Deciding on Medigap vs Medicare Advantage

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Tom_T
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Deciding on Medigap vs Medicare Advantage

Post by Tom_T »

I've read the threads debating Medigap vs. Medicare Advantage. This thread is about my particular situation, on which I need to make a decision about later this year when I turn 65. My health is excellent. I exercise and I don't take any medications. I see a specialist 3-4 times a year.

- Medigap G will cost 2300 including a prescription plan. I am a regular user of eye care services, so I'd have to handle that separately.
- Medigap N will cost 2000, and figure another 100 for doctor visit copays.
- Medicare Advantage from Blue Cross will cost me 420/year. Max OOP is 6700. Annual medical deductible is zero. I live in NJ, there are plenty of doctors around, and all my doctors are in this plan. It does include routine dental and eye care.

A medical surprise is always possible: a couple of months ago, I had to have outpatient sinus surgery. The "sticker price" was $19K, and my share under my company insurance was $1400. I'm not sure what this would cost under the MA plan which says that there is a $295 copay for outpatient service. My surgery also had lab tests and general anesthesia - would those be extra costs? Or does the $0 medical deductible cover it? I don't have a sense of what this would have cost under MA.

My wife will have to use ACA coverage the next four years, so I'm trying to keep our total costs down until she becomes eligible for Medicare (and these are my Social Security bridge years - I don't plan to claim until at least 68, so all uncovered expenses come from my accounts and I'm trying to minimize that.)

I feel like I'll end up spending a lot more on Medigap without really needing it, especially prescriptions. If my health remains good for the next few years, I think I could switch to Medigap if I wanted to and not have to worry about being declined. But my main concern is the "what ifs."

Thoughts on my situation? I'm sure I'm missing something in my analysis.
ModifiedDuration
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Re: Deciding on Medigap vs Medicare Advantage

Post by ModifiedDuration »

Tom_T wrote: Thu Mar 23, 2023 8:00 am I feel like I'll end up spending a lot more on Medigap without really needing it, especially prescriptions. If my health remains good for the next few years, I think I could switch to Medigap if I wanted to and not have to worry about being declined. But my main concern is the "what ifs."
If you sign-up for a Medicare Advantage Plan now in New Jersey and then decide in a few years that you want to switch to Original Medicare, you would then be subject to medical underwriting in order to get a Medicare Supplement Plan.

Have you considered a high-deductible Plan G? As a starting point, I used a zip code in Northern New Jersey and did see a lot of policies in the $600 - $750 annual premium range at age 65 (attained age pricing) - plus you’d need a Part D Plan.
Last edited by ModifiedDuration on Thu Mar 23, 2023 8:35 am, edited 1 time in total.
Topic Author
Tom_T
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Re: Deciding on Medigap vs Medicare Advantage

Post by Tom_T »

ModifiedDuration wrote: Thu Mar 23, 2023 8:12 am
Tom_T wrote: Thu Mar 23, 2023 8:00 am I feel like I'll end up spending a lot more on Medigap without really needing it, especially prescriptions. If my health remains good for the next few years, I think I could switch to Medigap if I wanted to and not have to worry about being declined. But my main concern is the "what ifs."
If you sign-up for a Medicare Advantage Plan now in New Jersey and then decide in a few years that you want to switch to Original Medicare, you would then be subject to medical underwriting in order to get a Medicare Supplement Plan.

Have you considered a high-deductible Plan G?
I meant that I think I'd be okay with the underwriting later on, although of course there are no guarantees.

A High-G plan looks like it would cost around 720/year with a 2700 deductible.
ModifiedDuration
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Re: Deciding on Medigap vs Medicare Advantage

Post by ModifiedDuration »

In making your decision, hopefully you understand how a Plan G-HD works. The “high-deductible” here is a misnomer, it’s not like the high-deductible plans people have at work.

With a Plan G, you just have the $226 Part B deductible.

If you have Plan G-HD, since it is a Supplement to Medicare, Medicare does pay its 80% of Part B expenses first (after the $226 annual deductible). So, your coverage for Part B is:

$226 annual deductible, then
20% copay (based on low Medicare-reimbursement rates)
$2,700 maximum out-of-pocket

The only kicker is that if you admitted to the hospital as an in-patient, you will have a $1,600 Part A deductible (which counts toward the $2,700 maximum out-of-pocket).

The $2,700 figure increases with inflation (tied to CPI-U). This is built-in cost sharing and results in HD premiums either having no annual increase or a minimal annual increase. Up until the last few years, the annual increase in the HD deductible limit was not significant.
kd2008
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Re: Deciding on Medigap vs Medicare Advantage

Post by kd2008 »

It is pay later vs pay now proposition.

With plan G, you are paying more now in premiums, but in old age you may not pay as much as advantage plan out of pocket max.

With advantage plan, you pay less now, get some dental vision benefits, prescription benefits. If you have health issues, you may have to pay up to out of pocket max.

Network of medical providers is not an issue for you - so this means in advantage plan's favor.

Depending on your advantage plan, prior authorization for some treatments may be needed.

Folks that have done due diligence, and are ok with local provider network (that is they are not snowbirding etc), find advantage plan is a good fit and results in lower cost to the person.

Some 3-5% of people in advantage plan hit their out of pocket max according some data propounded on internet (I don't know how good is that data).

Try to get zero dollar advantage plan since you are in good health.

If you have HSA funds they can be used for out of pocket costs, part B premium, advantage plan premiums.

With plan G, HSA funds cannot be used to pay plan G premiums.

Most Bogleheads are financially well off that they afford expensive plan G and move on with their life. YMMV.
ehh
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Re: Deciding on Medigap vs Medicare Advantage

Post by ehh »

ModifiedDuration wrote: Thu Mar 23, 2023 8:12 am Have you considered a high-deductible Plan G? As a starting point, I used a zip code in Northern New Jersey and did see a lot of policies in the $600 - $750 annual premium range at age 65 (attained age pricing) - plus you’d need a Part D Plan.
Since you don't take any medications currently, you can just sign up for the Part D plan with the lowest premium. Checking a random New Jersey zip code yields a lowest premium of $9.30 per month (for WellCare Value Script). If your needs change, each Fall you have the opportunity to change Part D plans. The Medicare Part D plan finder tool facilitates both the analysis of and requesting a change to your Part D plan.
Topic Author
Tom_T
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Re: Deciding on Medigap vs Medicare Advantage

Post by Tom_T »

Thanks, this is all helpful. I don't turn 65 until the end of the year, so I've got some time to think about this.
cashmoney
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Re: Deciding on Medigap vs Medicare Advantage

Post by cashmoney »

Tom_T wrote: Thu Mar 23, 2023 8:00 am I've read the threads debating Medigap vs. Medicare Advantage. This thread is about my particular situation, on which I need to make a decision about later this year when I turn 65. My health is excellent. I exercise and I don't take any medications. I see a specialist 3-4 times a year.

- Medigap G will cost 2300 including a prescription plan. I am a regular user of eye care services, so I'd have to handle that separately.
- Medigap N will cost 2000, and figure another 100 for doctor visit copays.
- Medicare Advantage from Blue Cross will cost me 420/year. Max OOP is 6700. Annual medical deductible is zero. I live in NJ, there are plenty of doctors around, and all my doctors are in this plan. It does include routine dental and eye care.

A medical surprise is always possible: a couple of months ago, I had to have outpatient sinus surgery. The "sticker price" was $19K, and my share under my company insurance was $1400. I'm not sure what this would cost under the MA plan which says that there is a $295 copay for outpatient service. My surgery also had lab tests and general anesthesia - would those be extra costs? Or does the $0 medical deductible cover it? I don't have a sense of what this would have cost under MA.

My wife will have to use ACA coverage the next four years, so I'm trying to keep our total costs down until she becomes eligible for Medicare (and these are my Social Security bridge years - I don't plan to claim until at least 68, so all uncovered expenses come from my accounts and I'm trying to minimize that.)

I feel like I'll end up spending a lot more on Medigap without really needing it, especially prescriptions. If my health remains good for the next few years, I think I could switch to Medigap if I wanted to and not have to worry about being declined. But my main concern is the "what ifs."

Thoughts on my situation? I'm sure I'm missing something in my analysis.

Most if not all MA plans bundle charges for daily in patient co pay, out patient procedures and ER meaning you don't get itemized for anything. Check the Evidence of Coverage document to confirm this for that plan. Also IMO your total cost analyses for plan N or G should include the part B deductible if it doesn't .

In my experience dealing with thousands of MA members since 2006 my observation has been less than 5 % of MA members hit their MOOP and this is mostly in Florida where the average MOOP on leading plans have a MOOP of less than 5000 for PPOs and 3500 for HMOs

disclaimer licensed agent not recommending any plan.
Nowizard
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Re: Deciding on Medigap vs Medicare Advantage

Post by Nowizard »

Anecdotal, but a friend who has a sister who marketed Advantage and Medigap for Blue Cross asked her. He had no significant health problems but probability of needing hearing aids. Her suggestion was an Advantage plan that provides some HA coverage and switching in the future to a standard medicare plan, plus Medigap to get a broader provider panel.

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Stinky
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Re: Deciding on Medigap vs Medicare Advantage

Post by Stinky »

Tom_T wrote: Thu Mar 23, 2023 8:00 am My health is excellent. I exercise and I don't take any medications.…….

- Medicare Advantage from Blue Cross will cost me 420/year. Max OOP is 6700. Annual medical deductible is zero. I live in NJ, there are plenty of doctors around, and all my doctors are in this plan. It does include routine dental and eye care……

I feel like I'll end up spending a lot more on Medigap without really needing it, especially prescriptions.
I think that you’re an ideal candidate for Medicare Advantage.

My situation is similar to yours, and I chose MA from my local Blue Cross. I’m very satisfied with my decision.
Retired life insurance company financial executive who sincerely believes that ”It’s a GREAT day to be alive!”
Carl53
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Re: Deciding on Medigap vs Medicare Advantage

Post by Carl53 »

I chose Part G and Part D a few years ago. In five years the Part G has gone from $106 to $165/month. I tried changing companies with the latest increase, and was asked some underwriting questions. I have been super healthy but honestly answered I had a minor elective surgery that I was considering and was rejected. Part D was $31 and now is less than $6 as I switched companies a few years ago. Seemed that I could get my few drugs written as 90 day generics and get them via GoodRx cheaper than using the insurance plan. The $6 prevents me from paying the uninsured tax penalty.

All this said, I would get Part G again, but maybe ask more questions of the provider as to understand how its priced. Anecdotal stories about those on MA having care curtailed by AI algorithms make it not worth exploring for a few bucks.
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Tom_T
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Re: Deciding on Medigap vs Medicare Advantage

Post by Tom_T »

I have a collection of useful BH threads bookmarked, and I've added this one. :)
radiowave
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Re: Deciding on Medigap vs Medicare Advantage

Post by radiowave »

I've been on Medicare 2 years now since retiring at 65 and chose first a Kaiser MA plan which transition me from my work Kaiser, now in NC (no Kaiser) so chose the Blue Cross HMO MA plan. It's affiliated with a major university so I have everything I need from a healthcare standpoint. With the NC BC plan, I can elect to transition to a Medigap policy without underwriting if I chose. That is a nice option - OP you may want to see if that is an option for you in NJ.

Also, I have my Medicare bill deducted from my SS monthly income so no added bill to pay.
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kd2008
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Re: Deciding on Medigap vs Medicare Advantage

Post by kd2008 »

cashmoney wrote: Thu Mar 23, 2023 9:14 am
Most if not all MA plans bundle charges for daily in patient co pay, out patient procedures and ER meaning you don't get itemized for anything. Check the Evidence of Coverage document to confirm this for that plan. Also IMO your total cost analyses for plan N or G should include the part B deductible if it doesn't .

In my experience dealing with thousands of MA members since 2006 my observation has been less than 5 % of MA members hit their MOOP and this is mostly in Florida where the average MOOP on leading plans have a MOOP of less than 5000 for PPOs and 3500 for HMOs

disclaimer licensed agent not recommending any plan.
Can you tell us more about our of pocket cost experience for Medicare advantage plans?

In our area typical OOP max is 5000.

How many hit $1000? How many hit $2000?

While they list out copays, it is hard to grasp what is the actual experience.

It would be helpful to know something like this:

Age 65-70: 50% hit $1000 or above, 30% hit $2000 or above, 10% hit $3000 or above, and 5% hit OOP max.

Similar for Age 70-75, Age 75-80, Age 80-85, Age 85+

If I can drill it down to the plan I am interested in then even better.

Is there CMS data like this?
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quantAndHold
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Re: Deciding on Medigap vs Medicare Advantage

Post by quantAndHold »

As a gross generalization, people who live in areas with good MA plans can save a lot of money by using a MA plan. People who don’t, do better with a Medigap plan.

I don’t know what plans look like where you are, but wife’s MA plan (Southern CA) is $0 premium, $0 deductible, most copays are $0, and she has a $2300 OOP max. The only way she could really hit her OOP max is with multiple week long hospital stays in the same year. It’s the same HMO she had when she was employed, and she’s always been happy with the providers and care. If she had Medigap, the premium would be more than her OOP max is now.

Also anecdotal, but I was a super healthy athlete, until I got cancer one day at age 59. Now I don’t meet anybody’s underwriting standards. The times you start really thinking about health insurance will be when you can’t get it.
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Re: Deciding on Medigap vs Medicare Advantage

Post by ncbill »

Tom_T wrote: Thu Mar 23, 2023 9:05 am Thanks, this is all helpful. I don't turn 65 until the end of the year, so I've got some time to think about this.
One MA versus Medigap advisor I came across notes in their experience clients' serious health issues began in their late 60s to early 70s.

So they recommend Medigap in most cases instead of Medicare Advantage no matter how healthy one "feels" at age 65.

When I'm eligible for Medicare I plan on picking Plan G - HD plus the cheapest Part D drug plan since I also takes no meds now.
OnTrack2020
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Re: Deciding on Medigap vs Medicare Advantage

Post by OnTrack2020 »

Husband is not currently on Medicare, but we are currently looking at our options also.

I have recently learned that the hospital that we would normally receive medical care does not take any Medicare Advantage plans, and they don't have any signed contracts with the Medicare Advantage Plans. You may want to check with the hospitals where you receive your health care to see if they take any of the advantage plans.
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Re: Deciding on Medigap vs Medicare Advantage

Post by anonenigma »

FYI, your medical eye care (ophthalmologist) is covered by Medicare, though not refraction, which costs perhaps $50. I've recently switched to buying my glasses at Costco, which is way less expensive than the Luxottica cartel.
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Re: Deciding on Medigap vs Medicare Advantage

Post by bobcat2 »

You may want to take into consideration that change may be coming to Medicare Advantage plans. This is from today's NYTimes.
The Biden proposal would significantly lower payments — by billions of dollars a year — to Medicare Advantage, the private plans that now cover about half of the government’s health program for older Americans.

The change in payment formulas is an effort, Biden administration officials say, to tackle widespread abuses and fraud in the increasingly popular private program. In the last decade, reams of evidence uncovered in lawsuits and audits revealed systematic overbilling of the government. A final decision on the payments is expected shortly, and is one of a series of tough new rules aimed at reining in the industry. The changes fit into a broader effort by the White House to shore up the Medicare trust fund. Without reforms, taxpayers will spend about $25 billion next year in “excess” payments to the private plans, according to the Medicare Payment Advisory Commission, a nonpartisan research group that advises Congress.

The insurers say the new rule ... would force the companies to reduce benefits or increase premiums for Medicare Advantage beneficiaries,...

The showdown underscores just how important — and lucrative — Medicare Advantage has become to insurers and doctors’ groups that are paid by the federal government to care for older Americans. Roughly $400 billion in taxpayer money went to these private plans last year. Profits on Medicare Advantage plans are at least double what insurers earn from other kinds of policies, according to a recent analysis by the Kaiser Family Foundation.

To the surprise of many in the industry, leaders in Congress have not stepped forward to vigorously defend the private plans.
Biden Plan to Cut Billions in Medicare Fraud
Link - https://www.nytimes.com/2023/03/22/heal ... d[/b].html

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cashmoney
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Re: Deciding on Medigap vs Medicare Advantage

Post by cashmoney »

kd2008 wrote: Thu Mar 23, 2023 9:48 am
cashmoney wrote: Thu Mar 23, 2023 9:14 am
Most if not all MA plans bundle charges for daily in patient co pay, out patient procedures and ER meaning you don't get itemized for anything. Check the Evidence of Coverage document to confirm this for that plan. Also IMO your total cost analyses for plan N or G should include the part B deductible if it doesn't .

In my experience dealing with thousands of MA members since 2006 my observation has been less than 5 % of MA members hit their MOOP and this is mostly in Florida where the average MOOP on leading plans have a MOOP of less than 5000 for PPOs and 3500 for HMOs

disclaimer licensed agent not recommending any plan.
Can you tell us more about our of pocket cost experience for Medicare advantage plans?

In our area typical OOP max is 5000.

How many hit $1000? How many hit $2000?

While they list out copays, it is hard to grasp what is the actual experience.

It would be helpful to know something like this:

Age 65-70: 50% hit $1000 or above, 30% hit $2000 or above, 10% hit $3000 or above, and 5% hit OOP max.

Similar for Age 70-75, Age 75-80, Age 80-85, Age 85+

If I can drill it down to the plan I am interested in then even better.

Is there CMS data like this?

There probably is data on this somewhere in the CMS data. I am more aware of the members hitting MOOP because they are more apt to bring it up. From my antidotal observation from speaking to many MA consumers the ones who do not have a hospital stay in the year with the typical number of doctor visits , diagnostic test ,out patient services etc may spend 200- 700.000 annual .The biggest reason one hits the MOOP is the 20% for chemo and dialysis however many middle class retirees can get help with this co insurance through different programs/foundations s

On the flipside of this the same person who has plan G may see the Medicare supplement G has paid out claims of 150-350.00 annual in this typical year. IMO the biggest reason to choose original medicare with a medigap is not financial protection but to avoid managed care and have complete flexibility on providers. This year i have had more of my medicare supplement clients call me and want to switch to MA plans. This has been a trend as medicare supplements premiums have been increasing and MA plans have been improving- in Florida especially. In fact as of 6/1 the biggest medicare supplement provider and long time rate leader in Florida UHC had their biggest increase ever up about 7% on plan G and 8.5% on plan N. What has really surprised me recently is the number of long time Mayo clinic patients who had Medicare supplements be willing to give up access to Mayo to get a MA plan-that never use to happen.

Of course all of this depends on where you live because some states like florida have high medicare supplement rates and very good MA plans and some states may have low medicare supplement rates and not so great MA options .

disclaimer licensed agent-not recommending any plans.
ModifiedDuration
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Re: Deciding on Medigap vs Medicare Advantage

Post by ModifiedDuration »

anonenigma wrote: Thu Mar 23, 2023 10:33 am FYI, your medical eye care (ophthalmologist) is covered by Medicare, though not refraction, which costs perhaps $50. I've recently switched to buying my glasses at Costco, which is way less expensive than the Luxottica cartel.
You may want consider trying Zenni online. I have had great success with them.
CharlatanPrime
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Re: Deciding on Medigap vs Medicare Advantage

Post by CharlatanPrime »

Last year when I hit 65 I used a Medicare brokerage service (or whatever they're called) which took all my health info and spit out that I should join a MA plan. I did it. Mid-year my hip started acting up and the x-rays showed I had bone-on-bone action, so the orthopedist scheduled me for a total hip replacement in the end of June. A couple of days prior to the replacement, the doctor's office called and said although they had tried and tried, the insurance agency would not approve the operation, because (according to some sort of checklist they go through) I had not tried physical therapy. My doctor was furious with them but there was nothing we could do.

So I dutifully did 3-4 weeks of PT on both legs. At the end of the PT time I was re-evaluated and the PT people said I still needed an operation. So I was then able to get approval for the hip replacement and it occurred last November.

I was fortunate in that I didn't have a ton of pain so putting the operation off a little bit didn't cause great issues. It was a pain in the neck (uh, hip) regardless.

My plan does not cost anything (or rather $0 per month). All the doctors I was going to prior to Medicare are in the network, so I didn't have to change anything in that regare. After all the PT and operations I had to pay $40 per PT session, and $1250 for the hip replacement (but strangely enough I got $1000 back from the hospital two months later. Not sure what happened there). I pay <$10/mo for the two tier 1 prescription drugs I take. My plan includes dental checkups and an annual vision exam and I think has eyeglass credits. So the cost feels low to me. My budgeting software says I spend an average of $40/month on healthcare. I am pretty healthy outside of my hips and don't need much in the way of doctoring.

My wife used the same brokers and her evaulation said she should use a Medigap policy and a specific drug plan. Her medical situation is much more complicated than mine with respect to both health and medications. She pays a monthly premium of $115, and her drug plan was like $10 but she switched to one that's $30/mo this year. Her plan does not include dental or eyeglass credits (I don't think it does!) and she's been spending around $300 (including the premiums) per month on healthcare. She takes a couple of expensive meds (some of which aren't covered) and goes to multiple doctors monthly.

I guess out of all this, my recommendation would be to use a broker or Medicare advice agency or whatever they're called. You don't pay them, and the one I used did a good job of steering us to plans that worked well for us.
Northern Flicker
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Re: Deciding on Medigap vs Medicare Advantage

Post by Northern Flicker »

Tom_T wrote: Thu Mar 23, 2023 8:33 am
ModifiedDuration wrote: Thu Mar 23, 2023 8:12 am
Tom_T wrote: Thu Mar 23, 2023 8:00 am I feel like I'll end up spending a lot more on Medigap without really needing it, especially prescriptions. If my health remains good for the next few years, I think I could switch to Medigap if I wanted to and not have to worry about being declined. But my main concern is the "what ifs."
If you sign-up for a Medicare Advantage Plan now in New Jersey and then decide in a few years that you want to switch to Original Medicare, you would then be subject to medical underwriting in order to get a Medicare Supplement Plan.

Have you considered a high-deductible Plan G?
I meant that I think I'd be okay with the underwriting later on, although of course there are no guarantees.
I suspect that your view of what would be a disqualifying condition differs from, and is less stringent than the insurer's view.

My understanding is that you can switch from MA to OM without needing to clear underwriting for the first 12 months you have MA. This would mean, for instance, that you can enroll in MA at age 65, and then switch to OM at the next open enrollment. If an MA plan has the same or a similar network to your ACA plan, that would be pretty seamless. (I probably would not switch providers for less than 12 months only to switch again).

One thing to factor into a plan N vs plan G comparison is that plan G covers surcharges by providers who don't accept Medicare assignment. This could increase the plan N copays/coinsurance.
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Tom_T
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Re: Deciding on Medigap vs Medicare Advantage

Post by Tom_T »

Northern Flicker wrote: Thu Mar 23, 2023 1:04 pm
Tom_T wrote: Thu Mar 23, 2023 8:33 am
ModifiedDuration wrote: Thu Mar 23, 2023 8:12 am
Tom_T wrote: Thu Mar 23, 2023 8:00 am I feel like I'll end up spending a lot more on Medigap without really needing it, especially prescriptions. If my health remains good for the next few years, I think I could switch to Medigap if I wanted to and not have to worry about being declined. But my main concern is the "what ifs."
If you sign-up for a Medicare Advantage Plan now in New Jersey and then decide in a few years that you want to switch to Original Medicare, you would then be subject to medical underwriting in order to get a Medicare Supplement Plan.

Have you considered a high-deductible Plan G?
I meant that I think I'd be okay with the underwriting later on, although of course there are no guarantees.
I suspect that your view of what would be a disqualifying condition differs from, and is less stringent than the insurer's view.

My understanding is that you can switch from MA to OM without needing to clear underwriting for the first 12 months you have MA. This would mean, for instance, that you can enroll in MA at age 65, and then switch to OM at the next open enrollment. If an MA plan has the same or a similar network to your ACA plan, that would be pretty seamless. (I probably would not switch providers for less than 12 months only to switch again).

One thing to factor into a plan N vs plan G comparison is that plan G covers surcharges by providers who don't accept Medicare assignment. This could increase the plan N copays/coinsurance.
I suspect you are right, and it wouldn't be a surprise if the conditions were much stricter than I imagine.

I'll definitely look into all of this a lot more, but my gut is telling me that Plan G is the best long-term solution.
vested1
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Re: Deciding on Medigap vs Medicare Advantage

Post by vested1 »

The OP may have this single opportunity to get the plan which covers the most under any circumstance, which is Plan G. The OP stated that he/she doesn't think they would have any problems passing underwriting, but no one knows when a disqualifying health problem might arise. If we did we wouldn't buy insurance until right before we needed it.

I attended a non-biased Medicare seminar and also consulted a non-biased Medicare consultant, and both told me that neither my wife nor myself could pass underwriting if we transitioned to MA and wanted to get back to OM. The questions might surprise you. Have you had an operation in the last two years, do you have COPD, asthma, do you take more than two medications for blood pressure and/or heart disease, what is your BMI, have you ever had cancer or have been diagnosed, even mistakenly with any number of diseases.

My wife and I have Plan N, which is less expensive than G, but we always wait with bated breath when we see a bill coming in informed delivery. If you have plan N the provider is allowed to charge you excess charges that aren't covered by Part B and Plan N. My wife had outpatient knee replacement surgery a month ago and was in the hospital for about 8 hours before being released.

Her total bill was $58,232. Medicare paid $11,796. Plan N paid $1,899. When you have Plan N the provider is allowed to charge 15% above Medicare's approved amount (total $13,808) which would be $15,879. That means we could be on the hook for the $2,184 that neither Medicare nor Plan N covered if the provider wants to bill us for that. That is over and above any deductible or copay. Most providers don't bill the excess charges, but my wife has specialists who do. Plan N has no maximum OOP either. Our Plan N through AARP UHC has co-pays for almost everything.

We pay a total of $270 a month combined at ages 69/70 for our Plan N premiums. We pay $24 a month combined for our Plan D coverage with a hefty deductible. The OOP max for prescriptions will be $2,000 per person on Medicare starting in 2025.

With a non-HD Plan G, after you pay the Part B deductible, you should get no bill.

Medicare Advantage is a non-starter for us.
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cheese_breath
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Re: Deciding on Medigap vs Medicare Advantage

Post by cheese_breath »

Tom_T wrote: Thu Mar 23, 2023 8:00 am ... I feel like I'll end up spending a lot more on Medigap without really needing it...
How much have you spent over your life on home owners and auto insurance without really needing it? Or life insurance?
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Re: Deciding on Medigap vs Medicare Advantage

Post by nisiprius »

A lot of discussions of Medigap versus Medicare Advantage smuggle in an assumption that you have a good handle on your personal future health costs. E.g. if you don't expect to be using much medical care because you're young, healthy, and work out, blah blah blah. This is an illusion. You don't really know what your medical costs will be, and to the extent that you do know, the insurance company has better information than you do.

I don't really understand whether disclosure of the "medical loss ratio" is mandated at the state or federal level, but one rational way to compare the value of the plans is to compare the "medical loss ratio," the percentage of the premium that is actually spent on providing medical care.

If the medical loss ratio is about the same and the Medicare Advantage plan costs less, then it is straightforward: you are paying less because you are, in fact, getting less insurance.
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Tom_T
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Re: Deciding on Medigap vs Medicare Advantage

Post by Tom_T »

cheese_breath wrote: Thu Mar 23, 2023 2:43 pm
Tom_T wrote: Thu Mar 23, 2023 8:00 am ... I feel like I'll end up spending a lot more on Medigap without really needing it...
How much have you spent over your life on home owners and auto insurance without really needing it? Or life insurance?
That's different. There's no alternative to insurance other than self-insuring. There is a reasonable alternative to Medigap, one that a number of BHers use.

That said, I did say that Medigap seems like the better long-term solution even if there are more upfront costs. My intention was not to make this thread another debate on the two. I received a lot of helpful information.
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Re: Deciding on Medigap vs Medicare Advantage

Post by Agent 99 »

MrRe did an exhaustive analysis of Medigap options last year. MrRe is a NJ resident. You might find something useful in this thread to help make your decision.

viewtopic.php?t=374687&start=100
Northern Flicker
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Re: Deciding on Medigap vs Medicare Advantage

Post by Northern Flicker »

Some detailed data and analysis on MA vs OM:

https://www.vox.com/policy/2023/3/17/23 ... ent-growth
Chuckles960
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Re: Deciding on Medigap vs Medicare Advantage

Post by Chuckles960 »

Tom_T wrote: Thu Mar 23, 2023 4:42 pm
cheese_breath wrote: Thu Mar 23, 2023 2:43 pm
Tom_T wrote: Thu Mar 23, 2023 8:00 am ... I feel like I'll end up spending a lot more on Medigap without really needing it...
How much have you spent over your life on home owners and auto insurance without really needing it? Or life insurance?
That's different. There's no alternative to insurance other than self-insuring. There is a reasonable alternative to Medigap, one that a number of BHers use.
No, it is not really different. Insurance vs no insurance is qualitatively the same dilemma as more vs less insurance.

If you have enough money in the bank that you can self-insure up to the max OOP for unforeseen expenses, sure, get the lower coverage. There is no one-size-fits-all answer. But it is a big mistake to assume that the current situation is always going to be the situation. It is just as in investing---when inflation is low, everyone starts to assume it will always be low; or when the stock market keeps going up for a few years, people assume it will always go up. But that's not how it works. As others have said upthread, insurance is about the things you cannot foresee.

Incidentally, to state the obvious, if the only consideration is saving money, the best deal is always no insurance at all. On the average, you will save money since the insurance companies are profiting off their customers. But first you have to answer the Clint Eastwood Question.
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Re: Deciding on Medigap vs Medicare Advantage

Post by rivercrosser »

Carl53 wrote: Thu Mar 23, 2023 9:29 am I chose Part G and Part D a few years ago. In five years the Part G has gone from $106 to $165/month. I tried changing companies with the latest increase, and was asked some underwriting questions. I have been super healthy but honestly answered I had a minor elective surgery that I was considering and was rejected. Part D was $31 and now is less than $6 as I switched companies a few years ago. Seemed that I could get my few drugs written as 90 day generics and get them via GoodRx cheaper than using the insurance plan. The $6 prevents me from paying the uninsured tax penalty.

All this said, I would get Part G again, but maybe ask more questions of the provider as to understand how its priced. Anecdotal stories about those on MA having care curtailed by AI algorithms make it not worth exploring for a few bucks.
I'm lucky here in Missouri. I have a plan G and can change companies on the anniversary of my plan without any questions asked.
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Re: Deciding on Medigap vs Medicare Advantage

Post by enad »

Tom_T wrote: Thu Mar 23, 2023 9:05 am Thanks, this is all helpful. I don't turn 65 until the end of the year, so I've got some time to think about this.
If you have a younger spouse who is still working you may be able to stay on her plan through her employer until she no longer has the plan and then you'd be allow to choose a Medicare plan or even Advantage if it suits you

Also if you have good health now, it's one thing but what if something happens in 5 years? If you pick an Advantage plan and may want to go into regular Medicare you'll be subject to underwriting with no guarantee of being able to get back to regular Medicare.
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Re: Deciding on Medigap vs Medicare Advantage

Post by 22twain »

vested1 wrote: Thu Mar 23, 2023 1:47 pm The OP may have this single opportunity to get the plan which covers the most under any circumstance, which is Plan G. The OP stated that he/she doesn't think they would have any problems passing underwriting, but no one knows when a disqualifying health problem might arise. If we did we wouldn't buy insurance until right before we needed it.
I went with traditional Medicare with a plan G supplement four years ago, as did my wife a few years earlier, because we live in a small town in a mostly rural area with limited Medicare Advantage plans. We wanted to maximize flexibility in choosing medical providers. A colleague's mother had been refused coverage by her Medicare Advantage plan for treatment at a major cancer center in an adjacent state.

I was basically healthy at that time. Two weeks ago, at age 69, I was diagnosed with very early stage prostate cancer. Now I'm really glad I have my current coverage.
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Re: Deciding on Medigap vs Medicare Advantage

Post by jmw »

Tom_T wrote: Thu Mar 23, 2023 8:33 am
I meant that I think I'd be okay with the underwriting later on, although of course there are no guarantees.
When you truly need Medigap, you will not pass underwriting. It's not really a matter of maybe you will pass underwriting when you need it. You won't pass. Go cheap and pound foolish with disAdvantage at your own risk. If you are financially set, get the Medigap. Only poor people take Advantage.
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Re: Deciding on Medigap vs Medicare Advantage

Post by Tom_T »

jmw wrote: Fri Mar 24, 2023 1:39 am Only poor people take [Medicare] Advantage.
You may get some pushback on that statement.
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Re: Deciding on Medigap vs Medicare Advantage

Post by cheese_breath »

Tom_T wrote: Fri Mar 24, 2023 4:42 am
jmw wrote: Fri Mar 24, 2023 1:39 am Only poor people take [Medicare] Advantage.
You may get some pushback on that statement.
I agree with that. Personally I'm on medigap plan G, but there are some very intelligent, and probably richer people than me here with MA.
The surest way to know the future is when it becomes the past.
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Re: Deciding on Medigap vs Medicare Advantage

Post by CloseEnough »

Tom_T wrote: Fri Mar 24, 2023 4:42 am
jmw wrote: Fri Mar 24, 2023 1:39 am Only poor people take [Medicare] Advantage.
You may get some pushback on that statement.
I agree with the pushback. OP, I am not a fully knowledgeable person about all the intricacies of this issue, but seems to me you have and are analyzing it correctly (if that is even possible). As I understand it, as a healthy person (now) with low use of medical you are making a decision to go with a much lower cost alternative (MA) with the idea that you will switch to OM and supplement (with all the advantages, but higher cost) before an intervening health issue makes the switch difficult. So, for example, if you stay healthy until 70 (that a roll of the dice, but seems like a good bet), maybe you switch over then. The risk is that some unknown health problem occurs before you make the switch that is both not covered as well by MA and makes the switch more difficult. Or that you just become enamored of the lower cost health and don't switch. My last comment is because it does seem that at some point most people are better off with OM and a supplement compared to MA. Good luck, not easy decision.
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Re: Deciding on Medigap vs Medicare Advantage

Post by ehh »

enad wrote: Fri Mar 24, 2023 1:15 am Also if you have good health now, it's one thing but what if something happens in 5 years? If you pick an Advantage plan and may want to go into regular Medicare you'll be subject to underwriting with no guarantee of being able to get back to regular Medicare.
During the annual "enrollment" period you can switch from MA or original Medicare. Without being subject to underwriting.

In most states, if you switch from MA to original Medicare and wish to purchase Medicare supplemental insurance (Plan G, etc) you will be subject to medical underwriting. And may either be denied Medicare supplemental coverage or be placed into a higher risk pool - and pay higher rates for your supplemental coverage.

In 2018 1 in 10 Medicare recipients were on Traditional Medicare with no supplemental coverage. That is, 9 in 10 Medicare recipients were either on MA or on Traditional Medicare with supplemental coverage (Medigap, employer sponsored supplemental, or Medicaid). https://www.kff.org/medicare/issue-brie ... s-in-2018/
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Re: Deciding on Medigap vs Medicare Advantage

Post by kd2008 »

cashmoney wrote: Thu Mar 23, 2023 11:21 am
There probably is data on this somewhere in the CMS data. I am more aware of the members hitting MOOP because they are more apt to bring it up. From my antidotal observation from speaking to many MA consumers the ones who do not have a hospital stay in the year with the typical number of doctor visits , diagnostic test ,out patient services etc may spend 200- 700.000 annual .The biggest reason one hits the MOOP is the 20% for chemo and dialysis however many middle class retirees can get help with this co insurance through different programs/foundations s

On the flipside of this the same person who has plan G may see the Medicare supplement G has paid out claims of 150-350.00 annual in this typical year. IMO the biggest reason to choose original medicare with a medigap is not financial protection but to avoid managed care and have complete flexibility on providers. This year i have had more of my medicare supplement clients call me and want to switch to MA plans. This has been a trend as medicare supplements premiums have been increasing and MA plans have been improving- in Florida especially. In fact as of 6/1 the biggest medicare supplement provider and long time rate leader in Florida UHC had their biggest increase ever up about 7% on plan G and 8.5% on plan N. What has really surprised me recently is the number of long time Mayo clinic patients who had Medicare supplements be willing to give up access to Mayo to get a MA plan-that never use to happen.

Of course all of this depends on where you live because some states like florida have high medicare supplement rates and very good MA plans and some states may have low medicare supplement rates and not so great MA options .

disclaimer licensed agent-not recommending any plans.
This post has so much wisdom and insightful information that I have looked but not found elsewhere. Thank you from the bottom of my heart.

When my DH goes on Medicare, we will most likely choose plan G for the reasons you listed. But we have options of MA plans - UHC plan and a local network called Community Care that may work out as well for most part and we will be ok and be cheaper.

Medical Savings Account (MSA) plans are an interesting wrinkle. They are a MA plan. $0 premiums. One can use any Medicare accepting provider nationally. $2000 per year in the savings account. $5000 deductible. $2000 can be used for vision and dental as well. The money is yours to use later on medical care if you don't spend it.

There is an option of $3000/yr savings account contribution plan with $8000 deductible.

Others Options I was thinking (not for us but in general):

1. Use this plan 65-70 and bank $10,000. Then go onto a traditional MA plan. Works if you are healthier. (Lucky few)

2. Use traditional MA plan and save on costs. If need be, go on to this plan if you need wider network. (Harder to do this when you need it and are sick, and need to be somewhat affluent to pay the deductible)

The deductible here is a true deductible, and not the faux deductible of plan G-HD where 80% is paid by part B.

Of course, waiting for Annual enrollment for MA plans is a hurdle.
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Re: Deciding on Medigap vs Medicare Advantage

Post by Northern Flicker »

cashmoney wrote: IMO the biggest reason to choose original medicare with a medigap is not financial protection but to avoid managed care and have complete flexibility on providers.
Except it is not complete flexibility on providers. This may just apply to people who live in an area served by Kaiser, but Kaiser is an example of a large provider that does not accept original Medicare. A Medicare recipient who wishes to receive care from Kaiser has to choose a Kaiser Advantage plan.

There are other providers who do not accept Medicare.

Generally, I think MA plans run by insurance foundations associated with large care providers, which generally are large provider organizations in urban areas, can be good medicare choices. People who live in smaller communities may lack access to good MA plans, and even in urban areas, there are bad MA plans.
Last edited by Northern Flicker on Fri Mar 24, 2023 2:10 pm, edited 1 time in total.
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Re: Deciding on Medigap vs Medicare Advantage

Post by twh »

Aside from the normal POS and MA differences, one of the main points if you go with MA, is to avoid the regional only plans. The national plans from, for example AARP UHC, give you the flexibility to have two residences or travel without worrying about being out of network if something were to happen.
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Re: Deciding on Medigap vs Medicare Advantage

Post by Northern Flicker »

Another trend in some parts of the country is a move toward the concierge model. Concierge practices can charge a membership fee (that Medicare will not cover) and still accept original Medicare patients.

https://www.medicare.gov/coverage/concierge-care
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Re: Deciding on Medigap vs Medicare Advantage

Post by GerryL »

Been on Medicare for 7+ years now. Like the OP, I don't tend to use a lot of healthcare services in a "normal" year. Opted for traditional Medicare with a high-deductible supplement. (Initially F-HD, switched to G-HD when that became available.)

I take several maintenance drugs that are available as generics. By reviewing Part D plans each year during open enrollment, I have gradually seen my premium go down from over $10/mo to $1.60/mo. (Cost of a generic prescription has been as low as $0 for a 3-month supply and is currently $2/mo.)

Even last year, when I had more doctor visits and procedures than usual, my Medicare deductible plus 20% copays did not come anywhere close to reaching my max oop, which is around $2500. In the meantime, I am paying only $45/mo for Medigap plus my Part D costs and Medicare Part B (withheld from SS). Oh, and I have vision coverage at under $7/mo.

Seems like a pretty good deal. And if I start having bad years, I know I can cover the "high" deductible. Just wish I had help with dental expenses. I'm in the process of getting an implant, and even with the 15% discount my long-time dentist is giving me, just this one "treatment" will cost way above my Medicare high deductible.
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Re: Deciding on Medigap vs Medicare Advantage

Post by jmw »

cheese_breath wrote: Fri Mar 24, 2023 6:35 am
Tom_T wrote: Fri Mar 24, 2023 4:42 am
jmw wrote: Fri Mar 24, 2023 1:39 am Only poor people take [Medicare] Advantage.
You may get some pushback on that statement.
I agree with that. Personally I'm on medigap plan G, but there are some very intelligent, and probably richer people than me here with MA.
OK, there are also some intelligent and richer people here who buy used tires or Chinese tires or postpone replacing the water heater until hot showers are less than 5 minutes because they get away with it. I don't like gambling when the downside is much larger than the amount I save by going cheap including the irrevocable decision to go with MA.

I admit there was a thread about an MA plan from IBM that looked fantastic. I admit I would have a lot of trouble choosing Medigap vs that particular IBM MA plan assuming IBM doesn't rugpull its retirees in a way that doesn't allow going back to Medigap in year 2+. Nevertheless, MA is almost always bad.

I buy Medigap, new tires well above Chinese tire quality, synthetic oil, replace the water heater just after the year the warranty expires (9 years), $500k liability limits on auto insurance, etc.

I cheap out by not eating out very much, higher deductibles on insurance, not buying the current flagship smartphone, never buying new cars, etc. Medigap doesn't belong in the cheap out category unless you are poor because the downside risk is huge due to the near guaranteed certainty of failing medical underwriting when you need it due to life threatening cancer or whatever. In other words, buy a 5-year old used car instead of new and use the savings to pay for the Medigap instead of MA.

I'm sorry if you made the long-term wrong decision to get a free gym membership, free dental, cheap RX generics, and premium discounts or no premiums from disAdvantage. Penny wise and pound foolish.
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Re: Deciding on Medigap vs Medicare Advantage

Post by Tom_T »

Can someone on G-High switch to G later on, or is that a potential problem?
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Re: Deciding on Medigap vs Medicare Advantage

Post by orlandoman »

Medicare – 3 Types of People
- people who have decided on a Medicare Advantage plan
- people who have decided on Traditional Medicare, with or without a supplement
- people who haven’t decided yet or are reconsidering

For those who haven’t decided yet or are reconsidering, here are the variable factors (summary):
1. Price of plan (many/most MA plans have no monthly premium, supplements have a monthly premium)
2. Deductibles
3. Co-pays
4. Out of pocket maximum’s
5. Extra benefits: prescriptions, dental vision, OTC, etc. (not offered with Traditional Medicare)
6. Medicare Advantage HMO or PPO Networks
7. Medical procedure/test prior authorization requirements

On a Medicare Advantage plan, all of the above can change on a yearly basis.

I also suggest those on or considering a MA plan, get the full Plan document and search for ‘prior authorization’ and note how many times that occurs.

Only very limited changes can be made on Traditional Medicare, for example when the annual Part B deductible went from $203 in 2021 to $233 in 2022 to $226 in 2023.

Part D prescription plans if chosen, can change plan price or prescription price/benefits on an annual basis.
Last edited by orlandoman on Fri Mar 24, 2023 5:52 pm, edited 1 time in total.
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Re: Deciding on Medigap vs Medicare Advantage

Post by dagsboro »

Advantage plans are great until they are not and I have been reading about many cases when they are not.
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Re: Deciding on Medigap vs Medicare Advantage

Post by GerryL »

Tom_T wrote: Fri Mar 24, 2023 4:18 pm Can someone on G-High switch to G later on, or is that a potential problem?
Most states, no, not without underwriting. There are a few states (Massachusetts? NY?) that allow switching pretty freely.
In a few states (Oregon, for one) you can change plans (usually in birth month) but only laterally (same plan different company) or down. G-HD to G would be considered a move to a higher-level plan.
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Re: Deciding on Medigap vs Medicare Advantage

Post by Northern Flicker »

Tom_T wrote: Fri Mar 24, 2023 4:18 pm Can someone on G-High switch to G later on, or is that a potential problem?
Not in most states. Where I live, one can switch from G to G-HD but not the other way around.

In many ways, the cash flows for care with G-HD are similar to a MA plan.

Pre-authorization of care is not advantageous, but it is not always a bad thing either. It does reduce unnecessary procedures. And original Medicare has authorization procedures. I have personally seen Medicare start denying coverage for some regular procedures a relative was getting for 6 months, on a weekly basis, that seemed to be doing little more than enriching the provider and causing distress for my relative. This would have been shut down faster with an MA plan.

It is incorrect to assume that the personal control of original medicare will prevent this scenario. It takes a while to understand what is happening.
Last edited by Northern Flicker on Fri Mar 24, 2023 5:01 pm, edited 2 times in total.
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