. No “pre-authorization when needed”. I don’t have to worry about which providers are “in-network”. And I don’t have to spend my valuable time on the phone, “on hold”, with the insurance company.

And I know I’m getting the “medicare rate” for every procedure my doctor orders. Traditional Medicare has fantastic protections against out-of-network billing and price gouging.

It’s amazing how much simpler health care is when you don’t have a $20 million/yr health insurance CEO between you and your doctor.

intercst

8 Likes

Pretty much makes sense. I just signed up for original Medicare, so now I have to decide about a supplemental plan and a drug plan, if any.

I can’t think of any good reason to go with anything other than the cheapest version of each. I can change them next year if I find I’m paying too much out of pocket. I’m expecting a few hundred dollars per year in prescription drugs, and likely a few thousand in doctor visits and lab tests.

Am I getting this right?

-IGU-

ItsGoingUp

Pretty much makes sense. I just signed up for original Medicare, so now I have to decide about a supplemental plan and a drug plan, if any.

I can’t think of any good reason to go with anything other than the cheapest version of each. I can change them next year if I find I’m paying too much out of pocket. I’m expecting a few hundred dollars per year in prescription drugs, and likely a few thousand in doctor visits and lab tests.

Am I getting this right?

I think so. If you’re wealthy, you probably don’t need the Medigap plan. I’ve found the Part D drug plans to be mostly scams. I’m routinely buying and paying cash for the 3 generic meds I take for about 1/3 the price the insurance company would charge. And if I need an expensive drug in the future, there’s no way to predict if it’s in the formulary for my current Part D plan. I may still pay through the nose for it even though I have “insurance”.

I went though a whole analysis on this a while back.

What I’m doing for Medicare insurance at age 65
https://retireearlyhomepage.com/medicare2020.html

That “Dr. Belk” article cited was a real eye opener. The biggest lie in Medicare Advantage sales & marketing is “the 20% Medicare doesn’t cover.” That’s true for doctor visits, x-rays, and outpatient tests. But if you get sick, your biggest charge is likely to be the hospital bill. And under traditional Medicare, your piece of a $1 million hospital bill is just $1,556 for 2022 – that’s 0.15%, not 20.00%.

intercst

6 Likes

5imple5: “My Medicare Advantage HMO plan doesn’t require referral to see specialists. Providers are required to obtain any pre-authorization when needed. I can move back to Medicare and get a supplement with the company through which I get my Advantage plan with no underwriting. I am responsible to make sure additional providers are in network, and if the Advantage plan doesn’t offer in network services, they will help me get the service at in-network prices. The video still feels like a con job for supplements.”

Will you share the name of this great Medicare Advantage HMO Plan?

Not Medicare, but that is not my experience with HMOs.

Regards, JAFO

7 Likes

intercst: You said you switched to a Blue Shield “advantage” plan, not Medigap. There isn’t any medical underwriting for switching from one advantage plan to another during a Special Enrollment Period.

Now if you really got a Medigap plan without underwriting, that would be a “secret deal”.

I must admit to ignorance about the distinction between “Medigap” and an “advantage” plan. So, I went to wiki (as usual): https://en.wikipedia.org/wiki/Medigap

Medigap (also called Medicare supplement insurance or Medicare supplemental insurance) refers to various private health insurance plans sold to supplement Medicare in the United States. Medigap insurance provides coverage for many of the co-pays and some of the co-insurance related to Medicare-covered hospital, skilled nursing facility, home health care, ambulance, durable medical equipment, and doctor charges. Medigap’s name is derived from the notion that it exists to cover the difference or “gap” between the expenses reimbursed to providers by Medicare Parts A and B for the preceding named services and the total amount allowed to be charged for those services by the United States Centers for Medicare and Medicaid Services (CMS).

Medigap offerings have been standardized by the Centers for Medicare and Medicaid Services (CMS) into ten different plans, labeled A through N, sold and administered by private companies.

The terms seem to be interchangesble?

I see that I have a Plan G. (I haven’t discovered an explanation of the various distinctions.)

Costs

Costs for Medicare Supplement insurance vary widely. The 2020 Medigap Price Index found that someone turning 65 could pay more than three times more for virtually identical coverage. Among the top-10 metro areas, the lowest cost for a male age 65 was $109-per-month available in Dallas. The highest cost was $509-per-month in Philadelphia.

I pay $300 a month. My HMO was “Free” (and worth every penny.)

CNC

me: I see that I have a Plan G. (I haven’t discovered an explanation of the various distinctions.)

https://www.medicare.gov/supplements-other-insurance/how-to-…

Part G does not cover Part B deductible.

CNC

Plan G is a Medigap plan, but $300/month is a hefty premium. I’m paying $44/month for my Plan G. And note, by law all Plan G’s cover the same stuff. The $300 plan doesn’t offer anything extra vs. the $200/month plan.

The State of California has a Medigap premium comparison tool.

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=111…

It looks like CA increases premiums with age. In WA everyone pays the same Medigap premium whether they’re 65 or 90.

Medigap and Medicare Advantage are not interchangable, they are two entirely separate programs with their own rules.

Medigap just pays the Medicare deductibles and co-pays, and leaves your traditional Medicare coverage in place and untainted.

With Medicare Advantage, the whole $12,000 or so value of your traditional Medicare coverage is transferred to the for-profit health insurer you chose and Medicare washes it’s hands of you. You answer to your for-profit health insurer who is allowed to skim off up to 15% of that $12,000 in for-profit insurance bureaucracy and excessive Executive Compensation.

intercst

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Part G does not cover Part B deductible.

The Part B deductible for 2022 is $233.

People got upset that Medicare folks were getting first dollar health coverage if they had a Medigap plan, while working folks were getting screwed up the wazoo with their private, employer-based health plans. So Congress changed the rules a few years ago so that you at least paid the Part D deductible. Older folks who had the deductible covered under their existing Medigap plan were grandfathered-in and didn’t see a change.

intercst

So Congress changed the rules a few years ago so that you at least paid the Part D deductible**.**

That should be “Part B deductible”.

intercst

Plan G is a Medigap plan, but $300/month is a hefty premium. I’m paying $44/month for my Plan G. And note, by law all Plan G’s cover the same stuff. The $300 plan doesn’t offer anything extra vs. the $200/month plan.

We can change the medigap plan in our birth month. I have already lined up another (less expensive) company, so I will be changing, with a “Thank You” and a tip of my hat to Blue Shield.

CNC

CNC,

I just found this.

California Medigap Birthday Rule
https://www.medicarefaq.com/medicare-supplements/medigap-by-…

The California birthday rule only applies if you already have a Medicare Supplement plan in California. When using the rule, beneficiaries can change their Medigap plan to one of equal or lesser benefits.

However, you may not change to a plan with more benefits than your current plan. This means you can go from a Medigap Plan G to a Medigap Plan N, or from a Medigap Plan N with one carrier to a Medigap Plan N with another carrier at a lower rate, but cannot switch from a Medigap Plan G to a Medigap Plan F.

Keep in mind, this rule only applies to those already on a Medicare Supplement plan. It does not apply to beneficiaries with Medicare Advantage plan who wish to switch to a Medicare Supplement. [i.e., Medigap]

It’s still unclear to me how you switched from Medicare Advantage to Medigap without undergoing medical underwriting unless there is some other California-specific loophole out there. The “Birthday Rule” won’t do it.

intercst

1 Like

It’s still unclear to me how you switched from Medicare Advantage to Medigap without undergoing medical underwriting unless there is some other California-specific loophole out there. The “Birthday Rule” won’t do it.

intercst

It’s not clear to me either, but “Thank You, Blue Shield”. This is apparently unique to Blue Shield, and it was limited to the month of February.

The Countess has been with Blue Shield ever since she went on Medicare.