Medicare Question

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Munir
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Location: Oregon

Re: Medicare Question

Post by Munir »

Music Teacher Tim wrote: Thu Mar 30, 2023 10:21 pm OP here: Please, please keep the comments coming. This is so helpful you can't believe it. There are just so many considerations, and so much fear about making the wrong decision that you can't undo, it's overwhelming. Every time I think I have a direction, something else pops up to make me wonder. That's a good thing though, I don't want to look back and say I wish I had known that. I am still leaning towards a medigap plan, but need to go back and study the posts so far in estimating what my future costs may be. I realize, like it was mentioned, that the estimates are not likely to be very accurate, but I still need to try. By the way, the high deductible plan G I know about, but haven't even put much thought into that one yet, but I will.
Having an original (traditional) Medicare policy plus a Medigap policy give you the most predictable and consistent financial numbers for a year. It should be zero out of pocket unless you have some expenditures not approved by Medicare- which is rare. I have had a number of major surgeries and not paid a cent out of pocket (medications are a different story). No co-pays and no deductibles but only the monthly fees for the Medigap policy and the traditional medicare fees paid out of your social security benefit..
AkBrian
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Joined: Fri Jul 19, 2019 2:13 pm

Re: Medicare Question

Post by AkBrian »

McDougal wrote: Fri Mar 31, 2023 7:53 am
Big Dog wrote: Thu Mar 30, 2023 6:37 pm
Agent 99 wrote: Thu Mar 30, 2023 6:15 pm
Music Teacher Tim wrote: Thu Mar 30, 2023 12:36 pm OP here: I looked on the medicare.gov site at plan G pricing. I saw that AARP had a plan G medigap plan that was "community pricing" which is supposed to be the same price for everyone regardless of age or gender (as opposed to attained age or issue age). However, when I put in various ages, I got different premiums ($152 age 65, $224 age 75, and $238 age 85). So I don't get that at all. How is it community based pricing if everyone is being quoted various amount?
According to the link in the post about changing Medigap plans annually there are no community rated plans in CA. Maybe “community pricing” is just a marketing buzzword.

Community rating (also known as “no age” rating) means that rates do not vary with age at all, but there are no Medigap insurers in California that use community rating (several states require community rating or issue-age rating, but California is not among thEm
According to the State's website, the United Health/AARP plan is Community Rated. (It's the only CR-rated plan offered in my zip code.). But yes, they offer 'discounts' to those young seniors.

https://interactive.web.insurance.ca.go ... f?p=111:30
Hmmm. I live in Georgia. According to this site, it states the following - "Medigap plans in Georgia are required to use issue-age rating (premiums do not increase based on an enrollee’s increasing age) or community rating."

I am 67 and have not yet applied for Medicare Part B as I am covered under my still-working spouse's plan. This makes me think I might want to enroll in Medicare B now (I am enrolled in Part A) to "lock-in" an age-related premium as opposed to waiting until around age 70. Before I start doing a lot of math, does anyone have any thoughts on an obvious way to proceed? Thanks!
What I did was go to the AARP-UnitedHealthcare website; https://www.aarpmedicaresupplement.com/ , put in zip code, then go to the bottom of the page and download where it says "rate sheets". There are both groups and levels. The way their rates are structured in my zip code is like this;

Group One (Applies to individuals whose plan effective date will be within ten years following their 65th
birthday or Medicare Part B effective date, if later)

Standard rates within Group One (either guaranteed issue or can pass medical underwriting)
Rates get higher each year for ages between 65 to 76
Rates top out at 77, then no longer increase due to age.

Level 2 rates within Group One (not guaranteed issue and have health problems)
one (high) rate for all ages 65 and up.
-------
Group Two (Applies to individuals whose plan effective date will be ten or more years following their 65th
birthday or Medicare Part B effective date, if later.)

Level One within Group Two (either guaranteed issue or can pass medical underwriting)
1 rate for ages 75 and up

Level Two within Group Two (not guaranteed issue and have health problems)
1 higher rate for ages 75 and up

All this of course my vary between states and zip codes.
Edit to add: Medicare calls this an "issue age pricing" policy.
Lynette
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Joined: Sun Jul 27, 2014 9:47 am

Re: Medicare Question

Post by Lynette »

I was forced to change to UHC Medicare Advantage PPO by my former employer or lose my $3,000 annual benefit. I am finding the UHC Medicare Advantage PPO much simpler as I do not need to sign up for Medicare Part D and do the annual hassle of comparing drug plans. I did a lot of research as I was not pleased with being forced to make the change. I think a major consideration is if your plan is a PPO and the health care plan you choose is well-represented in your area. In my area all of the specialists and hospitals I use accept my plan. My PCP told me 50% of his patients used Medicare Advantage. The main issue raised against Advantage plans is that you have to go through pre-approval. My PCP recommended that I pick Medigap G or Advantage dependent on which one was cheapestl

I am in my late seventies and in good health. The UHC Advantage PPO plan is much, much cheaper for me than the AARP UHC Medigap G. I was paying about $2400 for AARP Medigap G and $840 p.a for Part D. With my Advantage plan I do not pay a premium and pay nothing for my only statin drug as it is not even tier 1. I think most Advantage plans have options for no premium, dental, vision and hearing aids benefits.

My former employer is contributing to my UHC Employer Sponsored plan and so is probably offers more advantages that standard Advantage plans. On Monday, I am having a Nurse Practisioner come to my house and spend an hour with me. This is in addition to my annual wellness checks. Some claim the purpose of these house calls is so that that the health care companies are trying to make their clients sicker than they are to get more money from the government. I agreed to this as I sprained my ankles and was too lazy to go to the doctor. I will see how it works out. My only complaint was that I had to really clean my house. My maximum out of pocket for my plan is $750 per annum. I get all kinds of additional benefits such as 140 free meals, $160 to OTC, and there are a large number of options for free medical transportation (and meals) if I am hospitalized. I even get 8 hours for someone to clean my house.

The UHC reps are extremely respnsive and I get someone within a minute. So far, I am extremelympleased with the new Advantage plan - much cheaper and far more benefits.
Chuckles960
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Joined: Thu May 13, 2021 12:09 pm

Re: Medicare Question

Post by Chuckles960 »

Lynette wrote: Fri Mar 31, 2023 5:37 pmOn Monday, I am having a Nurse Practisioner come to my house and spend an hour with me. This is in addition to my annual wellness checks. Some claim the purpose of these house calls is so that that the health care companies are trying to make their clients sicker than they are to get more money from the government. I agreed to this as I sprained my ankles and was too lazy to go to the doctor...
There is no "some claim" about the fact that the nurse's job is to find every way to report that you are sicker than you really are. They are not doing this to help you but so they can find ways to charge Medicare more. If you have sprained your ankles, you may find yourself coded as paraplegic or some such
Topic Author
Music Teacher Tim
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Joined: Mon Dec 19, 2022 12:17 am

Re: Medicare Question

Post by Music Teacher Tim »

"Coded as paraplegic" for a sprained ankle - that's hilarious !!!! Each of these ailments probably get the same treatment anyway.
ModifiedDuration
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Joined: Sat Dec 05, 2015 3:33 pm

Re: Medicare Question

Post by ModifiedDuration »

Chuckles960 wrote: Fri Mar 31, 2023 6:00 pm
Lynette wrote: Fri Mar 31, 2023 5:37 pmOn Monday, I am having a Nurse Practisioner come to my house and spend an hour with me. This is in addition to my annual wellness checks. Some claim the purpose of these house calls is so that that the health care companies are trying to make their clients sicker than they are to get more money from the government. I agreed to this as I sprained my ankles and was too lazy to go to the doctor...
There is no "some claim" about the fact that the nurse's job is to find every way to report that you are sicker than you really are. They are not doing this to help you but so they can find ways to charge Medicare more. If you have sprained your ankles, you may find yourself coded as paraplegic or some such
This appears to be referring to last Fall’s Federal Government’s civil healthcare fraud lawsuit against Cigna, which was about Cigna having home visits that resulted in people allegedly being falsely classified as having chronic conditions, such as chronic kidney disease and congestive heart failure, so that Cigna could get on-going addition risk adjustment payments from Medicare:

“U.S. Attorney Damian Williams said: ‘As alleged, CIGNA obtained tens of millions of dollars in Medicare funding by submitting to the Government false and invalid diagnoses for its Medicare Advantage plan members. CIGNA knew that, under the Medicare Advantage reimbursement system, it would be paid more if its plan members appeared to be sicker. This Office is dedicated to holding insurers accountable if they seek to manipulate the system and boost their profits by submitting false information to the Government.’”

“The healthcare providers (typically nurse practitioners) who conducted these home visits did not perform or order the testing or imaging that would have been necessary to reliably diagnose the serious, complex conditions reported and were prohibited by CIGNA from providing any treatment during the home visit for the medical conditions they purportedly found. The diagnoses at issue were not supported by the information documented on the form completed by the vendor….”

“The Invalid Diagnoses included, but are not limited to, diagnoses for complex medical conditions such as chronic kidney disease, congestive heart failure, rheumatoid arthritis, and diabetes with renal complications…..CIGNA exerted pressure on Vendor HCPs [healthcare personnel] to record high-value diagnoses that significantly increased risk adjustment payments.”

https://www.justice.gov/usao-sdny/pr/un ... lating-its
Lynette
Posts: 2407
Joined: Sun Jul 27, 2014 9:47 am

Re: Medicare Question

Post by Lynette »

Chuckles960 wrote: Fri Mar 31, 2023 6:00 pm
Lynette wrote: Fri Mar 31, 2023 5:37 pmOn Monday, I am having a Nurse Practisioner come to my house and spend an hour with me. This is in addition to my annual wellness checks. Some claim the purpose of these house calls is so that that the health care companies are trying to make their clients sicker than they are to get more money from the government. I agreed to this as I sprained my ankles and was too lazy to go to the doctor...
There is no "some claim" about the fact that the nurse's job is to find every way to report that you are sicker than you really are. They are not doing this to help you but so they can find ways to charge Medicare more. If you have sprained your ankles, you may find yourself coded as paraplegic or some such
Lol. I was stupid doing some exercises three months ago and injured my ankles. I tend to think these things heal by themselves and wanted to avoid all of the doctor stuff. Once I fell and after much examination the technician found a hairline fracture. I had to wear a boot for 6 weeks - including on a trip to South Africa. I don't think it was necessary. I decided to sit in my recliner most of the time and wear a supportive shoes when I walked. I exercised by using my Concept2 rower and recumbent bike. It is three months since the injury and I have started swimming three times a week etc. Now I want to move on with more advanced exercises - and gardening.
Agent 99
Posts: 480
Joined: Wed May 25, 2016 6:44 pm

Re: Medicare Question

Post by Agent 99 »

ModifiedDuration wrote: Fri Mar 31, 2023 6:22 pm
Chuckles960 wrote: Fri Mar 31, 2023 6:00 pm
Lynette wrote: Fri Mar 31, 2023 5:37 pmOn Monday, I am having a Nurse Practisioner come to my house and spend an hour with me. This is in addition to my annual wellness checks. Some claim the purpose of these house calls is so that that the health care companies are trying to make their clients sicker than they are to get more money from the government. I agreed to this as I sprained my ankles and was too lazy to go to the doctor...
There is no "some claim" about the fact that the nurse's job is to find every way to report that you are sicker than you really are. They are not doing this to help you but so they can find ways to charge Medicare more. If you have sprained your ankles, you may find yourself coded as paraplegic or some such
This appears to be referring to last Fall’s Federal Government’s civil healthcare fraud lawsuit against Cigna, which was about Cigna having home visits that resulted in people allegedly being falsely classified as having chronic conditions, such as chronic kidney disease and congestive heart failure, so that Cigna could get on-going addition risk adjustment payments from Medicare:

“U.S. Attorney Damian Williams said: ‘As alleged, CIGNA obtained tens of millions of dollars in Medicare funding by submitting to the Government false and invalid diagnoses for its Medicare Advantage plan members. CIGNA knew that, under the Medicare Advantage reimbursement system, it would be paid more if its plan members appeared to be sicker. This Office is dedicated to holding insurers accountable if they seek to manipulate the system and boost their profits by submitting false information to the Government.’”

“The healthcare providers (typically nurse practitioners) who conducted these home visits did not perform or order the testing or imaging that would have been necessary to reliably diagnose the serious, complex conditions reported and were prohibited by CIGNA from providing any treatment during the home visit for the medical conditions they purportedly found. The diagnoses at issue were not supported by the information documented on the form completed by the vendor….”

“The Invalid Diagnoses included, but are not limited to, diagnoses for complex medical conditions such as chronic kidney disease, congestive heart failure, rheumatoid arthritis, and diabetes with renal complications…..CIGNA exerted pressure on Vendor HCPs [healthcare personnel] to record high-value diagnoses that significantly increased risk adjustment payments.”

https://www.justice.gov/usao-sdny/pr/un ... lating-its
Cigna - any relation to Wells Fargo? :moneybag
Chuckles960
Posts: 920
Joined: Thu May 13, 2021 12:09 pm

Re: Medicare Question

Post by Chuckles960 »

They all do it. Only the most egregious insurance companies get caught.

Why do you think they are eager to do one free home visit when home visits by medical personnel when you have a health need (e.g. are down with a fever) are not available or very expensive and never covered by insurance?

(Remember when actual doctors did home visits? Me neither.)
McDougal
Posts: 557
Joined: Tue Feb 27, 2018 2:42 pm
Location: Atlanta

Re: Medicare Question

Post by McDougal »

AkBrian wrote: Fri Mar 31, 2023 2:06 pm
McDougal wrote: Fri Mar 31, 2023 7:53 am
Hmmm. I live in Georgia. According to this site, it states the following - "Medigap plans in Georgia are required to use issue-age rating (premiums do not increase based on an enrollee’s increasing age) or community rating."

I am 67 and have not yet applied for Medicare Part B as I am covered under my still-working spouse's plan. This makes me think I might want to enroll in Medicare B now (I am enrolled in Part A) to "lock-in" an age-related premium as opposed to waiting until around age 70. Before I start doing a lot of math, does anyone have any thoughts on an obvious way to proceed? Thanks!
What I did was go to the AARP-UnitedHealthcare website; https://www.aarpmedicaresupplement.com/ , put in zip code, then go to the bottom of the page and download where it says "rate sheets". There are both groups and levels.

All this of course my vary between states and zip codes.
Edit to add: Medicare calls this an "issue age pricing" policy.
Exactly what I was looking for, thanks! :beer
Lynette
Posts: 2407
Joined: Sun Jul 27, 2014 9:47 am

Re: Medicare Question

Post by Lynette »

Chuckles960 wrote: Fri Mar 31, 2023 9:41 pm They all do it. Only the most egregious insurance companies get caught.

Why do you think they are eager to do one free home visit when home visits by medical personnel when you have a health need (e.g. are down with a fever) are not available or very expensive and never covered by insurance?

(Remember when actual doctors did home visits? Me neither.)
Yes, I agree but it saves me going to my PCP. The Nurse Practitioner may recommend this irregardless. There may be some really old and sickly people who do not have ready access to transport for whom this is an advantage. In addition, I am told the NP will spend up to an hour with me. I am lucky to get 15 minutes with my PCP.

My advice is still to look at the Medicare Advantage Plans. I am saving about $4,000 p.a. and I am getting great customer support. My only hesitation with Advantage plans is that you may need preauthorization that might affect you when you are really sick.
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cheese_breath
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Re: Medicare Question

Post by cheese_breath »

Chuckles960 wrote: Fri Mar 31, 2023 9:41 pm ... (Remember when actual doctors did home visits? Me neither.)
I remember. The doctor would come to your house with his old fashioned doctor's bag containing his old fashioned stethoscope and a variety of medications. And it always contained exactly what you needed; some kind of pill, syrup, or a shot of penicillin.
The surest way to know the future is when it becomes the past.
tallguy3891
Posts: 703
Joined: Sat Jul 03, 2021 10:47 am

Re: Medicare Question

Post by tallguy3891 »

Lynette wrote: Fri Mar 31, 2023 5:37 pm I was forced to change to UHC Medicare Advantage PPO by my former employer or lose my $3,000 annual benefit. I am finding the UHC Medicare Advantage PPO much simpler as I do not need to sign up for Medicare Part D and do the annual hassle of comparing drug plans. I did a lot of research as I was not pleased with being forced to make the change. I think a major consideration is if your plan is a PPO and the health care plan you choose is well-represented in your area. In my area all of the specialists and hospitals I use accept my plan. My PCP told me 50% of his patients used Medicare Advantage. The main issue raised against Advantage plans is that you have to go through pre-approval. My PCP recommended that I pick Medigap G or Advantage dependent on which one was cheapestl

I am in my late seventies and in good health. The UHC Advantage PPO plan is much, much cheaper for me than the AARP UHC Medigap G. I was paying about $2400 for AARP Medigap G and $840 p.a for Part D. With my Advantage plan I do not pay a premium and pay nothing for my only statin drug as it is not even tier 1. I think most Advantage plans have options for no premium, dental, vision and hearing aids benefits.

My former employer is contributing to my UHC Employer Sponsored plan and so is probably offers more advantages that standard Advantage plans. On Monday, I am having a Nurse Practisioner come to my house and spend an hour with me. This is in addition to my annual wellness checks. Some claim the purpose of these house calls is so that that the health care companies are trying to make their clients sicker than they are to get more money from the government. I agreed to this as I sprained my ankles and was too lazy to go to the doctor. I will see how it works out. My only complaint was that I had to really clean my house. My maximum out of pocket for my plan is $750 per annum. I get all kinds of additional benefits such as 140 free meals, $160 to OTC, and there are a large number of options for free medical transportation (and meals) if I am hospitalized. I even get 8 hours for someone to clean my house.

The UHC reps are extremely respnsive and I get someone within a minute. So far, I am extremelympleased with the new Advantage plan - much cheaper and far more benefits.
Someone might have already mentioned this, but some employers offer their Medicare Advantage Plans through something called Medicare Employer Group Waiver Plans (EGWP). I have heard that these are supposedly "better" than Advantage plans offered to the public in that they have enhanced benefits and often are PPO plans. These EGWP plans might be the reason some people seem to really like Advantage Plans and some do not. Apparently two different things but I do not know if there is a difference in the administration of EGWP plans versus "regular" Advantage (such as pre-authorization, approvals, Rx, extra benefits, etc.).
Lynette
Posts: 2407
Joined: Sun Jul 27, 2014 9:47 am

Re: Medicare Question

Post by Lynette »

tallguy3891 wrote: Sat Apr 01, 2023 10:59 am Someone might have already mentioned this, but some employers offer their Medicare Advantage Plans through something called Medicare Employer Group Waiver Plans (EGWP). I have heard that these are supposedly "better" than Advantage plans offered to the public in that they have enhanced benefits and often are PPO plans. These EGWP plans might be the reason some people seem to really like Advantage Plans and some do not. Apparently two different things but I do not know if there is a difference in the administration of EGWP plans versus "regular" Advantage (such as pre-authorization, approvals, Rx, extra benefits, etc.).
Medicare Advantage plans are so confusing as there is a great number of them and even a variation in one provider. A key factor is whether the provider has a large presence in the area in which you reside so that you can chose doctors, specialists and hospitals that are in network. I found this article on why medicare advantage plans are becoming more popular.

https://www.bcbs.com/the-health-of-amer ... -advantage

I think the main reason that people chose medigap plans is that stories that are spread that medicare advantage requires pre-authorization and one's doctor's recommendation may be turned down when one is really ill. I changed from medigap to advantage because my employer forced us to in order to retain our subsidy.

I have nothing further to add. Best wishes to everyone trying to navigate this confusing decision one has to make. Best wishes for good health as well.
nonnie
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Joined: Thu Mar 13, 2008 8:05 pm

Re: Medicare Question

Post by nonnie »

Music Teacher Tim wrote: Thu Mar 30, 2023 11:37 pm Thanks TJ, I will look into that tomorrow for sure.
80 y. o. In California. Just switched from Mutual of Omaha -cheapest policy with my broker last year, new rate was $245 per month--to USAA at $200 per month. Slightly embarrassed I didn't think to check USAA earlier but they are definitely the very cheapest we could find for Plan G. We had been switching plans every couple of years depending on price. I was able to switch to USAA early and pass underwriting but my spouse had to wait for his birthday month then didn't require underwriting.

Check the Medicare website to find the cheapest plan. Check with the broker if you wish but make sure you they offer the cheapest plan otherwise you need to purchase direct.

One consideration for original Medicare versus Medicare Advantage for my point of view is the ability to pick most any doctor or specialist in the US should an extremely serious condition arise where one would want the best --or perhaps a consult-- and not be worried about going out of network.

Another thing we have found over just the past half dozen years with increasing shortage of physicians in Northern California is that many primary physicians have monthly quotas for accepting Medicare patients. We mostly use the Sutter Health Network and as of a couple years ago they have required a primary physician referral to a specialist within the network. We've never been turned down and it's mostly paperwork. However, depending on the specialty, there can be a several months wait for an appointment. There is a shortage of neurologists in pulmonologists and wait times can be 2 to 3 months. Not really to do with your original question but as the cost of living soars, young physicians cannot afford to relocate.
Topic Author
Music Teacher Tim
Posts: 75
Joined: Mon Dec 19, 2022 12:17 am

Re: Medicare Question

Post by Music Teacher Tim »

Nonnie, can you expand on what you said about waiting for an appointment in the network? I thought the whole point of Medigap was that there were no networks. I thought that was the main benefit of a plan G like you mentioned.
tj
Posts: 9368
Joined: Wed Dec 23, 2009 11:10 pm

Re: Medicare Question

Post by tj »

Music Teacher Tim wrote: Sat Apr 01, 2023 5:09 pm Nonnie, can you expand on what you said about waiting for an appointment in the network? I thought the whole point of Medigap was that there were no networks. I thought that was the main benefit of a plan G like you mentioned.
Medicare lets you use whoever you want, doesn't mean a doctor's group has to accept everybody.
capran
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Joined: Thu Feb 18, 2016 9:45 am

Re: Medicare Question

Post by capran »

arcticpineapplecorp. wrote: Tue Mar 28, 2023 9:43 pm original medicare covers 80% of the care. The other 20% would be covered if you sign up for a medigap plan or choose medicare advantage (which takes over for original medicare).

you do have a medicare deductible with part B which is coverage for your doctors ($226 for 2023) to reach first before medicare kicks in it's 80% coverage. source: https://www.humana.com/medicare/medicar ... les-review

I wouldn't just have parts A&B only. I'd either get a medigap plan or medicare advantage.

You might want to check with your SHIP state health insurance assistance program and ask a lot of questions before signing up.

you also might want a part D (drug plan) if you need medications. Part A, B and medigap does not cover that.
It is my understanding that you need either a plan D or an advantage plan that covers meds. I believe if you do not have some form of Medication coverage, you will pay a severe penalty. In the PNW their "SHIP" info is called SHIBA, and that was immensely helpful getting real factual info from someone not interested in selling you anything. For me, the best fit was Plan F, but spouse was slightly younger and got a plan G, and we both have an Aetna plan D that is super cheap (1.60 each per month). Medicare makes looking for plan D's very easy. Go to Medicare.gov, find the Plan D page, plug in your zip code and any medications you take and it will list every plan D available listed by both monthly plan cost as well as cost of meds you take.
tj
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Joined: Wed Dec 23, 2009 11:10 pm

Re: Medicare Question

Post by tj »

capran wrote: Sat Apr 01, 2023 5:24 pm
arcticpineapplecorp. wrote: Tue Mar 28, 2023 9:43 pm original medicare covers 80% of the care. The other 20% would be covered if you sign up for a medigap plan or choose medicare advantage (which takes over for original medicare).

you do have a medicare deductible with part B which is coverage for your doctors ($226 for 2023) to reach first before medicare kicks in it's 80% coverage. source: https://www.humana.com/medicare/medicar ... les-review

I wouldn't just have parts A&B only. I'd either get a medigap plan or medicare advantage.

You might want to check with your SHIP state health insurance assistance program and ask a lot of questions before signing up.

you also might want a part D (drug plan) if you need medications. Part A, B and medigap does not cover that.
It is my understanding that you need either a plan D or an advantage plan that covers meds. I believe if you do not have some form of Medication coverage, you will pay a severe penalty. In the PNW their "SHIP" info is called SHIBA, and that was immensely helpful getting real factual info from someone not interested in selling you anything. For me, the best fit was Plan F, but spouse was slightly younger and got a plan G, and we both have an Aetna plan D that is super cheap (1.60 each per month). Medicare makes looking for plan D's very easy. Go to Medicare.gov, find the Plan D page, plug in your zip code and any medications you take and it will list every plan D available listed by both monthly plan cost as well as cost of meds you take.
The penalty is for signing up later in life. There's no penalty for not signing up.
ehh
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Joined: Mon Feb 01, 2021 10:04 am

Re: Medicare Question

Post by ehh »

Just so folks are clear on the Part D late enrollment penalty: https://www.medicare.gov/drug-coverage- ... nt-penalty

If you are enrolling in Medicare (Part A and Part B) but don't take any prescription drugs currently, enroll in the Part D plan with the lowest available monthly premium. As capran notes, Part D plans with very low monthly premiums are available.

Chances are you will need prescription drugs at some point in your life. When you do, you don't want to wait until the next open enrollment period (and wait until Jan 1 for coverage to begin). And you don't want to pay the late enrollment penalty for the remainder of your life.
nonnie
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Joined: Thu Mar 13, 2008 8:05 pm

Re: Medicare Question

Post by nonnie »

Music Teacher Tim wrote: Sat Apr 01, 2023 5:09 pm Nonnie, can you expand on what you said about waiting for an appointment in the network? I thought the whole point of Medigap was that there were no networks. I thought that was the main benefit of a plan G like you mentioned.
When I moved to my current area 15 years ago, I chose a primary physician. She is associated with the Sutter Medical Network, one of the larger networks here which also includes hospitals. I generally see mostly doctors who are in this network as I like the care received at the Sutter hospital more than the Providence medical network/hospital are they alternative Kaiser medical group.
"The Sutter Medical Network was created in 2007 to bring physicians across the Northern California healthcare delivery system together to strive to advance the quality, consistency and affordability of care for Sutter Health patients"

Sutter has recently started their own HMO and thus is limiting new Medicare patients with outside insurance plans so that affects one's ability--have no idea what happens to non-Medicare patients, just know Medicare reimbursement generally isn't as generous as other insurance plans.

Should the need arise,I can choose to go wherever I want to any physician or hospital in the United States who accepts Medicare and is not an HMO like Kaiser.

Does that answer your question? I did not mean to confuse you. The ability to get an appointment is constrained by the availability of physicians.
Topic Author
Music Teacher Tim
Posts: 75
Joined: Mon Dec 19, 2022 12:17 am

Re: Medicare Question

Post by Music Teacher Tim »

Thanks but I still am not sure. Let's say that I have medicare and a medigap plan G. Now let's say that I call your doctor for an appointment. Would they take me or reject me since I am not in "their" network. I mean it doesn't sound like you're describing an insurance related network. Does this have something to do with your previous insurance and not straight medicare and plan G. Thanks.
nonnie
Posts: 3014
Joined: Thu Mar 13, 2008 8:05 pm

Re: Medicare Question

Post by nonnie »

Music Teacher Tim wrote: Sat Apr 01, 2023 9:28 pm Thanks but I still am not sure. Let's say that I have medicare and a medigap plan G. Now let's say that I call your doctor for an appointment. Would they take me or reject me since I am not in "their" network. I mean it doesn't sound like you're describing an insurance related network. Does this have something to do with your previous insurance and not straight medicare and plan G. Thanks.
Are you in So. CA? Do you have a primary physician? If they take Medicare you should be OK. I think that's where you should start.

My doctor doesn't have a network-- she has a physican's group with whom she is affiliated. If you call *my* doctor it will be determined if she is accepting new patients. If she is and if her Medicare quotient of patients isn't filled for the month (they were limiting it 15 years ago) you will be accepted into the practice. Then you have to wait 2-2.5 months to get an appointment with her (you can always get a same day appt. with a PA, NP or most times another physician in the practice). Once you are seen by someone in the practice (in this case a medical group of physicians who have gone into practice with each other) they can then do a referral to the specialist needed. You then call that office and try to get the earliest appointment you can--in her group or it can be a specialist in another practice group of affiliated physicians.

AFAIK, most physicans now practice in groups, at least in my area, especially specialists-- there are specialists affiliated with the Hospital Network-- Sutter--that my doc is in and there are specialists affiliated with the 2nd hospital-- Providence-- and most are affiliated with both.

I still remember when I was signing up for Medicare and how complicated it seemed. It is at first but once you get over that first hurdle, it's fairly simple. Here are some quotes:

"Unlike certain Medicare Advantage (MA) plans, Medigap policies do not restrict you to a network of providers and facilities. If you have a Medigap policy, you can see any doctor or use any hospital that accepts Medicare."

If you want to really get complicated:

https://65medicare.org/do-all-doctors-a ... gap-plans/

I hope I've made it clear, if you have further questions, LMK.
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Music Teacher Tim
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Re: Medicare Question

Post by Music Teacher Tim »

Thank you. I went back and re-read your earlier posts and noticed your plan was USAA. Maybe that's the confusion. I mean is your plan a regular plan G that anyone can buy vs. ex military? I mean I would be pretty disappointed if I bought a plan G and discovered all these little private networks instead of what I've read about the freedom to go to any doctor. But you are saying you need pre-approval, I'm sorry but I must be missing something. Thanks.
nonnie
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Re: Medicare Question

Post by nonnie »

Music Teacher Tim wrote: Sat Apr 01, 2023 9:59 pm Thank you. I went back and re-read your earlier posts and noticed your plan was USAA. Maybe that's the confusion. I mean is your plan a regular plan G that anyone can buy vs. ex military? I mean I would be pretty disappointed if I bought a plan G and discovered all these little private networks instead of what I've read about the freedom to go to any doctor. But you are saying you need pre-approval, I'm sorry but I must be missing something. Thanks.
One has to be ex-miliary or grandfathered in to purchase a plan from USAA and in some cases--Medigap-- it's cheaper (homeowners, auto, etc aren't necessarily cheaper). Otherwise, though, everything else is the same. It's Plan G same as any other Plan G. Everything I've said also applied to my Plan G last year purchased from Mutual of Omaha.
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JAZZISCOOL
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Re: Medicare Question

Post by JAZZISCOOL »

ModifiedDuration wrote: Fri Mar 31, 2023 6:22 pm
Chuckles960 wrote: Fri Mar 31, 2023 6:00 pm
Lynette wrote: Fri Mar 31, 2023 5:37 pmOn Monday, I am having a Nurse Practisioner come to my house and spend an hour with me. This is in addition to my annual wellness checks. Some claim the purpose of these house calls is so that that the health care companies are trying to make their clients sicker than they are to get more money from the government. I agreed to this as I sprained my ankles and was too lazy to go to the doctor...
There is no "some claim" about the fact that the nurse's job is to find every way to report that you are sicker than you really are. They are not doing this to help you but so they can find ways to charge Medicare more. If you have sprained your ankles, you may find yourself coded as paraplegic or some such
This appears to be referring to last Fall’s Federal Government’s civil healthcare fraud lawsuit against Cigna, which was about Cigna having home visits that resulted in people allegedly being falsely classified as having chronic conditions, such as chronic kidney disease and congestive heart failure, so that Cigna could get on-going addition risk adjustment payments from Medicare:

“U.S. Attorney Damian Williams said: ‘As alleged, CIGNA obtained tens of millions of dollars in Medicare funding by submitting to the Government false and invalid diagnoses for its Medicare Advantage plan members. CIGNA knew that, under the Medicare Advantage reimbursement system, it would be paid more if its plan members appeared to be sicker. This Office is dedicated to holding insurers accountable if they seek to manipulate the system and boost their profits by submitting false information to the Government.’”

“The healthcare providers (typically nurse practitioners) who conducted these home visits did not perform or order the testing or imaging that would have been necessary to reliably diagnose the serious, complex conditions reported and were prohibited by CIGNA from providing any treatment during the home visit for the medical conditions they purportedly found. The diagnoses at issue were not supported by the information documented on the form completed by the vendor….”

“The Invalid Diagnoses included, but are not limited to, diagnoses for complex medical conditions such as chronic kidney disease, congestive heart failure, rheumatoid arthritis, and diabetes with renal complications…..CIGNA exerted pressure on Vendor HCPs [healthcare personnel] to record high-value diagnoses that significantly increased risk adjustment payments.”

https://www.justice.gov/usao-sdny/pr/un ... lating-its
The NY Times has had a couple recent articles on the topic of MA plans and the billing/coding issues, etc. The title of one such recent article 3/22/23 is:

"Biden Plan to Cut Billions in Medicare Fraud Ignites Lobbying Frenzy

The Biden administration has proposed changes to how it would pay private Medicare Advantage plans."

https://www.nytimes.com/2023/03/22/heal ... Position=2

Then, after push-back from the healthcare insurance lobbyists, the administration just decided to phase it in over 3 years.

https://www.nytimes.com/2023/03/31/heal ... Position=1
tj
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Re: Medicare Question

Post by tj »

nonnie wrote: Sat Apr 01, 2023 10:04 pm
Music Teacher Tim wrote: Sat Apr 01, 2023 9:59 pm Thank you. I went back and re-read your earlier posts and noticed your plan was USAA. Maybe that's the confusion. I mean is your plan a regular plan G that anyone can buy vs. ex military? I mean I would be pretty disappointed if I bought a plan G and discovered all these little private networks instead of what I've read about the freedom to go to any doctor. But you are saying you need pre-approval, I'm sorry but I must be missing something. Thanks.
One has to be ex-miliary or grandfathered in to purchase a plan from USAA and in some cases--Medigap-- it's cheaper (homeowners, auto, etc aren't necessarily cheaper). Otherwise, though, everything else is the same. It's Plan G same as any other Plan G. Everything I've said also applied to my Plan G last year purchased from Mutual of Omaha.
According to this, you don't.

https://www.nerdwallet.com/article/insu ... ompetitors.
Topic Author
Music Teacher Tim
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Re: Medicare Question

Post by Music Teacher Tim »

Maybe this was already addressed, don't remember, but when comparing Plan G's against each other, is there any reason to go with the higher priced one (assuming both are attained age for example for comparing apples to apples)? I could see an issue with MA plans in this regard, but with a Plan G, I don't get why you would pay more.
tj
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Re: Medicare Question

Post by tj »

Music Teacher Tim wrote: Sat Apr 01, 2023 11:51 pm Maybe this was already addressed, don't remember, but when comparing Plan G's against each other, is there any reason to go with the higher priced one (assuming both are attained age for example for comparing apples to apples)? I could see an issue with MA plans in this regard, but with a Plan G, I don't get why you would pay more.
If you value the free perks above the cost differential such as free gym memberships, free OTC stuff from CVS, etc.
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Music Teacher Tim
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Re: Medicare Question

Post by Music Teacher Tim »

So if you don't go for those gimmicks, then just go for the lowest price then ???
tj
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Re: Medicare Question

Post by tj »

Music Teacher Tim wrote: Sat Apr 01, 2023 11:58 pm So if you don't go for those gimmicks, then just go for the lowest price then ???
In California, absolutely, because you can switch every year. Don't overthink it.
Topic Author
Music Teacher Tim
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Re: Medicare Question

Post by Music Teacher Tim »

Thanks for the help, good night.
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FrugalInvestor
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Re: Medicare Question

Post by FrugalInvestor »

Music Teacher Tim wrote: Wed Mar 29, 2023 11:35 am OP here. All good points I am absorbing. You know, some of the stuff I've read implies that with original medicare and a medigap supplement, you basically have no problems (except paying the premium!!). I don't mind paying more upfront if I can avoid all, or most, problems later should I get really sick. I would just hate to go the original route, rather than the advantage route, then have to deal with problems later like rejected claims, etc. In other words, I would just really like to know what I am paying for with a medigap supplement plan. That is why boards like this are helpful since some of you have actually been through this stuff.

Your concerns are exactly why I chose traditional Medicare + supplement (Plan G). I was willing to pay more as long as it resulted in:
1. My available network of doctors being as large and broad as possible,
2. My out-of-pocket costs being minimized,
3. My out-of-pocket costs being predictable, and
4. The billing and payment process being simplified as much as possible.

I know that as I age navigating the medical care system will continue to become more difficult for me and I wanted to streamline it as much as possible. I felt that this was the best choice to accomplish my goals.
Have a plan, stay the course and simplify. Then ignore the noise!
journey
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Re: Medicare Question

Post by journey »

Thank you all for this important and timely thread.

Help, please. My parents were in an Ohio Assisted Living (AL) facility - their hometown, their choice – but with no family. Due to poor care, we, their children, just moved them to an AL in Maryland, within a mile of family members.

Mom has original Medicare A and B plus D plus a 2nd insurance from her previous employer. Her coverage through the move has been seamless (so far).

Dad has parts A, B, C (MA), and D. I learned last Friday, during the move, that the Maryland AL’s doctors do not accept MA so dad will be out of network … even though dad pays for part B (confirmed with SSA). It seems that having MA negates his original part A and B coverages.

I called dad’s AARP UHC. They had me transfer him to a plan in the new AL’s county and said he is covered, despite me pressing on why the new AL doctors do not show online in his new plan. Called the AL doctors’ office again and they said dad is still out of network. That was end of day Friday.

Did I let UHC pull a fast one? Do I need to find dad a non-AL doctor until the next open enrollment? I want to drop dad's MA and replace it with a new plan D plus F or G. Any insights will be greatly appreciated!

OP, depending on the learned responses from this community, you may want to consider whether you might ever move … or be moved.
chalet
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Re: Medicare Question

Post by chalet »

journey wrote: Sun Apr 02, 2023 9:06 am
Dad has parts A, B, C (MA), and D. I learned last Friday, during the move, that the Maryland AL’s doctors do not accept MA so dad will be out of network …

can he switch to a medigap? I don't know the rules in that state.


Lynette wrote: Fri Mar 31, 2023 5:37 pm I was forced to change to UHC Medicare Advantage PPO by my former employer or lose my $3,000 annual benefit.




The UHC reps are extremely respnsive and I get someone within a minute. So far, I am extremelympleased with the new Advantage plan - much cheaper and far more benefits.

yours is not a typical zero-premium plan. it is subsidized by your former employer, and not open to the public.
SuzBanyan
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Re: Medicare Question

Post by SuzBanyan »

Really appreciate all the comments on this thread.

I will be going on Medicare this year. I am in CA and trying to choose between Plan G and Plan G high deductible. I have an HSA with a comfortable balance and expect to be paying IRMAA starting in 2025. G High deductible is at about $90 less per month than G and about $100 month less than G Extra(with Silver Sneakers, VSP and $100/quarter online at CVS). I understand that I can change plans under the birthday month rule from G to another G or G-HD, but cannot move from G-HD to G without underwriting.

Should I be freaked out that none of the G-HD providers are “name brands”? Do I need to use a broker to sign up with a company like Globe Life or Washington National? What is the significance of the “waiting period”? Globe Life has a 60 day waiting period and Washington National has no waiting period.
ModifiedDuration
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Re: Medicare Question

Post by ModifiedDuration »

SuzBanyan wrote: Sun Apr 02, 2023 12:01 pm Really appreciate all the comments on this thread.

I will be going on Medicare this year. I am in CA and trying to choose between Plan G and Plan G high deductible. I have an HSA with a comfortable balance and expect to be paying IRMAA starting in 2025. G High deductible is at about $90 less per month than G and about $100 month less than G Extra(with Silver Sneakers, VSP and $100/quarter online at CVS). I understand that I can change plans under the birthday month rule from G to another G or G-HD, but cannot move from G-HD to G without underwriting.

Should I be freaked out that none of the G-HD providers are “name brands”? Do I need to use a broker to sign up with a company like Globe Life or Washington National? What is the significance of the “waiting period”? Globe Life has a 60 day waiting period and Washington National has no waiting period.
You do not need to be concerned about the G-HD providers not being “name brand”. The biggest player in the HD arena is United American, which isn’t a name brand, but HD Medigap is their “bread and butter.”

By the way, if your Medigap insurer goes bankrupt or exits the Medigap market, you have a Guaranteed Issue Right to buy a Plan G or G-HD from any issuer in your state (and they would have to cover all your pre-existing health conditions and could not charge you more because of past or present health problems).

No waiting period for pre-existing conditions is, of course, better than a 60-day waiting period.

You should be aware of the three different pricing methodologies for Medigap pricing (attained-age, issue-age, and community-rated) when comparing insurers and premiums, as that would have a significant impact on your premium in the years ahead.
SuzBanyan
Posts: 2015
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Re: Medicare Question

Post by SuzBanyan »

ModifiedDuration wrote: Sun Apr 02, 2023 12:15 pm
SuzBanyan wrote: Sun Apr 02, 2023 12:01 pm Really appreciate all the comments on this thread.

I will be going on Medicare this year. I am in CA and trying to choose between Plan G and Plan G high deductible. I have an HSA with a comfortable balance and expect to be paying IRMAA starting in 2025. G High deductible is at about $90 less per month than G and about $100 month less than G Extra(with Silver Sneakers, VSP and $100/quarter online at CVS). I understand that I can change plans under the birthday month rule from G to another G or G-HD, but cannot move from G-HD to G without underwriting.

Should I be freaked out that none of the G-HD providers are “name brands”? Do I need to use a broker to sign up with a company like Globe Life or Washington National? What is the significance of the “waiting period”? Globe Life has a 60 day waiting period and Washington National has no waiting period.
You do not need to be concerned about the G-HD providers not being “name brand”. The biggest player in the HD arena is United American, which isn’t a name brand, but HD Medigap is their “bread and butter.”

By the way, if your Medigap insurer goes bankrupt or exits the Medigap market, you have a Guaranteed Issue Right to buy a Plan G or G-HD from any issuer in your state (and they would have to cover all your pre-existing health conditions and could not charge you more because of past or present health problems).

No waiting period for pre-existing conditions is, of course, better than a 60-day waiting period.

You should be aware of the three different pricing methodologies for Medigap pricing (attained-age, issue-age, and community-rated) when comparing insurers and premiums, as that would have a significant impact on your premium in the years ahead.
Thanks for the prompt response. There are no pricing methodologies in my area other than Attained Age.

Can you tell me more about the waiting period? Does the waiting period apply when I first sign up or only if I switch providers? The no waiting period policy is $410/year versus $358 for a 60 day waiting period. I have a pre-existing cardiac condition, so would hate to have limited benefits if the worst happened during the first 2 months on Medicare.
ModifiedDuration
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Re: Medicare Question

Post by ModifiedDuration »

SuzBanyan wrote: Sun Apr 02, 2023 12:49 pm
ModifiedDuration wrote: Sun Apr 02, 2023 12:15 pm
SuzBanyan wrote: Sun Apr 02, 2023 12:01 pm Really appreciate all the comments on this thread.

I will be going on Medicare this year. I am in CA and trying to choose between Plan G and Plan G high deductible. I have an HSA with a comfortable balance and expect to be paying IRMAA starting in 2025. G High deductible is at about $90 less per month than G and about $100 month less than G Extra(with Silver Sneakers, VSP and $100/quarter online at CVS). I understand that I can change plans under the birthday month rule from G to another G or G-HD, but cannot move from G-HD to G without underwriting.

Should I be freaked out that none of the G-HD providers are “name brands”? Do I need to use a broker to sign up with a company like Globe Life or Washington National? What is the significance of the “waiting period”? Globe Life has a 60 day waiting period and Washington National has no waiting period.
You do not need to be concerned about the G-HD providers not being “name brand”. The biggest player in the HD arena is United American, which isn’t a name brand, but HD Medigap is their “bread and butter.”

By the way, if your Medigap insurer goes bankrupt or exits the Medigap market, you have a Guaranteed Issue Right to buy a Plan G or G-HD from any issuer in your state (and they would have to cover all your pre-existing health conditions and could not charge you more because of past or present health problems).

No waiting period for pre-existing conditions is, of course, better than a 60-day waiting period.

You should be aware of the three different pricing methodologies for Medigap pricing (attained-age, issue-age, and community-rated) when comparing insurers and premiums, as that would have a significant impact on your premium in the years ahead.
Thanks for the prompt response. There are no pricing methodologies in my area other than Attained Age.

Can you tell me more about the waiting period? Does the waiting period apply when I first sign up or only if I switch providers? The no waiting period policy is $410/year versus $358 for a 60 day waiting period. I have a pre-existing cardiac condition, so would hate to have limited benefits if the worst happened during the first 2 months on Medicare.
Most group (company with more than 20 employees) or individual medical policies prior to signing up for Medicare and a Supplement would provide one-for-one offset of the 60-day waiting period.

So, if you have group or individual medical coverage for at least 60 days prior to signing up for Medicare and a Supplement, then the Supplement’s 60-day waiting period is moot.

“The good news is that the Medigap pre-existing condition waiting period is often reduced by the number of months that you had creditable coverage before enrolling. Having credible insurance for six months before Medigap could eliminate the waiting period. Thus, those with six months of creditable coverage before Medigap shouldn’t worry about the carrier implementing a waiting period. Employer-sponsored health plans from companies with more than 20 employees are an example of creditable coverage.”

https://www.medicarefaq.com/faqs/medica ... onditions/
nonnie
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Re: Medicare Question

Post by nonnie »

tj wrote: Sat Apr 01, 2023 11:17 pm
nonnie wrote: Sat Apr 01, 2023 10:04 pm
Music Teacher Tim wrote: Sat Apr 01, 2023 9:59 pm Thank you. I went back and re-read your earlier posts and noticed your plan was USAA. Maybe that's the confusion. I mean is your plan a regular plan G that anyone can buy vs. ex military? I mean I would be pretty disappointed if I bought a plan G and discovered all these little private networks instead of what I've read about the freedom to go to any doctor. But you are saying you need pre-approval, I'm sorry but I must be missing something. Thanks.
One has to be ex-miliary or grandfathered in to purchase a plan from USAA and in some cases--Medigap-- it's cheaper (homeowners, auto, etc aren't necessarily cheaper). Otherwise, though, everything else is the same. It's Plan G same as any other Plan G. Everything I've said also applied to my Plan G last year purchased from Mutual of Omaha.
According to this, you don't.

https://www.nerdwallet.com/article/insu ... ompetitors.
Great, I did not know that as we are USAA members. I would urge folks, especially those using brokers who cannot sell USAA, to price compare the product. As I said above it was $40 a month cheaper than My utual of Omaha.
RetiredArtist
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Re: Medicare Question

Post by RetiredArtist »

deleted
Last edited by RetiredArtist on Thu May 18, 2023 4:04 pm, edited 1 time in total.
journey
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Joined: Mon Feb 15, 2021 11:49 am

Re: Medicare Question

Post by journey »

chalet wrote: Sun Apr 02, 2023 11:09 am
journey wrote: Sun Apr 02, 2023 9:06 am
Dad has parts A, B, C (MA), and D. I learned last Friday, during the move, that the Maryland AL’s doctors do not accept MA so dad will be out of network …
can he switch to a medigap? I don't know the rules in that state.
Thank you chalet and great question. I don't know Maryland laws yet and am a novice with this topic in general. I plan to call SHIP tomorrow. Today, I am trying to gather as much information as possible to formulate better questions.
chalet
Posts: 235
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Re: Medicare Question

Post by chalet »

RetiredArtist wrote: Sun Apr 02, 2023 1:26 pm
I have never needed pre-approval. And if Medicare pays, Medigap pays.



I have received care, such as physical therapy, from providers who while licensed & registered with Medicare, required me to pay them, & then file Medicare Form 1490S for reimbursement. Reimbursement for this care was ALL denied, even after I filed appeals.
another way of looking at this, is that you did need a pre-approval. (to get it paid).


also, maybe those providers expected a denial from medicare. so asked to be paid directly.
SuzBanyan
Posts: 2015
Joined: Thu Jun 02, 2016 11:20 am

Re: Medicare Question

Post by SuzBanyan »

ModifiedDuration wrote: Sun Apr 02, 2023 1:03 pm
SuzBanyan wrote: Sun Apr 02, 2023 12:49 pm
ModifiedDuration wrote: Sun Apr 02, 2023 12:15 pm
SuzBanyan wrote: Sun Apr 02, 2023 12:01 pm Really appreciate all the comments on this thread.

I will be going on Medicare this year. I am in CA and trying to choose between Plan G and Plan G high deductible. I have an HSA with a comfortable balance and expect to be paying IRMAA starting in 2025. G High deductible is at about $90 less per month than G and about $100 month less than G Extra(with Silver Sneakers, VSP and $100/quarter online at CVS). I understand that I can change plans under the birthday month rule from G to another G or G-HD, but cannot move from G-HD to G without underwriting.

Should I be freaked out that none of the G-HD providers are “name brands”? Do I need to use a broker to sign up with a company like Globe Life or Washington National? What is the significance of the “waiting period”? Globe Life has a 60 day waiting period and Washington National has no waiting period.
You do not need to be concerned about the G-HD providers not being “name brand”. The biggest player in the HD arena is United American, which isn’t a name brand, but HD Medigap is their “bread and butter.”

By the way, if your Medigap insurer goes bankrupt or exits the Medigap market, you have a Guaranteed Issue Right to buy a Plan G or G-HD from any issuer in your state (and they would have to cover all your pre-existing health conditions and could not charge you more because of past or present health problems).

No waiting period for pre-existing conditions is, of course, better than a 60-day waiting period.

You should be aware of the three different pricing methodologies for Medigap pricing (attained-age, issue-age, and community-rated) when comparing insurers and premiums, as that would have a significant impact on your premium in the years ahead.
Thanks for the prompt response. There are no pricing methodologies in my area other than Attained Age.

Can you tell me more about the waiting period? Does the waiting period apply when I first sign up or only if I switch providers? The no waiting period policy is $410/year versus $358 for a 60 day waiting period. I have a pre-existing cardiac condition, so would hate to have limited benefits if the worst happened during the first 2 months on Medicare.
Most group (company with more than 20 employees) or individual medical policies prior to signing up for Medicare and a Supplement would provide one-for-one offset of the 60-day waiting period.

So, if you have group or individual medical coverage for at least 60 days prior to signing up for Medicare and a Supplement, then the Supplement’s 60-day waiting period is moot.

“The good news is that the Medigap pre-existing condition waiting period is often reduced by the number of months that you had creditable coverage before enrolling. Having credible insurance for six months before Medigap could eliminate the waiting period. Thus, those with six months of creditable coverage before Medigap shouldn’t worry about the carrier implementing a waiting period. Employer-sponsored health plans from companies with more than 20 employees are an example of creditable coverage.”

https://www.medicarefaq.com/faqs/medica ... onditions/
Thank you!
Topic Author
Music Teacher Tim
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Joined: Mon Dec 19, 2022 12:17 am

Re: Medicare Question

Post by Music Teacher Tim »

OP back with another question: Most of what I read about original medicare is that it covers pretty much everything. But what I don't read too much about and would be interested in are cases where original medicare denied a claim. For example, if someone goes to the doctor for frequent urination and the doctor does blood tests for diabetes but the results are normal and they send you home. There was no diagnosis, so is the visit and labs covered? I only ask because things I read mention denials because the visit was coded wrong, or labs denied because it didn't jibe with the diagnosis. But what if there was no diagnosis? Anyone ran into things like this or similar? I think original medicare is probably pretty good, but I still would like to be informed of the pitfalls. Thanks.
capran
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Re: Medicare Question

Post by capran »

Music Teacher Tim wrote: Sun Apr 09, 2023 11:02 pm OP back with another question: Most of what I read about original medicare is that it covers pretty much everything. But what I don't read too much about and would be interested in are cases where original medicare denied a claim. For example, if someone goes to the doctor for frequent urination and the doctor does blood tests for diabetes but the results are normal and they send you home. There was no diagnosis, so is the visit and labs covered? I only ask because things I read mention denials because the visit was coded wrong, or labs denied because it didn't jibe with the diagnosis. But what if there was no diagnosis? Anyone ran into things like this or similar? I think original medicare is probably pretty good, but I still would like to be informed of the pitfalls. Thanks.
That has happened twice in 5 1/2 years. if they code it wrong, you may get a bill from the provider. Kind of stressful and a pain, but you then call and confirm with your (plan F or G provider) that the claim was denied. then you call the doctors office with the info, talk to someone in billing and they have always said "oops. Yes, looks like they coded it wrong. We'll resubmit" and it gets taken care of. One of our times was the pneumococcal vaccine. Wife was fine but mine was denied. (they paid for the vaccine but not for the administration for me, so some stress as they corrected their submission.) I hate dealing with inefficiency, especially when it was not something I did. another time, the person that entered the info for my blood work, which included checking for PSA/Prostate issues. a coding issue, as I, like many, have an enlarged prostate. still, never any out of pocket with my plan F and no deductible, and wife has had no payments other than her annual deductible.
Topic Author
Music Teacher Tim
Posts: 75
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Re: Medicare Question

Post by Music Teacher Tim »

Thanks for that info. A thing like a PSA test that you mentioned, I assume you have to present to the doctor your issues first (like trouble peeing etc) then they would authorize the test. In other words, you can't just ask for the test as a preventative measure, right. Just using this as an example so I understand real world examples of what they are calling "medically necessary".

This is just a side thought but I always laugh at the total disconnect between the "authorities" that tell you to be proactive with your health to catch things early like cancer, etc. But the system is not designed for that, it is designed to get you through a crisis after it occurs (if you're lucky) then send you on your way. I mean the average person couldn't afford to have multiple expensive tests out of pocket just for the heck of it every year. Okay that's all my ranting, I know it doesn't do any good so I try to keep it to a minimum !!!
capran
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Re: Medicare Question

Post by capran »

Music Teacher Tim wrote: Mon Apr 10, 2023 9:59 pm Thanks for that info. A thing like a PSA test that you mentioned, I assume you have to present to the doctor your issues first (like trouble peeing etc) then they would authorize the test. In other words, you can't just ask for the test as a preventative measure, right. Just using this as an example so I understand real world examples of what they are calling "medically necessary".

This is just a side thought but I always laugh at the total disconnect between the "authorities" that tell you to be proactive with your health to catch things early like cancer, etc. But the system is not designed for that, it is designed to get you through a crisis after it occurs (if you're lucky) then send you on your way. I mean the average person couldn't afford to have multiple expensive tests out of pocket just for the heck of it every year. Okay that's all my ranting, I know it doesn't do any good so I try to keep it to a minimum !!!
i agree. when my old doc stopped practicing, switched to new and each office makes mistakes. pretty silly to have an enlarged prostate but have them code the blood work incorrectly so the psa wouldn't be covered. And really laughed when wifes pneumococcal shot and administration of shot covered, but because of a coding issue, my vaccine was covered but the administration of the shot wasn't covered. Still, over all, like not having to deal with copays, co insurance and deductibles.
cashmoney
Posts: 724
Joined: Thu Jun 29, 2017 11:15 pm

Re: Medicare Question

Post by cashmoney »

tallguy3891 wrote: Sat Apr 01, 2023 10:59 am
Lynette wrote: Fri Mar 31, 2023 5:37 pm I was forced to change to UHC Medicare Advantage PPO by my former employer or lose my $3,000 annual benefit. I am finding the UHC Medicare Advantage PPO much simpler as I do not need to sign up for Medicare Part D and do the annual hassle of comparing drug plans. I did a lot of research as I was not pleased with being forced to make the change. I think a major consideration is if your plan is a PPO and the health care plan you choose is well-represented in your area. In my area all of the specialists and hospitals I use accept my plan. My PCP told me 50% of his patients used Medicare Advantage. The main issue raised against Advantage plans is that you have to go through pre-approval. My PCP recommended that I pick Medigap G or Advantage dependent on which one was cheapestl

I am in my late seventies and in good health. The UHC Advantage PPO plan is much, much cheaper for me than the AARP UHC Medigap G. I was paying about $2400 for AARP Medigap G and $840 p.a for Part D. With my Advantage plan I do not pay a premium and pay nothing for my only statin drug as it is not even tier 1. I think most Advantage plans have options for no premium, dental, vision and hearing aids benefits.

My former employer is contributing to my UHC Employer Sponsored plan and so is probably offers more advantages that standard Advantage plans. On Monday, I am having a Nurse Practisioner come to my house and spend an hour with me. This is in addition to my annual wellness checks. Some claim the purpose of these house calls is so that that the health care companies are trying to make their clients sicker than they are to get more money from the government. I agreed to this as I sprained my ankles and was too lazy to go to the doctor. I will see how it works out. My only complaint was that I had to really clean my house. My maximum out of pocket for my plan is $750 per annum. I get all kinds of additional benefits such as 140 free meals, $160 to OTC, and there are a large number of options for free medical transportation (and meals) if I am hospitalized. I even get 8 hours for someone to clean my house.

The UHC reps are extremely respnsive and I get someone within a minute. So far, I am extremelympleased with the new Advantage plan - much cheaper and far more benefits.
Someone might have already mentioned this, but some employers offer their Medicare Advantage Plans through something called Medicare Employer Group Waiver Plans (EGWP). I have heard that these are supposedly "better" than Advantage plans offered to the public in that they have enhanced benefits and often are PPO plans. These EGWP plans might be the reason some people seem to really like Advantage Plans and some do not. Apparently two different things but I do not know if there is a difference in the administration of EGWP plans versus "regular" Advantage (such as pre-authorization, approvals, Rx, extra benefits, etc.).
Medicare Employer Group Waiver Plans give more flexibility to employers around enrollment rules ( ie can automatically enroll retirees), marketing rules/restrictions , benefit design and bidding process vs non waiver Employer Group Health Plan MA and individual MA plans. Most but not all EGWP and EGHP MA plans are PPO's and can have better benefits than individual MA plans but they often have premiums much higher than individual MA plans so it usually comes down to how generous is the employer in subsidizing the benefits or premiums .If the employer is not subsidizing at all or just providing a healthcare stipend for you to use how you please then depending on where you live an individual MA PPO or HMO can be a better deal. It is always good to compare. One thing that is fairly common with both waiver and non waiver EGHP PPO plans is that in network and out of network cost will be the same and it will have a better provider network vs the individual MA plans with same insurance carrier.

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tallguy3891
Posts: 703
Joined: Sat Jul 03, 2021 10:47 am

Re: Medicare Question

Post by tallguy3891 »

cashmoney wrote: Mon Apr 10, 2023 11:29 pm
tallguy3891 wrote: Sat Apr 01, 2023 10:59 am
Lynette wrote: Fri Mar 31, 2023 5:37 pm I was forced to change to UHC Medicare Advantage PPO by my former employer or lose my $3,000 annual benefit. I am finding the UHC Medicare Advantage PPO much simpler as I do not need to sign up for Medicare Part D and do the annual hassle of comparing drug plans. I did a lot of research as I was not pleased with being forced to make the change. I think a major consideration is if your plan is a PPO and the health care plan you choose is well-represented in your area. In my area all of the specialists and hospitals I use accept my plan. My PCP told me 50% of his patients used Medicare Advantage. The main issue raised against Advantage plans is that you have to go through pre-approval. My PCP recommended that I pick Medigap G or Advantage dependent on which one was cheapestl

I am in my late seventies and in good health. The UHC Advantage PPO plan is much, much cheaper for me than the AARP UHC Medigap G. I was paying about $2400 for AARP Medigap G and $840 p.a for Part D. With my Advantage plan I do not pay a premium and pay nothing for my only statin drug as it is not even tier 1. I think most Advantage plans have options for no premium, dental, vision and hearing aids benefits.

My former employer is contributing to my UHC Employer Sponsored plan and so is probably offers more advantages that standard Advantage plans. On Monday, I am having a Nurse Practisioner come to my house and spend an hour with me. This is in addition to my annual wellness checks. Some claim the purpose of these house calls is so that that the health care companies are trying to make their clients sicker than they are to get more money from the government. I agreed to this as I sprained my ankles and was too lazy to go to the doctor. I will see how it works out. My only complaint was that I had to really clean my house. My maximum out of pocket for my plan is $750 per annum. I get all kinds of additional benefits such as 140 free meals, $160 to OTC, and there are a large number of options for free medical transportation (and meals) if I am hospitalized. I even get 8 hours for someone to clean my house.

The UHC reps are extremely respnsive and I get someone within a minute. So far, I am extremelympleased with the new Advantage plan - much cheaper and far more benefits.
Someone might have already mentioned this, but some employers offer their Medicare Advantage Plans through something called Medicare Employer Group Waiver Plans (EGWP). I have heard that these are supposedly "better" than Advantage plans offered to the public in that they have enhanced benefits and often are PPO plans. These EGWP plans might be the reason some people seem to really like Advantage Plans and some do not. Apparently two different things but I do not know if there is a difference in the administration of EGWP plans versus "regular" Advantage (such as pre-authorization, approvals, Rx, extra benefits, etc.).
Medicare Employer Group Waiver Plans give more flexibility to employers around enrollment rules ( ie can automatically enroll retirees), marketing rules/restrictions , benefit design and bidding process vs non waiver Employer Group Health Plan MA and individual MA plans. Most but not all EGWP and EGHP MA plans are PPO's and can have better benefits than individual MA plans but they often have premiums much higher than individual MA plans so it usually comes down to how generous is the employer in subsidizing the benefits or premiums .If the employer is not subsidizing at all or just providing a healthcare stipend for you to use how you please then depending on where you live an individual MA PPO or HMO can be a better deal. It is always good to compare. One thing that is fairly common with both waiver and non waiver EGHP PPO plans is that in network and out of network cost will be the same and it will have a better provider network vs the individual MA plans with same insurance carrier.

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An example of cost difference might be some of the FEHB plans (federal), which I'm guessing fall under EGWP regs? A publicly offered Medicare Advantage Plan might very well have a zero premium, whereas a quick check of some FEHB MA plan options show 2023 premiums ranging from $275/mo to $767.56/mo for a self plus one. Considering the fact that one is also paying the Medicare Part B premiums in addition to this, it can be costly in my opinion. For some reason so far they appear to be the same cost as the "regular " plan to which they are attached. I believe these plans do offer up to $2400 reimbursement per year for a couple both on the MA option. So one can see that they can be more expensive than public offerings, and the question then becomes are they that much better to justify the cost? Hopefully they are.
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