coinsurance with Medicare Advantage (Part C) plans, and other associated questions

Non-investing personal finance issues including insurance, credit, real estate, taxes, employment and legal issues such as trusts and wills.
Post Reply
Topic Author
protagonist
Posts: 9277
Joined: Sun Dec 26, 2010 11:47 am

coinsurance with Medicare Advantage (Part C) plans, and other associated questions

Post by protagonist »

How does coinsurance with Medicare advantage plans work?

For example, this plan charges "45% coinsurance" for a number of out-of-network services (e.g.: MRI). https://www.medicare.gov/plan-compare/# ... 2#overview

Medicare part B typically charges 20% co-insurance.

Question 1: So if one has this plan does "45% coinsurance" mean that one pays 45% of the 20% that basic Medicare (Parts A+B) does not cover, or 45% of the total bill?

Question 2: Also, when, for example, they claim to pay "45% per stay" in an out-of-network hospital, is that 45% of the total hospital bill or just 45% of what is not covered by basic Medicare (covered by Parts A+B)?

Question 3: And when they claim a maximum annual in and out of network bill of $6700, does that include all medical services, so you are guaranteed to never pay more than $6700/year for total health care, in or out of network?
sobogled
Posts: 37
Joined: Wed Apr 13, 2022 3:11 pm

Re: coinsurance with Medicare Advantage (Part C) plans, and other associated questions

Post by sobogled »

The part C option replaces A/B, so these aren't incremental like a supplemental plan. What's stated in the part C plan is your plan and coverage.

So for #1 and #2, yes it would be 45% of the total bill.

And #3, yes. So while 45% OON is a steep charge, you have cap on your risk.

Note on all of this: Part D is still separate, unless you select a MA + PD plan, so when we talk health care here we mean not pharmacy.
Topic Author
protagonist
Posts: 9277
Joined: Sun Dec 26, 2010 11:47 am

Re: coinsurance with Medicare Advantage (Part C) plans, and other associated questions

Post by protagonist »

sobogled wrote: Thu Aug 11, 2022 1:01 pm The part C option replaces A/B, so these aren't incremental like a supplemental plan. What's stated in the part C plan is your plan and coverage.

So for #1 and #2, yes it would be 45% of the total bill.

And #3, yes. So while 45% OON is a steep charge, you have cap on your risk.

Note on all of this: Part D is still separate, unless you select a MA + PD plan, so when we talk health care here we mean not pharmacy.
Ah, so pharmacy does not contribute to the cap at $6700 with the Advantage plan?

If I go with a conventional plan, A plus B plus D plus supplemental, the premiums would run about $2500/year plus $170/mo. for part B.
If I go with the Advantage plan I would pay nothing in premiums on top of the part B charge, but I could wind up easily spending $6700 in a year on top of my part B premiums if I got sick and had to go out of network. The Advantage plan would also reimburse me for routine dental, eye exams and a little bit for health club membership.

Tough decision, since I am a "snowbird" and thus may find myself out of network. I can afford $6700 if I need to, and I believe that Mass. is unique in that they would let me switch to a supplemental plan any time during an enrollment period, so if I found myself with a chronic health problem in the future I could potentially limit my max. liability to one year.

A lot to think about.....
runninginvestor
Posts: 1796
Joined: Tue Sep 08, 2020 8:00 pm

Re: coinsurance with Medicare Advantage (Part C) plans, and other associated questions

Post by runninginvestor »

The link you provided doesn't work, and at least it doesn't appear so for me. If you felt comfortable, you could always share the plan ID you are considering. But that can narrow you down to a certain number of counties if anonymity is a concern.

One thing to look at, is if the plan has a travel benefit. For instance, I've been on Aetna and Humana plans that allow you to see any of their doctors nationwide. So traveling really hasn't been an issue. Even with the Medicare advantage, you will likely have to pay the Medicare part b premium. I've only seen a few plans that will have a Medicare give back option, where they give a portion of your premium back. Dental insurance is typically a wash if you just get cleanings every year. It's kind of like prepaying for the basic preventive services. Silver sneakers gym membership doesn't get you into any of the really good gyms. Other than the YMCA, I don't know if I've ever seen a gym with a pool that covers silver sneakers. But your mileage may vary.

All of that is saying, the extra benefits that come with Medicare advantage plans can be helpful, but they also come with limits.
sport
Posts: 12094
Joined: Tue Feb 27, 2007 2:26 pm
Location: Cleveland, OH

Re: coinsurance with Medicare Advantage (Part C) plans, and other associated questions

Post by sport »

For my MA plan, the provider submits a claim for the full rate. The plan allows the Medicare allowed amount which is generally a lot less. Then the plan pays its percentage of the allowed amount and I pay the remaining percentage. My plan is an expensive one. However, after a $150 deductible for in-network, the plan pays 96% and I pay 4% with a maximum OOP of $1500 for in-network claims. The numbers are higher for out-of-network. My premium is about $350/month.
Topic Author
protagonist
Posts: 9277
Joined: Sun Dec 26, 2010 11:47 am

Re: coinsurance with Medicare Advantage (Part C) plans, and other associated questions

Post by protagonist »

runninginvestor wrote: Thu Aug 11, 2022 9:58 pm The link you provided doesn't work, and at least it doesn't appear so for me. If you felt comfortable, you could always share the plan ID you are considering. But that can narrow you down to a certain number of counties if anonymity is a concern.

One thing to look at, is if the plan has a travel benefit. For instance, I've been on Aetna and Humana plans that allow you to see any of their doctors nationwide. So traveling really hasn't been an issue. Even with the Medicare advantage, you will likely have to pay the Medicare part b premium. I've only seen a few plans that will have a Medicare give back option, where they give a portion of your premium back. Dental insurance is typically a wash if you just get cleanings every year. It's kind of like prepaying for the basic preventive services. Silver sneakers gym membership doesn't get you into any of the really good gyms. Other than the YMCA, I don't know if I've ever seen a gym with a pool that covers silver sneakers. But your mileage may vary.

All of that is saying, the extra benefits that come with Medicare advantage plans can be helpful, but they also come with limits.
I agree.
I currently have the Tufts Preferred Medicare Basic HMO plan that costs $45/mo. They do have good travel benefits. But we bought a place in FL last year and are now snowbirds. Though I have received emergency services in FL covered by Tufts, there are limits and out-of-network services are not capped. So I am considering either switching to a supplemental plan plus part D drug coverage, or another Advantage plan that is a PPO rather than an HMO and caps out-of-network expenses.

The one that I tried linking to was Aetna Medicare Explorer Plan (PPO)
Aetna Medicare | Plan ID: H5521-160-0 . Maybe this link will work. https://www.medicare.gov/plan-compare/# ... =en&page=1

I picked that one more or less randomly among 3 or 4 similar plans, just to get an idea. My drug costs are currently pretty trivial....a few hundred dollars per year I suppose.

All of the doctors that I see in Mass. and my local hospitals accept the Tufts plan....I wonder if they would also accept Aetna. I also wonder whether my chosen doctors in FL (St. Petersburg area) would be considered "in network" or "out of network" if I bought the plan in Mass (I am a MA resident).
runninginvestor
Posts: 1796
Joined: Tue Sep 08, 2020 8:00 pm

Re: coinsurance with Medicare Advantage (Part C) plans, and other associated questions

Post by runninginvestor »

protagonist wrote: Fri Aug 12, 2022 12:00 am I agree.
I currently have the Tufts Preferred Medicare Basic HMO plan that costs $45/mo. They do have good travel benefits. But we bought a place in FL last year and are now snowbirds. Though I have received emergency services in FL covered by Tufts, there are limits and out-of-network services are not capped. So I am considering either switching to a supplemental plan plus part D drug coverage, or another Advantage plan that is a PPO rather than an HMO and caps out-of-network expenses.

The one that I tried linking to was Aetna Medicare Explorer Plan (PPO)
Aetna Medicare | Plan ID: H5521-160-0 . Maybe this link will work. https://www.medicare.gov/plan-compare/# ... =en&page=1

I picked that one more or less randomly among 3 or 4 similar plans, just to get an idea. My drug costs are currently pretty trivial....a few hundred dollars per year I suppose.

All of the doctors that I see in Mass. and my local hospitals accept the Tufts plan....I wonder if they would also accept Aetna. I also wonder whether my chosen doctors in FL (St. Petersburg area) would be considered "in network" or "out of network" if I bought the plan in Mass (I am a MA resident).
If you go to Aetna Medicare directly, you should be able to search their plans and then do provider searches to see if you're chosen doctors and hospitals are in network. I can't remember how big of a presence aetna has in Florida. I've also moved a few times while on Medicare, and it's odd because sometimes Aetna will have the lowest out of pocket, sometimes there will be a Humana plan with the lowest out of pocket.

And either case, you can look at their evidence of coverage document to see how they handle any travel coverage. If I remember right, if you get that document from their website after searching for the plan, Aetna will be something like "visitor/travel benefit" where they will cover cover you at network rates for any Aetna networked provider.
Topic Author
protagonist
Posts: 9277
Joined: Sun Dec 26, 2010 11:47 am

Re: coinsurance with Medicare Advantage (Part C) plans, and other associated questions

Post by protagonist »

runninginvestor wrote: Fri Aug 12, 2022 7:10 am
protagonist wrote: Fri Aug 12, 2022 12:00 am I agree.
I currently have the Tufts Preferred Medicare Basic HMO plan that costs $45/mo. They do have good travel benefits. But we bought a place in FL last year and are now snowbirds. Though I have received emergency services in FL covered by Tufts, there are limits and out-of-network services are not capped. So I am considering either switching to a supplemental plan plus part D drug coverage, or another Advantage plan that is a PPO rather than an HMO and caps out-of-network expenses.

The one that I tried linking to was Aetna Medicare Explorer Plan (PPO)
Aetna Medicare | Plan ID: H5521-160-0 . Maybe this link will work. https://www.medicare.gov/plan-compare/# ... =en&page=1

I picked that one more or less randomly among 3 or 4 similar plans, just to get an idea. My drug costs are currently pretty trivial....a few hundred dollars per year I suppose.

All of the doctors that I see in Mass. and my local hospitals accept the Tufts plan....I wonder if they would also accept Aetna. I also wonder whether my chosen doctors in FL (St. Petersburg area) would be considered "in network" or "out of network" if I bought the plan in Mass (I am a MA resident).
If you go to Aetna Medicare directly, you should be able to search their plans and then do provider searches to see if you're chosen doctors and hospitals are in network. I can't remember how big of a presence aetna has in Florida. I've also moved a few times while on Medicare, and it's odd because sometimes Aetna will have the lowest out of pocket, sometimes there will be a Humana plan with the lowest out of pocket.

And either case, you can look at their evidence of coverage document to see how they handle any travel coverage. If I remember right, if you get that document from their website after searching for the plan, Aetna will be something like "visitor/travel benefit" where they will cover cover you at network rates for any Aetna networked provider.
Thanks!

Do you know if I go with a PPO with a national provider like Aetna , do they consider "in network" to include any Aetna provider nationally, or is their "network" defined locally, so that even though a FL provider might accept Aetna, they would not be in the defined Mass. Aetna network and so considered an "out of network provider" for me?
MGBMartin
Posts: 1145
Joined: Thu Nov 04, 2021 11:09 am

Re: coinsurance with Medicare Advantage (Part C) plans, and other associated questions

Post by MGBMartin »

protagonist wrote: Fri Aug 12, 2022 10:49 am
runninginvestor wrote: Fri Aug 12, 2022 7:10 am
protagonist wrote: Fri Aug 12, 2022 12:00 am I agree.
I currently have the Tufts Preferred Medicare Basic HMO plan that costs $45/mo. They do have good travel benefits. But we bought a place in FL last year and are now snowbirds. Though I have received emergency services in FL covered by Tufts, there are limits and out-of-network services are not capped. So I am considering either switching to a supplemental plan plus part D drug coverage, or another Advantage plan that is a PPO rather than an HMO and caps out-of-network expenses.

The one that I tried linking to was Aetna Medicare Explorer Plan (PPO)
Aetna Medicare | Plan ID: H5521-160-0 . Maybe this link will work. https://www.medicare.gov/plan-compare/# ... =en&page=1

I picked that one more or less randomly among 3 or 4 similar plans, just to get an idea. My drug costs are currently pretty trivial....a few hundred dollars per year I suppose.

All of the doctors that I see in Mass. and my local hospitals accept the Tufts plan....I wonder if they would also accept Aetna. I also wonder whether my chosen doctors in FL (St. Petersburg area) would be considered "in network" or "out of network" if I bought the plan in Mass (I am a MA resident).
If you go to Aetna Medicare directly, you should be able to search their plans and then do provider searches to see if you're chosen doctors and hospitals are in network. I can't remember how big of a presence aetna has in Florida. I've also moved a few times while on Medicare, and it's odd because sometimes Aetna will have the lowest out of pocket, sometimes there will be a Humana plan with the lowest out of pocket.

And either case, you can look at their evidence of coverage document to see how they handle any travel coverage. If I remember right, if you get that document from their website after searching for the plan, Aetna will be something like "visitor/travel benefit" where they will cover cover you at network rates for any Aetna networked provider.
Thanks!

Do you know if I go with a PPO with a national provider like Aetna , do they consider "in network" to include any Aetna provider nationally, or is their "network" defined locally, so that even though a FL provider might accept Aetna, they would not be in the defined Mass. Aetna network and so considered an "out of network provider" for me?
Aetna and others have regional MA plans and I think that is typical.
I don’t know if they have truly nationwide in network plans so you may have to look at specific plan details to find out.

The Medicare.gov website has a pretty good tool for finding MA plans as does this website…

https://q1medicare.com/PartD-SearchMA-M ... olsHomeBox
Bad spellers of the world untie | Autocorrect is my worst enema
runninginvestor
Posts: 1796
Joined: Tue Sep 08, 2020 8:00 pm

Re: coinsurance with Medicare Advantage (Part C) plans, and other associated questions

Post by runninginvestor »

protagonist wrote: Fri Aug 12, 2022 10:49 am Thanks!

Do you know if I go with a PPO with a national provider like Aetna , do they consider "in network" to include any Aetna provider nationally, or is their "network" defined locally, so that even though a FL provider might accept Aetna, they would not be in the defined Mass. Aetna network and so considered an "out of network provider" for me?
Disclaimer: I'm not recommending plans, just showing what to look for from my experience.

Going to https://www.aetnamedicare.com/
And looking for that plan, you can find a MA plan, the look at plan details to locate the Evidence of Coverage. Thids one may or may not be the one you are looking at:
H5521-160 Evidence of Coverage

If you search "Travel", on pg 144 there is: "Section 2.2 Getting care using our plan’s optional visitor/traveler benefit"
They state (emphasis mine):
"When you are continuously absent from our plan’s service area for more than six months, we usually must disenroll you from our plan. However, we offer as a supplemental benefit a visitor/traveler program that is available within the United States, which will allow you to remain enrolled in our plan when you are in the visitor/traveler area and outside of our plan’s service area for up to 12 months. This program is available to all Aetna Medicare Explorer Plan (PPO) members who are temporarily in the visitor/traveler area and outside our plan’s service area. Under our visitor/traveler program you may receive all plan covered services at in-network cost-sharing when you see a network provider. In most cases, when you receive non-urgent/non-emergency care from an out-of-network provider (a provider who is not an Aetna Medicare provider), your share of the costs for your covered services may be higher, see Chapter 3, Section 2.3 for more information. Please contact the plan for assistance in locating a provider when using the visitor/traveler benefit.

If you are in the visitor/traveler area and outside the plan’s service area, you can stay enrolled in our plan for up to 12 months. If you have not returned to the plan’s service area within 12 months, you will be disenrolled from the plan. Please be sure to notify us when you will be out of the plan’s service area for more than six months.
"

So with that benefit, you can get in-network cost sharing care from a national Aetna networked provider that isn't in the plan's service area. To double check your providers are networked with Aetna Medicare, you can use their provider lookup tool.

Not all health insurers/plans will offer something like this. I've seen it in Aetna PPO's, and Humana PPO plans doing something similar.

For example, this is from a Humana plan's EOC:
"You have access to providers in the HumanaChoice network in all of our service areas. If you receive care from
HumanaChoice providers, you will pay the same in-network copay or coinsurance you would pay if you received
care within your home service area. If you are travelling outside of your plan’s service area and need assistance
finding a HumanaChoice provider, please call Customer Care. We’ll tell you whether you’re in one of our other
HumanaChoice service areas and help you find an in-network provider. You may see any provider you choose, but
your out-of-pocket costs may be higher if you see an out-of-network provider.
"
Topic Author
protagonist
Posts: 9277
Joined: Sun Dec 26, 2010 11:47 am

Re: coinsurance with Medicare Advantage (Part C) plans, and other associated questions

Post by protagonist »

runninginvestor wrote: Fri Aug 12, 2022 11:35 am
protagonist wrote: Fri Aug 12, 2022 10:49 am Thanks!

Do you know if I go with a PPO with a national provider like Aetna , do they consider "in network" to include any Aetna provider nationally, or is their "network" defined locally, so that even though a FL provider might accept Aetna, they would not be in the defined Mass. Aetna network and so considered an "out of network provider" for me?
Disclaimer: I'm not recommending plans, just showing what to look for from my experience.

Going to https://www.aetnamedicare.com/
And looking for that plan, you can find a MA plan, the look at plan details to locate the Evidence of Coverage. Thids one may or may not be the one you are looking at:
H5521-160 Evidence of Coverage

If you search "Travel", on pg 144 there is: "Section 2.2 Getting care using our plan’s optional visitor/traveler benefit"
They state (emphasis mine):
"When you are continuously absent from our plan’s service area for more than six months, we usually must disenroll you from our plan. However, we offer as a supplemental benefit a visitor/traveler program that is available within the United States, which will allow you to remain enrolled in our plan when you are in the visitor/traveler area and outside of our plan’s service area for up to 12 months. This program is available to all Aetna Medicare Explorer Plan (PPO) members who are temporarily in the visitor/traveler area and outside our plan’s service area. Under our visitor/traveler program you may receive all plan covered services at in-network cost-sharing when you see a network provider. In most cases, when you receive non-urgent/non-emergency care from an out-of-network provider (a provider who is not an Aetna Medicare provider), your share of the costs for your covered services may be higher, see Chapter 3, Section 2.3 for more information. Please contact the plan for assistance in locating a provider when using the visitor/traveler benefit.

If you are in the visitor/traveler area and outside the plan’s service area, you can stay enrolled in our plan for up to 12 months. If you have not returned to the plan’s service area within 12 months, you will be disenrolled from the plan. Please be sure to notify us when you will be out of the plan’s service area for more than six months.
"

So with that benefit, you can get in-network cost sharing care from a national Aetna networked provider that isn't in the plan's service area. To double check your providers are networked with Aetna Medicare, you can use their provider lookup tool.

Not all health insurers/plans will offer something like this. I've seen it in Aetna PPO's, and Humana PPO plans doing something similar.

For example, this is from a Humana plan's EOC:
"You have access to providers in the HumanaChoice network in all of our service areas. If you receive care from
HumanaChoice providers, you will pay the same in-network copay or coinsurance you would pay if you received
care within your home service area. If you are travelling outside of your plan’s service area and need assistance
finding a HumanaChoice provider, please call Customer Care. We’ll tell you whether you’re in one of our other
HumanaChoice service areas and help you find an in-network provider. You may see any provider you choose, but
your out-of-pocket costs may be higher if you see an out-of-network provider.
"
That was really helpful, runninginvestor, and researching all that for me was above and beyond the call of duty. Thanks a million!!
Topic Author
protagonist
Posts: 9277
Joined: Sun Dec 26, 2010 11:47 am

Re: coinsurance with Medicare Advantage (Part C) plans, and other associated questions

Post by protagonist »

MGBMartin wrote: Fri Aug 12, 2022 11:28 am
protagonist wrote: Fri Aug 12, 2022 10:49 am
runninginvestor wrote: Fri Aug 12, 2022 7:10 am
protagonist wrote: Fri Aug 12, 2022 12:00 am I agree.
I currently have the Tufts Preferred Medicare Basic HMO plan that costs $45/mo. They do have good travel benefits. But we bought a place in FL last year and are now snowbirds. Though I have received emergency services in FL covered by Tufts, there are limits and out-of-network services are not capped. So I am considering either switching to a supplemental plan plus part D drug coverage, or another Advantage plan that is a PPO rather than an HMO and caps out-of-network expenses.

The one that I tried linking to was Aetna Medicare Explorer Plan (PPO)
Aetna Medicare | Plan ID: H5521-160-0 . Maybe this link will work. https://www.medicare.gov/plan-compare/# ... =en&page=1

I picked that one more or less randomly among 3 or 4 similar plans, just to get an idea. My drug costs are currently pretty trivial....a few hundred dollars per year I suppose.

All of the doctors that I see in Mass. and my local hospitals accept the Tufts plan....I wonder if they would also accept Aetna. I also wonder whether my chosen doctors in FL (St. Petersburg area) would be considered "in network" or "out of network" if I bought the plan in Mass (I am a MA resident).
If you go to Aetna Medicare directly, you should be able to search their plans and then do provider searches to see if you're chosen doctors and hospitals are in network. I can't remember how big of a presence aetna has in Florida. I've also moved a few times while on Medicare, and it's odd because sometimes Aetna will have the lowest out of pocket, sometimes there will be a Humana plan with the lowest out of pocket.

And either case, you can look at their evidence of coverage document to see how they handle any travel coverage. If I remember right, if you get that document from their website after searching for the plan, Aetna will be something like "visitor/travel benefit" where they will cover cover you at network rates for any Aetna networked provider.
Thanks!

Do you know if I go with a PPO with a national provider like Aetna , do they consider "in network" to include any Aetna provider nationally, or is their "network" defined locally, so that even though a FL provider might accept Aetna, they would not be in the defined Mass. Aetna network and so considered an "out of network provider" for me?
Aetna and others have regional MA plans and I think that is typical.
I don’t know if they have truly nationwide in network plans so you may have to look at specific plan details to find out.

The Medicare.gov website has a pretty good tool for finding MA plans as does this website…

https://q1medicare.com/PartD-SearchMA-M ... olsHomeBox

Thanks!
Good Listener
Posts: 927
Joined: Wed Dec 30, 2015 4:24 pm

Re: coinsurance with Medicare Advantage (Part C) plans, and other associated questions

Post by Good Listener »

I am long on record as being a fierce opponent of any Medicare advantage plan, I don't care how good it is because it can always change. Yes so you save the supplement fee of maybe 200 a month and instead you have to deal with copays and priorior authorizations and potential networks and all sorts of things. With traditional Medicare and a supplement and I have a G, all I pay is the deductible each year and then never get another bill for anything. I don't care if they give you gymss or whatever who needs to deal with that as you get older? Unless you are destitute and $200 a month matters I suggest you just do traditional medicare. I was in a Medicare advantage plan by a prior employer that I was automatically put into and the first day on Medicare I had to get a prior authorization for something and that was it for me. I suggest you just get out of it and return to Medicare traditional if you are able to be underwritten to get a supplement..
Topic Author
protagonist
Posts: 9277
Joined: Sun Dec 26, 2010 11:47 am

Re: coinsurance with Medicare Advantage (Part C) plans, and other associated questions

Post by protagonist »

Good Listener wrote: Fri Aug 12, 2022 7:16 pm I am long on record as being a fierce opponent of any Medicare advantage plan, I don't care how good it is because it can always change. Yes so you save the supplement fee of maybe 200 a month and instead you have to deal with copays and priorior authorizations and potential networks and all sorts of things. With traditional Medicare and a supplement and I have a G, all I pay is the deductible each year and then never get another bill for anything. I don't care if they give you gymss or whatever who needs to deal with that as you get older? Unless you are destitute and $200 a month matters I suggest you just do traditional medicare. I was in a Medicare advantage plan by a prior employer that I was automatically put into and the first day on Medicare I had to get a prior authorization for something and that was it for me. I suggest you just get out of it and return to Medicare traditional if you are able to be underwritten to get a supplement..
Unless I understand wrong (my info is about 5 years old and I intend to confirm it prior to the next open enrollment period), this is much less of an issue in Massachusetts. In MA, one is able to switch during any open enrollment period without underwriting or penalty for existing conditions. So if you get chronically ill, say, early in 2023, you can switch to a supplemental plan (or vice versa) in October 2023 at no cost (other than the difference in premium). You can switch as often as you wish providing it is during open enrollment.
That alone is a good part of the reason that I plan to maintain my MA residency for now, even though becoming a FL resident would leave me paying no state income tax. The insurance guarantee is huge.

That said, I am considering switching to traditional Medicare with supplemental. I am investigating all options.

With Plan G., other than your $233 deductible, are you really totally free of any potential health care costs? I noticed it only pays for the first three pints of blood. Also, unless I read wrong, it appears not to cover extended hospital stays or nursing home stays over 100 days, and what quality nursing homes accept Medicare? Are you convinced you could find a nursing facility that accepts Medicare that you would choose to live in? It only pays 80% of costs if out of country....I imagine even 20% of emergency evacuation can be quite expensive.

I'm not saying it's not a great plan...just that you can still potentially wind up with high medical bills. MA has a plan similar to Plan G (called "Supplement 1A") that I am seriously considering, if for no other reason than to simplify my life, even if I wind up paying more in premiums. Another great thing about the Massachusetts plan is that it uses community pricing, so you don't have to worry about your premiums increasing as you age, other than cost of living increases.
jmw
Posts: 328
Joined: Thu Jul 02, 2015 2:01 pm

Re: coinsurance with Medicare Advantage (Part C) plans, and other associated questions

Post by jmw »

I'm another opponent of Medicare Advantage. Don't be cheap and cheap out on your health by having to wait for the next open enrollment or fighting the insurance company's denial of an authorization when you have a health crisis. You don't sound destitute. It's not like shopping for a good deal on a TV. Quit doing that. MA plans have a role.. it's for poor folks who can't afford premiums. You're not poor.
runninginvestor
Posts: 1796
Joined: Tue Sep 08, 2020 8:00 pm

Re: coinsurance with Medicare Advantage (Part C) plans, and other associated questions

Post by runninginvestor »

protagonist wrote: Fri Aug 12, 2022 7:35 pm
Good Listener wrote: Fri Aug 12, 2022 7:16 pm
Unless I understand wrong (my info is about 5 years old and I intend to confirm it prior to the next open enrollment period), this is much less of an issue in Massachusetts. In MA, one is able to switch during any open enrollment period without underwriting or penalty for existing conditions. So if you get chronically ill, say, early in 2023, you can switch to a supplemental plan (or vice versa) in October 2023 at no cost (other than the difference in premium). You can switch as often as you wish providing it is during open enrollment.
That alone is a good part of the reason that I plan to maintain my MA residency for now, even though becoming a FL resident would leave me paying no state income tax. The insurance guarantee is huge.

That said, I am considering switching to traditional Medicare with supplemental. I am investigating all options.

With Plan G., other than your $233 deductible, are you really totally free of any potential health care costs? I noticed it only pays for the first three pints of blood. Also, unless I read wrong, it appears not to cover extended hospital stays or nursing home stays over 100 days, and what quality nursing homes accept Medicare? Are you convinced you could find a nursing facility that accepts Medicare that you would choose to live in? It only pays 80% of costs if out of country....I imagine even 20% of emergency evacuation can be quite expensive.

I'm not saying it's not a great plan...just that you can still potentially wind up with high medical bills. MA has a plan similar to Plan G (called "Supplement 1A") that I am seriously considering, if for no other reason than to simplify my life, even if I wind up paying more in premiums. Another great thing about the Massachusetts plan is that it uses community pricing, so you don't have to worry about your premiums increasing as you age, other than cost of living increases.
(For others, medigap is different in WI, MN, and MA and provide separate Medigap offerings that aren't plan A,G,F,L,K, etc)

"With Plan G., other than your $233 deductible, are you really totally free of any potential health care costs?"

Typically, yes for covered services. Inpatient has it's own deductible.

"...nursing..."
Medicare doesn't typically cover nursing home/custodial/long-term care. They cover skilled nursing, but that usually is part of a transition to recovery.
______________

i was curious about what some of these medigap plans cover. I just clicked on BCBS in MA. They seem to have the most members by far.
https://medicare.bluecrossma.com/member ... -documents

Then selected the plan doc for "2022 Medex®' Outline of Coverage"
https://home.bluecrossma.com/collateral ... verage.pdf

It actually has a decent description and table of patient costs/bcbs cost sharing.

For ex, page 7 has some helpful info regarding pints of blood for just 1 of their plan options.

Also seems their fgirst plan provides a little more expansive coverage for hospital stays.

(Sorry, I like reading plan docs!)

I would look into some of these documents and see if you feel more comfortable with these over Medicare advantage. I think as far as simplifying your life, you have it right that you usually have to pay for flexibility and simplicity.

You'll have to get part d still. If you want dental you'll have to get coverage elsewhere. But most Medicare adv plans dental coverages are really just cleanings and basic exams, you have to pay more for more comprehensive coverage anyways.
______________

(these are for others who might be curious after finding the thread)
Medicare seems to still show this:
https://www.medicare.gov/supplements-ot ... sachusetts

Googled SHIP Medigap MA to see where their document that usually provides more details and/or premiums:
https://www.mass.gov/doc/2022-medicare- ... g/download

If curious to try and see which provider is most frequently used, more members can usually mean better stability:
https://www.mass.gov/service-details/20 ... membership
Jagger
Posts: 68
Joined: Fri Sep 25, 2020 10:05 am

Re: coinsurance with Medicare Advantage (Part C) plans, and other associated questions

Post by Jagger »

Protagonist: "Unless I understand wrong (my info is about 5 years old and I intend to confirm it prior to the next open enrollment period), this is much less of an issue in Massachusetts. In MA, one is able to switch during any open enrollment period without underwriting or penalty for existing conditions. So if you get chronically ill, say, early in 2023, you can switch to a supplemental plan (or vice versa) in October 2023 at no cost (other than the difference in premium). You can switch as often as you wish providing it is during open enrollment."

Your info is not accurate. In Massachusetts, Medigap plans, aka. Medicare supplement plans, are governed by "continuous open enrollment." That means one can join a supplemental plan at any time, the only constraint being that the effective date of coverage is the first of the following month. If you're in a Medicare Advantage plan and you sign up for Medigap, your Advantage plan is automatically cancelled, effective the first of the following month.

I agree: continuous open enrollment for Medigap is a huge plus.
sobogled
Posts: 37
Joined: Wed Apr 13, 2022 3:11 pm

Re: coinsurance with Medicare Advantage (Part C) plans, and other associated questions

Post by sobogled »

Good Listener wrote: Fri Aug 12, 2022 7:16 pm I am long on record as being a fierce opponent of any Medicare advantage plan, I don't care how good it is because it can always change. Yes so you save the supplement fee of maybe 200 a month and instead you have to deal with copays and priorior authorizations and potential networks and all sorts of things. With traditional Medicare and a supplement and I have a G, all I pay is the deductible each year and then never get another bill for anything. I don't care if they give you gymss or whatever who needs to deal with that as you get older? Unless you are destitute and $200 a month matters I suggest you just do traditional medicare. I was in a Medicare advantage plan by a prior employer that I was automatically put into and the first day on Medicare I had to get a prior authorization for something and that was it for me. I suggest you just get out of it and return to Medicare traditional if you are able to be underwritten to get a supplement..
Prior authorization isn't something you or any patient should have to 'get', it's something the provider submits in order to authorize their reimbursement.

FWIW, traditional Medicare has prior authorizations as well.
Broken Man 1999
Posts: 8626
Joined: Wed Apr 08, 2015 11:31 am
Location: West coast of Florida, near Champa Bay !

Re: coinsurance with Medicare Advantage (Part C) plans, and other associated questions

Post by Broken Man 1999 »

sobogled wrote: Sat Aug 13, 2022 11:55 am
Good Listener wrote: Fri Aug 12, 2022 7:16 pm I am long on record as being a fierce opponent of any Medicare advantage plan, I don't care how good it is because it can always change. Yes so you save the supplement fee of maybe 200 a month and instead you have to deal with copays and priorior authorizations and potential networks and all sorts of things. With traditional Medicare and a supplement and I have a G, all I pay is the deductible each year and then never get another bill for anything. I don't care if they give you gymss or whatever who needs to deal with that as you get older? Unless you are destitute and $200 a month matters I suggest you just do traditional medicare. I was in a Medicare advantage plan by a prior employer that I was automatically put into and the first day on Medicare I had to get a prior authorization for something and that was it for me. I suggest you just get out of it and return to Medicare traditional if you are able to be underwritten to get a supplement..
Prior authorization isn't something you or any patient should have to 'get', it's something the provider submits in order to authorize their reimbursement.

FWIW, traditional Medicare has prior authorizations as well.
Please don't confuse the issue with facts! :D

Broken Man 1999
“If I cannot drink Bourbon and smoke cigars in Heaven then I shall not go." - Mark Twain
Topic Author
protagonist
Posts: 9277
Joined: Sun Dec 26, 2010 11:47 am

Re: coinsurance with Medicare Advantage (Part C) plans, and other associated questions

Post by protagonist »

runninginvestor wrote: Sat Aug 13, 2022 9:51 am
protagonist wrote: Fri Aug 12, 2022 7:35 pm
Good Listener wrote: Fri Aug 12, 2022 7:16 pm
Unless I understand wrong (my info is about 5 years old and I intend to confirm it prior to the next open enrollment period), this is much less of an issue in Massachusetts. In MA, one is able to switch during any open enrollment period without underwriting or penalty for existing conditions. So if you get chronically ill, say, early in 2023, you can switch to a supplemental plan (or vice versa) in October 2023 at no cost (other than the difference in premium). You can switch as often as you wish providing it is during open enrollment.
That alone is a good part of the reason that I plan to maintain my MA residency for now, even though becoming a FL resident would leave me paying no state income tax. The insurance guarantee is huge.

That said, I am considering switching to traditional Medicare with supplemental. I am investigating all options.

With Plan G., other than your $233 deductible, are you really totally free of any potential health care costs? I noticed it only pays for the first three pints of blood. Also, unless I read wrong, it appears not to cover extended hospital stays or nursing home stays over 100 days, and what quality nursing homes accept Medicare? Are you convinced you could find a nursing facility that accepts Medicare that you would choose to live in? It only pays 80% of costs if out of country....I imagine even 20% of emergency evacuation can be quite expensive.

I'm not saying it's not a great plan...just that you can still potentially wind up with high medical bills. MA has a plan similar to Plan G (called "Supplement 1A") that I am seriously considering, if for no other reason than to simplify my life, even if I wind up paying more in premiums. Another great thing about the Massachusetts plan is that it uses community pricing, so you don't have to worry about your premiums increasing as you age, other than cost of living increases.
(For others, medigap is different in WI, MN, and MA and provide separate Medigap offerings that aren't plan A,G,F,L,K, etc)

"With Plan G., other than your $233 deductible, are you really totally free of any potential health care costs?"

Typically, yes for covered services. Inpatient has it's own deductible.

"...nursing..."
Medicare doesn't typically cover nursing home/custodial/long-term care. They cover skilled nursing, but that usually is part of a transition to recovery.
______________

i was curious about what some of these medigap plans cover. I just clicked on BCBS in MA. They seem to have the most members by far.
https://medicare.bluecrossma.com/member ... -documents

Then selected the plan doc for "2022 Medex®' Outline of Coverage"
https://home.bluecrossma.com/collateral ... verage.pdf

It actually has a decent description and table of patient costs/bcbs cost sharing.

For ex, page 7 has some helpful info regarding pints of blood for just 1 of their plan options.

Also seems their fgirst plan provides a little more expansive coverage for hospital stays.

(Sorry, I like reading plan docs!)

I would look into some of these documents and see if you feel more comfortable with these over Medicare advantage. I think as far as simplifying your life, you have it right that you usually have to pay for flexibility and simplicity.

You'll have to get part d still. If you want dental you'll have to get coverage elsewhere. But most Medicare adv plans dental coverages are really just cleanings and basic exams, you have to pay more for more comprehensive coverage anyways.
______________

(these are for others who might be curious after finding the thread)
Medicare seems to still show this:
https://www.medicare.gov/supplements-ot ... sachusetts

Googled SHIP Medigap MA to see where their document that usually provides more details and/or premiums:
https://www.mass.gov/doc/2022-medicare- ... g/download

If curious to try and see which provider is most frequently used, more members can usually mean better stability:
https://www.mass.gov/service-details/20 ... membership
Thanks for all this, and you are right about dental (a couple of hundred dollars per year).

I will review your links when I get home later this week.

I am leaning towards medigap plus part D (largely the simplification factor, esp. being a snowbird), but want to gather all the info first.

It isn't "continuous open enrollment"...if I understood correctly when researching it 5 years ago, it is the ability to switch between any plans during the open enrollment period, as often as desired but only during open enrollment, at no charge, avoiding underwriting. So if you suddenly became chronically ill and required , for example, over the $6700 limit in personal expenses that year, you could switch during the Oct-Dec enrollment period to a different plan that better suited your needs.
Post Reply