No, and nobody said you'd be stuck with a $xxx,xxx bill. Just with basically 20% of the $xxx,xxx on advantage vs. basically none on supplement.
Medicare with Medigap or Medicare Advantage?
- Thread starter ZZman
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OK sure, but still - No not 20%. It will be your out of pocket max depending on your policy.
Sure "basically none" on G, but what does G cost extra per year?
If you have bad eating habits and no exercise and otherwise bad health, spending more on a premium is probably worth it. I can afford the max so I choose not to pay more premium.
I’m 73, darling bride is 72. We’re in Medicare, each with a Plan G supplement that costs $150 apiece. Dental is out of pocket. Dental plans aren’t cheap and most of them lock you into a yearly premium that you pay regardless. Wife has had numerous surgeries (hip/shoulder replacements) to only mention a few and Medicare has paid their 80% and her Plan G has paid their 20% without fail. All without medical underwriting since we applied for our Plan G coverage within the 6 month window of eligibility. I think you can save money with Advantage when you’re younger but if anyone has figured out how to continue to stay younger I’m all ears. The older we get the more comfortable we are with our decision to go Traditional. YMMV.
You can be healthy today and not healthy tomorrow. In 2011 my wife signed up for Medicare with Plan F. One week later her doctor called and said she needed a pacemaker. The bill was $61k - we paid zero. Three years later she developed congestive heart failure and spent 23 days in intensive care on life support before she passed away. The bill was hundreds if thousands of dollars - I paid zero. (Plan F is no longer available because zero deductibles and co-pays encouraged too many unnecessary doctor visits. Plan G offers the same coverage as the old Plan F except it does not pay the $240 annual deductible in Medicare Part B.)
Most Advantage plans are HMOs restricting you to a network of providers with co-pays and other limitations. Since I travel a lot I went with Medicare plus Plan G which covers me everywhere with any doctor, and even has some international coverage. If I ever get cancer or heart issues I want to be able to see the best specialist no matter where he/she is located. YMMV depending on where you live, your health, and your travel. Best to do your homework specific to you.
Most Advantage plans are HMOs restricting you to a network of providers with co-pays and other limitations. Since I travel a lot I went with Medicare plus Plan G which covers me everywhere with any doctor, and even has some international coverage. If I ever get cancer or heart issues I want to be able to see the best specialist no matter where he/she is located. YMMV depending on where you live, your health, and your travel. Best to do your homework specific to you.
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1. You can only go to doctors and hospitals that accept Medicare which is depending on your state about 97% of all doctors accept.
2. Medicare is a fantastic system, NO ONE needs to be concerned as you found out
3. You can switch Advantage C plans during the annual enrollment period that starts OCT of every year.
4. For people with Advantage C plans you have a second chance to switch every Jan 1st to March 31for Medicare Advantage Holders only.
5. It is true under most circumstances should you decide to opt for private Medigap insurance after having an Advantage C plan for a period of one year the automatic guaranteed acceptance expires. There are exceptions but the general rule is no. The exceptions are things like should your existing Plan decide to pull out or if you move and there are no others, stuff like that.
6. You pay dearly for Medigap Supplement Plan G AS you get on later years in life its costing you starting around $150 to 400 a month PLUS $175 = $325 to $575 a month and that doesnt include a drug prescription plan "Part D" and the prices go up over time.
Source - https://www.medicare.gov/medigap-su.../plans?fips=37019&zip=28467&year=2024&lang=en
My Advantage C Plan cost me nothing but the mandatory Medicare $175 a month and they pay my dentist, Eye doctor and lens, prescription drugs, $180 a year of free over the counter items and $1,200 to buy any type of activity equipment or couching and also includes a gym. Private Medigap G pays none of that.
My Advantage C plan does not require referrals, in fact most do not
Most every hospital and doctor takes Advantage C plans, at least I can speak of the big ones like United Health Care and Aetna
I never found a doctor or hospital or health care network that did not. But it's easy to check the government website is a fantastic tool.
With that said, I do have co-pays and a $4,500 out of pocket limit but no deductible. My primary doctor is $0 co-pay and any specialist is $10 co-pay. I can go to ANY specialist I want without a referral they do much like Medigap have to be in your plan.
I stated, I never found one that wasnt in both United Health Care C plan and Aetna C Health plan. But I caution this is a big country, so use the easy to use Medicare.gov website to check your area.
Example, 2022 $130,000 in hospital and doctor bills and supplies. my cost was $800. With that in mind they also paid for a free $1,200 orange theory gym membership, $400 in over the counter items, free dental, free contact lens, and free drug prescription plan.
It really a matter of choice, and choices are great! I love choices. I can afford an out of pocket limit should I get ill to the point of many hundreds of thousands of dollars a year in medical bills when I have a limit of what I have to pay at $4,500 a year.
There is soooo much mis-information on Advantage C plans and by well meaning people who do not understand them.
By the way, Medigap and Medicare Advantage C plans are ALL private insurance companies. In fact it's the same companies in most cases that offer both. Some are not aware of this.
I see another comment in here about travel. Some Medi-Gap plans pay for out of country medical emergencies. This is important if you travel. Many Advantage also pay out of country. I find the Advantage C plans from UHC and Aetna cover much more to the tune of $250,000 to $500,000+
It's important to note, things change so always look for documented information on any health plan.
Welcome to Medicare
The official U.S. government website for Medicare, a health insurance program for people age 65 or older and younger people with disabilities.
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Excellent post!
You're making incorrect statements and why I warn people to go to medicare.gov for the correct information. Your so wrong you really should not be commenting but ok, this is a forum and why, one last time, dont anyone rely on statements in here, even my own, even though I only make correct statements
Advantage C plans have an out of pocket limit. Perfect Example, my own brother based on him watching what I signed up for with an Advantage C plan, he was getting tired of the constant rate increases in his Medigap C and D plan.
He switched to Humana Advantage C with a low $2,500 out of pocket limit. He underwent over $500,000 (not an mis print) of medical procedures on his heart last year. Every hospital and every doctor accepted his plan, in fact there isnt anyone in any of the 3 to 7 major medical centers in our area of the Coastal Carolinas that do not. SO his total cost for the $500,000 was his out of pocket limit of $2,500.
His monthly Advantage C premium is $0 plus the mandatory $170 a month from Medicare. This includes the 10 drugs he must take everyday though there are co-pays its working better for him then his Part D drug plan did when he had Medigap.
Choices are GREAT, so with what one is comfortable with but we need to leave out the mis-information which is slowly subsiding since I think we are now about 51% of Americans choosing Advantage plans. No one plans is right for everyone, again, choices are great. I LOVE the SYSTEM, it works!
He chose that plan on the low out of pocket. I use another with what I call low at $4,500 because of many other benefits that give me more money towards dentists, eye doctors, everything else. IN fact by the years end, the plan puts more money in my pocket than what Medicare takes out (the $170 a month)
People really need to be careful and confirm whatever they read, even confirm what an insurance "specialist" is telling you, it is so easy it's silly not too.
I am also seeing rate quotes from other in here but the information is not complete. I see one who says they pay $150 a month each for Medigap G but in reality they pay $150 each PLUS another $175 each for a total of $325 each per month. It's NOT $150 each they leave out the mandatory $175 automatic medicare deduction from their SS Check. SO the couple pays $650 a month for Medigap G coverage and we still do not know if he included a Part D drug plan in that price.
They also do not mention that their plan costs go up according to attained age. There is one company that does "community pricing" that does not to the best of my knowledge and that is United Health.
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Here is the key, I see this a lot.
A Medigap A,B and D plan will cover doctors, hospitals, and drugs. Nothing else, no dentists, no eye doctors or lens, no hearing doctors or aids. Cost is in rough numbers around $370 to $470 a month to start. Prices vary widely. On top of that, most but not all, the rates are lower to start called "age attained" but go up as you get older. Some, I only know one uses "community pricing"
Pretty much, except for some minor costs and some possible HUGE drug costs medical care is all paid for in that monthly premium>
Advantage C, cost is in most cases just the government cost of $175 a month.
The Advantage plan will cover doctors, hospitals, and drugs. It also contains coverage for dentists, eye doctors and lens, hearing doctors and aids plus some really nice perks if you use them such as over the counter items free, gym free and all kind of other things.
The costs you will have are co-pays for doctors, hospitals, tests and treatments. The co-pays are low. Your only exposure is how much you have to pay each year. But like your corporate health insurance you have an out of pocket limit. Unlike your corporate health insure with Advantage C there is no deductible with most plans.
SO all one has to decide, assuming everything else is equal and the medical networks near you take both plans, which most do is if, under the worst possible scenario can you afford the out of pocket limit of an Advantage C plan or would you rather pay hundreds more per month to not have an out of pocket exposure. Family member of mine out of pocket is $2,900 this year mine is $4,500. but depending on what you chose it can go up to $8000 ish out of pocket limit.
No right or wrong really though you can tell by my posts I love Advantage C plans, I was very tortured at first on deciding, I was the ONLY sibling to go into one, after another saw how it worked he switched over and now his wife just joined too.
It really doesnt matter, choices are great but they need to be informed choices. Way too much mis-information out there.
Im not concerned but doesnt mean someone else might be, so then pay the extra $200+ a month over time, per person, plus the mandatory $175. I rather keep the money until I get sick.
ALL this and YOUR STATE comes into play hugely. I mean - I assume your state is involved at the very least - what companies offer plans.
Here's another thing, regardless of what road you go down. Make sure the "in house" pharmacy is a good one. The insurance part might be fine, and the pharmacy TERRIBLE. You can still choose Safeway, local pharmacy, Costco, whatever (I think all avenues allow this). I will tell you, I made a mistake. I chose Humana, and the insurance has been perfect. No complaints. I used my local tiny pharmacy for a few odd things. No problem. Then because I wanted a BG checker (Blood Glucose) I jumped to Human CenterWell. All sorta OK, I am weaseling the system a bit, they paid for the device and two a day strips and lancets (boo, but OK, I buy them cheap on Amazon). All is well. BUT then I decide I want a Continuous BGM. A fancier device, no doubt. Medicare simply does not automatically cover that. I won't go into details, but I have more than once offered just to pay for it through CenterWell and more than once they said 'Halt, wait - it might be covered with an authorization and review approval" I am now 6 weeks into this now, no device. Got approval only to have THEM say time ran out............Humana apologized to me. The phone support is in Guatemala - really not a huge issue, the ladies speak perfect English, more clear than the support center in the USA(!). But the process gets stuck. They say they are now going back to my doc.........uggh
Yes, mostly correct your statement regarding Plan G, Completely wrong your statement about Advantage C.
After one year of Advantage C should you want to go back to a Medigap policy you will have to go to underwriting and they will give a price and possibly deny you.
There are limited situations which allow you to go back to a Medigap G, such as the Advantage C plan pulling out and not others available ect. Moving to a location with nothing else available.
YOU NEVER NEED TO UNDERGO A PHYSICAL TO SWITCH ADVANTAGE C PLANS. (not yelling *LOL*) But this is important.
This is what I LOVE about Advantage C plans. You get two times a year to switch plans, it's great! You dont even need to pick up a phone, it takes seconds online and I mean SECONDS. You never even make contact with the new Advantage C company.
Click on your online Medicare.gov account, chose the plan you rather switch to and click! Everything is then handled by the system. It shows up instantly on your account and shows the date it will become effective.
You can switch every year should you choose. Oct thru Nov for the following year and another chance Jan 1st to March 31st.
SO of course, I did switch from my MUCH LOVED United Heath Care Advantage C plan back in Dec to starting Jan 1st Aetna Advantage C plan which I think I will love just as much.
Why did I switch?
My United Health Plan C paid over $1,500 a year for me to go to an expensive premium gym called Orange Theory. God what a great deal, Thing is we moved to an area near the coast and the nearest Orange Theory to me is just shy of a 30 minute drive. the UHC plan also cost me $29 a month in addition to the mandatory $175.
Both the above plans also offer more perks but Im tired of re-typing. (I know thank god)
Anyway, the Aetna plan available to me in my new area is slightly better. I get more money back for contact lens, a bit better selection of dentists though slightly less coverage. But key is, in addition to a basic gym that I do not want. Aetna allows me $1,200 a year to buy ANYTHING I want as long as it's an activity. So I have the option to still go to that gym on a less frequent basis and have money left over or just go out any buy anything I want with it. I can go buy fishing rods with the $1,200 or a mix of gym, pickle ball paddles, fishing rods and maybe a pickle ball coach.
The co-pay for the primary dr is $0 and my specialists are only $10.
My out of pocket limit under the worst case possible is $4,500 with no deductible. It's true now that I am a couple years into Advantage C I can not go back to a Medigap Policy even with the same insurance company Aetna or UHC without going into underwriting. But I'll never want to go back, you can switch every year if you wish to any Advantage C plan with just a click of your mouse, the government handles it all, as they are the ones that pay for it. I never talk to the company. Its instant, meaning the following month/term.
NO,
Medicare is a Federal System, States are not involved. But you may mean, different areas will have different networks that may or may not be covered, without question yes, that is a possibility. But medicare.gov makes it so easy to check. I cant find a hospital network in two states that UHC and Aetna Advantage C doesnt cover, though I didnt go through every one, just the respected ones.
If I need open heart surgery (gulp, most likely never) Both of them are even in the Duke University network which I think it loosely tied with the HUGE Novant Network in NC.
I dont know of any plan that limits Pharmacy anymore than a Corporate health plan. They all have preferred networks. With Advantage C you are no more limited than that of Medicare Part D. They are both private insurance.
Me personally I prefer BIG health networks offered by the big players, Aetna and United Health Care and then some large but not as large, yeah Humana is one that my brother uses for Advantage C. If you go with them Pharmacies are not an issue here. He actually chose Humana for its low $2,500 out of pocket and its superior drug coverage (here on the coast) compared to the Medicare Part D he had before switching. He spends a fortune on drugs, he wouldnt be on this earth without them. They even covered without issue an involved procedure done on equipment so advanced he drove 2 hours to Charleston as they at the time were one of two locations in the world to have it and the one doctor that would do what he needed to be done.
There is no physical "in house" pharmacy but with my Aetna plan CVS is the preferred network since CVS owns Aetna it only makes sense but Walgreens on their list and almost as good using Aetna plus of course online pharmacies.
I can see getting caught up in that monitor. I know what they are. I dont even have diabetes and got a free BG and test strips from the UHC store. Im sure it's not the best but if it's sold as one it has to be accurate. I once in a while test myself because of family history and like to understand the spikes etc.
Whether it is Medigap or Advantage C. Medicare dictates what is covered. Meaning the level of coverage has to be the same with perks that Advantage C puts on. I think I saw you have a C plan.
BTW -- I need to get out of here now. Boy I typed a lot and never directly replied to the OP like I intended hours ago. But if he reads all the crazy posts maybe it will give him some things to investigate. Im not disagreeing with you, dont want it to sound that way, just for others to know, any type of insurance at times takes some wiggling around where you are at the edge of what is covered and what is not. One thing for sure, no matter what plan you have, if the government (Medicare) says it is covered it is covered but if it is not, you can be any insurance company will try to deny it. I have found the online appeal to work well. I did this on a set of contact lens last year with UHC. I did not realize I had to buy them from a UHC approved vendor for them to pay $200 of the cost. I get a better deal at $300 for double the amount. I thought when I submitted it, they would send me a check for $200 but they denied it, because it wasnt their vendor.
They were right, I did not see that in the PDF I had but it was there. Anyway, I returned the contacts, got my $300 back and ordered half the quantity at the UHC approved vendor for $200. That was great, I didnt even have to give Credit card, UHC paid it. But before I did that I appealed the $299 that they denied. It was taking to long to hear back and that is when I ordered the $200 from UHC and returned the $299 contacts for full credit form the non approved vendor.
Long story short, so I got $200 in contacts free and get this UHC mailed me a check for $299 for the denied claim. At the time I told them they were correct in was in my policy but I was tripped up because the statement to use an approved vendor was on the next screen when viewing the PDF on my computer and I didnt see it.
SO I got the $299 check plus free $200 in contact lens. I felt guilty accepting the check since I was wrong and already UHC sent me $200 of contacts. So I called them up, think the guy was shocked, had me on hold a couple times, said he spoke with his superiors and they said to cash the check and not worry about it. I was shocked and thought WOW.
Not sure if this is why but one thing some dont know in here. ALL these Advantage C plans and (I think Medigap) are rated by Medicare for customer satisfaction. Medicare determines the reimbursement that they pay to these companies based on the "Star Rating" that you see on the medicare.gov site. I believe that is why some companies can offer so much more because the high star ratings.
over and out!
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@alarmguy has some good information.
Also, You can't have Medicare Advantage & a Medigap policy at the same time. It's one or the other. Original Medicare is wise to have a Medigap plan to cover out of pocket costs. However, If you're low income then Original Medicare & your states Medicaid may be all that you need. No need to pay for a Medigap policy.
Advantage plans come with the benefit of capped out of pocket costs that Original Medicare doesn't have those protections. Advantage plans are available in HMO, PPO, etc depending on your state. They can include dental, vision, & hearing too. Advantage Plan may be all you need if you have state Medicaid also.
If your income is low enough another important point to Original OR Advantage plans is having some or no obligation to pay any remaining bill that Medicare or Advantage plan pays on. Their known as Qualified Medicare Beneficiary, Specified Low-Income Beneficiary, & some other ones. But the QMB comes with billing protections that give you no obligation to pay the remainder of the bill.
Also, You can't have Medicare Advantage & a Medigap policy at the same time. It's one or the other. Original Medicare is wise to have a Medigap plan to cover out of pocket costs. However, If you're low income then Original Medicare & your states Medicaid may be all that you need. No need to pay for a Medigap policy.
Advantage plans come with the benefit of capped out of pocket costs that Original Medicare doesn't have those protections. Advantage plans are available in HMO, PPO, etc depending on your state. They can include dental, vision, & hearing too. Advantage Plan may be all you need if you have state Medicaid also.
If your income is low enough another important point to Original OR Advantage plans is having some or no obligation to pay any remaining bill that Medicare or Advantage plan pays on. Their known as Qualified Medicare Beneficiary, Specified Low-Income Beneficiary, & some other ones. But the QMB comes with billing protections that give you no obligation to pay the remainder of the bill.
Of course I know that.
But in WA state it even goes county by county for insurance companies.............I'm sure you know this. You put your bloody zip code in even when first shopping
Find a Medicare plan
yes, correct and this also helps focus on your area and networks available.Of course I know that.
But in WA state it even goes county by county for insurance companies.............I'm sure you know this. You put your bloody zip code in even when first shopping
Find a Medicare plan
www.medicare.gov
Ps. In case it's not apparent *LOL* I love the medicare discussions because I love the system. Most of my life I paid my own health insurance.Of course I know that.
But in WA state it even goes county by county for insurance companies.............I'm sure you know this. You put your bloody zip code in even when first shopping
Find a Medicare plan
To me, this is so cool to be able to go online and get the best deal for me at almost no cost. Furthermore as I get older I dont shy away from doctors anymore. I want every test and procedure and nothing more but the same as what is available to the President of the United States to live a long healthy life. I paid my whole life and now it's my turn.
Medicine has developed so rapidly and we have the privilege to have the best health care system in the world and I down care what anyone says to the contrary.
Have a great day, enjoyed this thread and now, almost 60 degrees, Im heading to the pickleball courts for a good workout.
Nice!
I retired obviously before 65 and had to buy insurance on the marketplace so I know exactly what you mean. At first I was paying over $600/month for the exact coverage I have now. Same docs.
Senior PB league was postponed today. BOO. The roads are just impassable dang it. I will have to do weights today. But PB workout is the best. Once in decent shape, it really maintains FLEXIBILITY and BALANCE.
I am a physician in private practice. I take Medicare and am in network with the vast majority of the private insurers. I'm also getting within spitting distance of being a Medicare beneficiary myself, and care for aging parents and in-laws, some have regular Medicare with a supplement and some an Advantage plan. There are definitely some perks that may be available with the Advantage plans and I know some folks are quite happy with them. Choice is great!
However, I recommend to my patients, relatives(and will for myself) to get traditional Medicare with a supplement if you can afford it. With this, your only out of pocket for medical care each year will be your Medicare deductible, currently a little over $200. Obviously, drug costs need to be considered and depending on whether you need a part D will add to your expense.
The main reason I advise this is that Advantage plans will sometimes not cover treatments or procedures that are covered by regular Medicare. This is often true of newer treatments, but also some older "tried and true" treatments. I see this daily in my specialty. Also, many treatments will require prior authorizations with Advantage plans, which can slow down care. There are also a couple major insurers that are not prone to give facility contracts to smaller practices, which can limit where you can get care.
However, I recommend to my patients, relatives(and will for myself) to get traditional Medicare with a supplement if you can afford it. With this, your only out of pocket for medical care each year will be your Medicare deductible, currently a little over $200. Obviously, drug costs need to be considered and depending on whether you need a part D will add to your expense.
The main reason I advise this is that Advantage plans will sometimes not cover treatments or procedures that are covered by regular Medicare. This is often true of newer treatments, but also some older "tried and true" treatments. I see this daily in my specialty. Also, many treatments will require prior authorizations with Advantage plans, which can slow down care. There are also a couple major insurers that are not prone to give facility contracts to smaller practices, which can limit where you can get care.
So the additional cost of the premium is not considered "out of pocket"?
Good to get your perspective.
This is what we have done, and fully believe it is the way to go if affordable. That being said the wife and I have a very highly discounted supplement with Plan G from her former employer. My understanding is that if a procedure is partially covered by regular medicare, it is then covered by the supplement.
I understand your are a doctor but Advantage C plans must cover everything that Medicare covers.
Yes, prior authorizations maybe needed but cannot be denied if covered by medicare if medically necessary. These authorizations are also required by standard employee health care plans.
"Medicare Advantage Plans provide all of your Part A and Part B benefits, including new benefits that come from laws or Medicare policy decisions. Plans must cover all emergency and urgent care (both physical and mental), and almost all medically necessary services Original Medicare covers. Medicare Advantage Plan benefits exclude clinical trials and hospice services. But if you’re in a Medicare Advantage Plan, Original Medicare will still help cover your costs for hospice care, and some costs for clinical research studies.
The plan can choose not to cover the costs of services that aren't medically necessary
under Medicare. If you're not sure whether a service is covered, check with your provider before you get the service.
With a Medicare Advantage Plan, you may have coverage for things Original Medicare doesn't cover, like fitness programs (gym memberships or discounts) and some vision, hearing, and dental services (like routine check ups or cleanings). Plans can also cover even more benefits. For example, some plans may offer coverage for services like transportation to doctor visits, over-the-counter drugs that Part D doesn’t cover, and services that promote your health and wellness. Check with the plan before you enroll to see what benefits it offers, if you might qualify, and if there are any limitations."
Here it is, right from your Medicare insurance company
Your health plan options
Medicare Advantage, and other health plans, are another way to get your Part A and Part B benefits instead of Original Medicare.
Im not saying dont get a suppliment G and D plan. I am saying for many people including me. I like the extra coverage I got with the Advantage C and I dont pay an extra $200 a month to start with escalating fees as the years go by for less coverage. Choices are good for sure. That is the only thing that bothers me, you say that only "out of pocket" cost using a Medigap supplement plans $200. That is not true, you have to pay an additional $200 to $300 plus a month in premiums that escalate as the years go on. And that doesnt include eyeglasses, contacts, dentists, hearing aids, over the counter products and you need to make sure you get part D prescription drug coverage with the Supplement typically Part D.
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