OT: Medicare Advantage Plans

[Pugsy]

CPAP is covered under Part B, which seems a bit weird to me.

CPAP equipment falls under the durable medical equipment classification...along with wheelchairs, walkers and the like.
All durable medical equipment falls under Part B.
Actually pretty much everything outside of the hospital falls under Part B.
Any goods or services received outside the hospital is under Part B. Doctor office visits...out patient surgery procedures even if done in a hospital (which is totally weird to me).
If you aren't formally admitted to the hospital..it's a Part B expense.

[Okie bipap]

When I had my minor heart problem (AFIB) last year, I was never formally admitted to the hospital. I was ther for "observation" only, so it was covered under Part B. Since I was not admitted, they could not charge Medicare for any medications given to me, so they were provided free. I'm sure they charged enough for the other stuff to cover the cost of medicattions.

[Janknitz]

Advantage plans vary by state AND locality within the state.

Be very, very careful! The information is confusing, but here's the scoop from https://www.medicareresources.org/faqs/ ... -medicare/

Q: Can I switch between Medicare Advantage and Original Medicare?
A: Medicare open enrollment occurs each fall, from October 15 to December 7. During that time, you can switch from Original Medicare to Medicare Advantage, or vice versa. If you are already enrolled in a Medicare Advantage plan, you can drop it and enroll in Original Medicare and a Part D plan during open enrollment, with coverage effective January 1.

And between January 1 and March 31 each year, if you are enrolled in a Medicare Advantage plan, you can decide to leave your plan and return to Original Medicare (and purchase a Part D plan to supplement your Original Medicare coverage), OR you can switch to a different Medicare Advantage plan. (This option became available as of 2019; prior to that, there wasn’t an option to switch from one Medicare Advantage plan to another in the first part of the year).

There are also some circumstances in which you’ll have a special enrollment right that will allow you to switch from Medicare Advantage to Original Medicare or enroll for the first time.

See the words in bold??? Oh, no problem, I just switch plans during open enrollment.

Not so fast.

You can switch from an Advantage plan to

Original Medicare coverage

. That does NOT mean you can get a supplemental Medi-Gap plan in all states (you can in SOME states). It only means that you have original Medicare and you pay your own 20% co-pays and deductibles (which MAY be OK if you don't have major expenses). To get a Medi-Gap supplement, as Chunky points out, you have to be underwritten, and that can cost a lot, or insurers may not agree to cover you at all.

So you need to be very, very sure before going for an Advantage plan. Use your state's SHIP/HICAP program to help you understand the details.

Pay attention to the details of the Advantage plan, not just CPAP coverage as a perpetual rental vs. capped rental. If it will only cover doctors on the plan, are your favored doctors providers? Do they intend to remain providers indefinitely? Are the drugs you take or may have to take in the future (get out your crystal ball!) covered on their formulary? What are there tiers for co-payments on the medications you take? Does your area REALLY have providers willing to take on new patients? One employer gave us an HMO type of dental plan that sounded OK until we found that NONE of the dentists listed in our local area as providers would take new patients on that plan. Essentially we were paying for a share of dental plan we could not use.

If it's a self-contained HMO like Kaiser or Humana you are stuck with their doctors, providers, hospitals, pharmacies, laboratories, etc. With certain very limited exceptions, there's NO going outside their systems. I have to travel all the way across town in morning rush hour traffic for fasting labs because of this, while there is a Lab Corp AND a Pharmacy right across the parking lot from my office (I can't use either). And if you travel for extended periods outside of their service area it's a pain. For certain issues, HMO's can do a good job, but I always fear someone in the family will develop a cancer that needs a medication outside of the Kaiser formulary or a doctor with expertise that Kaiser doesn't have.

I recently lost a dear friend to cancer (not Kaiser) and her insurance company dictated that she had to receive a certain chemotherapy agent her doctor advised against in order to get coverage for the recommended treatments, and the side effects caused her needless suffering (still so very angry about this!!!!). But I can see an HMO like Kaiser saying "we won't pay for treatment not on our formulary until you first fail our formulary treatment", costing valuable time and much suffering. The stuff of nightmares!!! I don't know how you check that out in advance without said crystal ball, though.

In any case, Advantage plans CAN be a good deal for some. My very healthy husband loves his Advantage plan because it's inexpensive, gave him a free gym membership (when people were allowed to go a gym), paid a portion of his glasses and will cover a small part of his new hearing aids. For him it makes sense. I still have time to decide if I'm going to keep Kaiser when I go on Medicare, and I'm not sure at this point (though Kaiser has gotten so much of the marketshare here that there are almost no private providers left).

[Sheriff Buford]

From my heart, I thank you guys for your responses. I foolishly spent 1 1/2 hours on the phone yesterday with Social security. I was trying to set up an account with Medicare and they wanted my Medicare number. The place where I was trying to set up the account stated that I could find it in my social security account. The social security lady didn't ask me when I was going to turn 65 (next March). I was going on the advise to sign up 6 months before I turn 65. I/m beginning to think that was bad advise and a ploy to get me talking to an insurance agent. I'm gonna need to figure out how to look at specific policies and prices without be hounded with phone calls.

Sheriff

[chunkyfrog]

First time on the phone, I selected a lookalike site, and was shunted straight to an agent.
Instead of answering my question, she started asking for MY information.
I stopped her, with "If you can't answer MY question, we are through talking."
She hung up.

[LSAT]

From my heart, I thank you guys for your responses. I foolishly spent 1 1/2 hours on the phone yesterday with Social security. I was trying to set up an account with Medicare and they wanted my Medicare number. The place where I was trying to set up the account stated that I could find it in my social security account. The social security lady didn't ask me when I was going to turn 65 (next March). I was going on the advise to sign up 6 months before I turn 65. I/m beginning to think that was bad advise and a ploy to get me talking to an insurance agent. I'm gonna need to figure out how to look at specific policies and prices without be hounded with phone calls.

Sheriff

What's your concern with talking to an agent. Many of them specialize in Medicare and different Medicare Plans. They can review your health history and Meds and pick the plan that suits you well....Some plans may not cover your Meds... Some have co pays..others do not...Some are complicated..You are better off NOT trying to do it yourself. The price on these plans are the same no matter who you buy them from.

[chunkyfrog]

I respectfully disagree.
Agents are salespeople, and only offer a limited selection of plans.
Your own state's senior health information department will offer free, UNBIASED evaluation
to help direct you to the best plan--for you.
My state has SHIIP--it may go by another name in your state.

[ElusiveSleep]

I have UHC Advantage Plan through my previous employer. It is an excellent plan with low deductible and copays, and annual premium of $500.

Items for PAP machine are replaced periodically according to Medicare rules, but plan does not give you ownership of machine after 13 months.

Since my coverage just started, too early to decide if buying PAP machine is worthwhile.

[chunkyfrog]

. . . plan does not give you ownership of machine after 13 months. . . .

Just do the math.
Most machines are more than paid for at 13 months.
The rest is maintenance--if you use it.
If you use a machine for 5 years, times your 20% of the "rental" . . .
Your payments would be small--but never-ending.
Look at the bottom line, or what you can afford.
Or buy secondhand . . .

[prodigyplace]

From my heart, I thank you guys for your responses. I foolishly spent 1 1/2 hours on the phone yesterday with Social security. I was trying to set up an account with Medicare and they wanted my Medicare number. The place where I was trying to set up the account stated that I could find it in my social security account. The social security lady didn't ask me when I was going to turn 65 (next March). I was going on the advise to sign up 6 months before I turn 65. I/m beginning to think that was bad advise and a ploy to get me talking to an insurance agent. I'm gonna need to figure out how to look at specific policies and prices without be hounded with phone calls.

Sheriff

I went through that late last year. 3 months prior is correct.

[Pugsy]

I'm gonna need to figure out how to look at specific policies and prices without be hounded with phone calls.

Yeah...that's what you have to do unless you can find an agent who has your financial well being ahead of his own and can sell either the supplement to traditional medicare or the advantage plans....and they are hard to find. Guess how insurance agents make money...they get a percentage of the annual premium you pay the first year and that's when they make the biggest chunk of money. Renewals are pennies on the dollar compared to that first year check they get. Now I don't know what the percentage is now as it likely has changed over the years since I sold medicare supplement plans but it was a sweet deal back when I sold them...around 45% the first year and renewals dropped to maybe 5%. Back when I sold insurance there weren't many advantage plans but now agents can sell both and there are tons out there to choose from depending on where you live. More rules now about agents and restrictions on what happens when people want to change something. I haven't kept up with those but there are rules agents have to follow...lots of them so that Medicare folks don't get screwed by agents.
Obviously when you get a big chunk of a first sale...you want the biggest chunk possible so you want the biggest annual premium possible when selling insurance is how you put food on the table and money in the bank. The traditional supplements costs more each month than advantage plans...cold hard fact of life.
A lot of not so honest agents are out there unfortunately. They will not always explain the options fully because they are either lazy, stupid or greedy.

Advantage plans are cheaper because the patient is assuming some of the risk out of pocket and traditional supplements pretty much tell you that the only thing you will ever have to pay (depending on the plan you select) is X amount of dollars for the monthly premium.
The biggest risk out of pocket with the advantage plans is the cost if a hospital stay is needed but even then there are max out of pocket limits (and they vary with each advantage plan) vs the traditional supplement paying the deductible for you and the sometimes 20% of medicare Part B expenses that are high. Like a doctor's fee for a surgery or a 20% surgery facility fee that falls under part B.

If I were to have to be hospitalized there is a set amount for each day that I would have to pay...up to a total amount which I think is around 3,750 per year max. If I have a procedure done at a surgery center it's a flat 200 that I pay per procedure....no limits either. That 200 is still a lot better than a 20% of part B allowed though.. As long as I don't have a bunch of out patient procedures done...I won't have much out of pocket costs. The most I had one year was when I was having the SI joint injection thing where I had to have the lidocaine trial injection prior to getting approval for the RFA nerve burning procedure...3 visits...600 total out of pocket...2 for the trials and 1 for the RFA. Yes I could have had a supplement pay for the 20% and avoided the 600 out of my pocket but even if the supplement cost me 100 a month (which I know they would cost a lot more than that) that would have been 1200 out of pocket for the year. I still saved money....it's a for sure pay the 1200 or maybe pay the 600 kind of thing. If I hadn't needed the procedures I would have saved even more. This is where the risk comes into play...do you want to assume some risk and maybe pay later or just pay up front so you won't have to worry about it.

That's where a patient's overall health comes into play....If someone is basically healthy and there's not much chance of hospital stays or procedures in the future...there won't be much out of pocket. You can either pay X amount of dollars every month for a traditional supplement for sure...or maybe pay some out of pocket expense later. It all depends on how much of the risk you want to assume that you are comfortable accepting.

Medicare doesn't pay everything...even part A which is the hospital coverage has a deductible and it isn't an annual deductible..it's a per hospital stay deductible unless you are re-hospitalized within a certain time frame (I forget the time frame but it used to be 60 days but that might have changed) AND it's for the same condition within that time frame. If you are sick with the flu and hospitalized 4 days you have a 1,408 deductible and next month you have a stroke...that's another 1,408 deductible. There is a potential for a lot of deductibles and that's why we have supplements.

Even Part B has a deductible but at least it's an annual deductible before Medicare starts paying it's 80% and your portion is 20 %.

It does take a lot of work for the patient to learn about the plans and the risks and what Medicare will and won't pay for....and then what the supplements cover and what they don't cover....and compare that to the advantage plans.

The year I broke my wrist...probably my biggest out of pocket expense year because it required surgical pinning....
I added up my costs....Between the ER out of pocket cost $65 and the doctor office visits (first was to try to set it in the office which failed) and the surgery center cost when it had to be fixed with pins....my total out of pocket was less than 800. Still far less than a supplement would have cost me that year just to have it pay so I didn't pay that 800. If I hadn't done something stupid and climbed on something I shouldn't have and fell and broke my wrist I wouldn't have been out that 800.

Now the advantage plans tout all those little things they say that Medicare doesn't pay for....like it's a big deal...like for glasses and stuff like that....watch those carefully as there are limits to what they pay. I call them "fluff" to lure people. Mine says it pays dental but when you look at the fine print...there's a 35 deductible with each dental visit before it pays for any dental stuff and it as a max yearly of something around 250 dollars...it's not going to be a good dental plan if you have a big expense...but it is better than nothing which is what you get with Medicare and a supplement. With a supplement if Medicare doesn't pay anything...the supplement won't pay anything unless you get one of the higher plans that has some extra coverage and guess what...they cost more per month as well. You are paying for that extra coverage up front to maybe use it later.
Same thing with glasses....look at the fine print...they don't pay the full amount...it's a portion but again it's better than nothing.

Janknitz husband's advantage plan...comes with a gym membership...I got to looking and so does mine but it would involve my driving into Springfield which is an hour drive one way and deal with all that traffic and that isn't going to happen even if we weren't in the middle of all this Covid mess. So worthless to me but if I lived a block from the facility....might be a nice perk.

Now for me to get a supplement plan...it could be done but it would cost me more than it would someone like our Sheriff here because I went on Medicare prior to age 65 which opens up a whole new can of worms which I talked about in another thread in detail but even if it didn't...I save money having the advantage plan. I am basically healthy except for doing stupid things like climbing on a rickety old bench and have some back and arthritis issues. I am willing to take the risk of maybe paying out of pocket later for something and I have reviewed the plan and I know how much I would be expected to pay should that happen. It's a risk I am willing to take to not pay a monthly premium and not have to get a separate part D plan for my meds.

Not everyone is willing or can accept that risk. I understand that and those people probably will do better with the traditional supplement plan of their choice. Yes...it does take some work figuring out how much risk you might be taking but it can be done.
I am fortunate in that my prior business partner (when I sold insurance) is still in the business and we are good friends and he keeps me up on what works best for me and any changes that might impact my risk significantly. I don't have to do much work and with my prior business I had a good basic knowledge of how Medicare works so it made my own education a bit easier.

There are pros and cons to both choices...each person has to decide which is more important to them and how much risk they can comfortably assume. If someone is like me and basically healthy...they can save a lot of money with an advantage plan of some sort.
Now obviously if there is some significant medical history involved or current expensive treatment of some sort (like chemo therapy) then the person needs to look extra close at that risk.
And this all can vary widely by state or even county....ChunkyFrog has a history of cancer but in her state it isn't so easy to play around with supplements and advantage plans because in her area there is medical underwriting involved. Where I live the only real health question for anything is the "are you in end stage kidney failure" question. Duh...if I was in end stage kidney failure and on dialysis I wouldn't be changing insurance.

Gotta do our homework folks. PITA I know but you gotta do it.
If you don't want to do any homework and don't need to or care about saving money and just want to pay for your insurance and know that is all you ever have to pay each month....get a traditional plan that covers all the deductibles and be done with it.

[zonker]

From my heart, I thank you guys for your responses. I foolishly spent 1 1/2 hours on the phone yesterday with Social security. I was trying to set up an account with Medicare and they wanted my Medicare number.

don't worry, it's happened to me too.

also, not sure if this is the same in every state, but in washington state, you have one place for drivers license and another for license PLATES. when i first moved here from indiana, i spent two hours waiting in the wrong building!

[LSAT]

Every year the US Government puts out a booklet called MEDICARE AND YOU. It describes Medicare Benefits and in the back lists and describes all the different plans available in your area.

[Sheriff Buford]

Gulp! Thank you Pugs! Thanks to all of you for your input! Your charity is also why I've stuck around.... to give back. My body has been through a lot. Partly from my own doing and for the profession I was in for so many years. Plus, both my parent's health went south after they got older, so if it is hereditary, I sorta know what my future holds. After a break from all this, I will check out both plans. I plan to make a list of questions, then go to the Medicare web site and see if they are answered. If not, then I will call them once the list of questions get long enough.... to justify the wait. I see that I have more time. December, verses September.

Thanks, again.

Sheriff

[Pugsy]

Sheriff...you do have time and it's not really all that difficult to learn once you learn the basics...it's the basics as to what is or isn't covered and what is or isn't your responsibility that is the difficult part IMHO. Once you understand the basics then figuring out which plan or supplement is best option for you...isn't all that difficult because you will understand the terminology better.

Get with me privately and if you can get some more specifics about the various advantage plans available to you that look interesting to you....I can review them and explain things better once I see plan specifics if you are having trouble wrapping your head around things.
While I am a bit lazy and let my friend do the work...I can still do it for the most part. I still have a decent grasp on the basics.
I would be happy to try to help you sort through it and teach you what to look for so you can make a more informed choice as to which way to go is going to suit your needs the best.

The first basic you need to learn....what Medicare covers and doesn't and how it works and what your responsibility might be.