Medicare Revelation

[Lisa Starr]

I'm not 65 yet, but was forced into Medicare 3 years ago due to receiving disability after beginning treatment for Lymphoma. After much research, I chose a MA plan that is a PPO, not an HMO. I was careful to choose one with my Oncologist and his team listed as in network. The plan has a small Deductible ($750.00), but also a low ($1750) Maximum Out of Pocket, which I consider more important. For a whopping $22.00/month plus my $1750 max, I've had spectacular coverage. Each year I've met my deducible and max out of pocket and never paid another cent more. Every drug, every chemotherapy, the Stem Cell Transplant, the follow up visits, PET scans, and 2 other hospitalizations were all 100% covered by the plan.

I think the take away on this is like all things. Due diligence is needed. Make sure you know what your purchasing and what the ramifications of your choice will be down the road.

[Jim Becker]

Thanks for bringing that up, Lisa...my daughter's setup is MA via the state and it's a PPO, too, not an HMO. That said, I'm finding this discussion interesting as I'm going to have to deal with it myself in two years, although as long as Professor Dr. SWMBO remains in her tenured position at the university, her health insurance will continue to cover me, albeit with modifications once I have to sign up for Medicare. 'Kinda a shame we have to do all this dancing, but that's the way the system is setup currently. So EVERYONE has to do their own due-diligence to insure they have coverage that best fits their needs.

[Rich Engelhardt]

The downside............. ?

Coverage....
The amounts the advantage plans cover here where I'm at are pathetic. One trip to the hospital will wipe you out.
Also - Humana doesn't provide Silver Sneakers anymore - they have some other rinky dink provision instead that nobody accepts in my area. That alone is lose to $100 a month for the two places I am a member at.

[Jim Becker]

It's important to fully understand what's covered and what isn't covered and what providers are part of the network for HMO/PPO plans. Don't assume that because the plan is from a particular carrier that it's the same coverage and network as other plans they offer. Case in point...as a family, we've been on Keystone Health Plan East (Independence BC/BS) for many years now. The coverage is good and there are many in-network providers. Prescriptions are through OptumRX. Our older daughter also now has a state provided "MA" type plan because of her disability to supplement Medicare. It's also a Keystone plan...but...there are far few providers on the network. Prescriptions are via Humana. Same company; different coverage and network for the medical.

Right now, "traditional Medicare" is looking more favorable for many folks in some areas...choose carefully.

[Ken Fitzgerald]

The Medicare Advantage plans using HMOs may work in metropolitan areas but in some rural areas there may not be a provider within 100 or more miles radius.

Before being old enough for Medicare, the corporation I worked for offered 2 insurance plans. One was cheaper using a HMO. The other plan used regular providers and was more expensive but we had no real choice since there were no providers in our immediate area.

When my wife and I went on Medicare, we went with original Medicare and our supplement is a plan F supplement. We may pay more each month but have no out of pocket expenses other than drug plan Part D expenses. We can budget for the Plan F monthly expense.

[Mike Henderson]

Medicare Advantage plans can be very worthwhile if you don't have any serious or chronic conditions. The horror stories are essentially all about someone who comes down with an expensive condition or disease or has some expensive long lasting (chronic) condition.

As long as you never have anything like that, a Medicare Advantage plan works well. The point I was making in my original post is that if you do come down with one of those situations, you will essentially be blocked from going back to Original Medicare because you won't be able to purchase a supplemental policy.

Mike

[Bob Grier]

Mike - I believe you can move to Original Medicare (this should be easy to verify) but you may not be able to get a Supplemental Plan. If you apply for a Supplemental Plan it may have to go through the underwriting process and you may or may not be allowed into the plan. If you are accepted then it could be subject to conditions like: 1) Probation for 2 years with accompanying conditions such as who pays for preexisting conditions and for how long, 2) Possible ejection from the plan at end of probation period of say 2 years and then a retroactive settlement of who reimburses who for expenses incurred during the probation period. 3) Or you may have a higher premium (I don't know about this higher premium first hand but have been told that it can happen). I do know about the first 2 conditions because I traversed those.

Another way I believe you can do it is to move to a place where your Advantage Plan does not cover you and then get a broker or someone very knowledgeable to help you navigate Medicare application and enrollment in a Supplemental Plan. This may be limited to only certain states, I do not know that but moving from Washington State to Phoenix area works. No underwriting.

If you have traditional Medicare only with no plan, you can also apply for a Supplemental Plan years after initial eligibility but again, you will have to go through the underwriting process and there is no guarantee of being accepted, even with conditions. It is not a gamble I would take but I accidentally did it because I did not understand the system when I needed to apply. I was off cruising on a sailboat and not in the States.

I completely understand how people struggle with what to do regarding Medicare. TV ads all sound so good with the one bill for everything plus the extras thrown in but ......

[Doug Dawson]

Medicare Advantage plans can be very worthwhile if you don't have any serious or chronic conditions. The horror stories are essentially all about someone who comes down with an expensive condition or disease or has some expensive long lasting (chronic) condition.

As long as you never have anything like that, a Medicare Advantage plan works well.

"As long as you never have anything like that." Those are the operative words. But we're all getting older, and there's no way to know.

[Doug Garson]

Wow, as the title says this is a real revelation. As a Canadian this thread makes me appreciate our healthcare system that much more. Our system is far from perfect, doesn't include visioncare, dental, physiotherapy etc or prescription drugs (we can and I do buy supplemental coverage for this) and there are constant debates on whether the program is adequately funded and we do have waitlists for non life threatening procedures but we aren't faced with the kinds of decisions described in this thread which could lead to bankruptcy or worse if made incorrectly. This year in BC, premiums for basic medical insurance were eliminated, last year the highest rate which depended on income, was $900 per year for couple making over $42000 per year. Everytime I hear the phrase " doctors who accept Medicare" I shake my head. In Canada there is no such thing, the rate for all medically required procedures is negotiated between the Ministry of Health for each province and the doctors association of that province and that's what the doctor receives there is no option for a doctor to not accept the negotiated rate for medically required procedures. I've had four minor surgerys, two for my sinuses, one for my sleep apnea and one last year to remove a basil cell mole, three or four emergency room visits and two colonoscopies in my soon to be 71 years, my out of pocket cost? Not counting parking, $0 and I can choose which hospital I go to not which one some HMO owns. As someone commented earlier insurance companies are not business to provide health care they are in business to make a profit for their shareholders and huge paychecks for their executives.
And before anyone asks, life expectancy in Canada is about 3 years longer than the US, infant mortality rates are lower and we pay just over half of what the US pays per person.

[Rich Engelhardt]

Wow, as the title says this is a real revelation. As a Canadian this thread makes me appreciate our healthcare system that much more.

Before you get to feeling too comfortable with what you've got.....

You pay pretty close to what I would pay - - only difference is - you pay it as taxes.

If I lived in Canada - my income taxes would be very close to what I pay for Medicare & my supplement & ancillary programs - like Silver Sneakers.

[Lisa Starr]

Mike - I think you missed the point of my post. I DO have a serious medical condition and my MA plan is working just fine. I consider a total cost of $2000/year a pretty reasonable amount to pay per year for my health care. I paid $8500/year + $3700 Max out of pocket prior to becoming eligible for Medicare.

[Mike Henderson]

Mike - I think you missed the point of my post. I DO have a serious medical condition and my MA plan is working just fine. I consider a total cost of $2000/year a pretty reasonable amount to pay per year for my health care. I paid $8500/year + $3700 Max out of pocket prior to becoming eligible for Medicare.

I don't remember commenting on your situation, Lisa. I'm glad your MA is working out for you. The horror stories you hear about Medicare Advantage plans generally involve someone who was healthy and then came down with a serious disease or condition (often cancer), and then was "limited" in their treatment options because of the Medicare Advantage plan. I'm sure you can find those stories if you look - they're all over.

What I was saying in my opening post is to be aware of that risk. If you decide to switch to Original Medicare at that time, you may not be able to get a supplemental plan which will pay the remaining 20% of your medical expenses because the insurance companies are not required to accept you. They are only required to accept you when you turn 65 and sign up for Medicare.

Mike

[Bob Turkovich]

In Michigan - per my Medicare Insurance Broker - you have three years to decide which type of coverage you want and can switch between Advantage and Supplemental carriers at the annual enrollment period. During that period, any participating carrier can not turn you down for coverage nor cancel you after the three years are up regardless of pre-existing conditions. If you wish to switch after the three years are up, a carrier has the right to not accept you.

[Jim Becker]

Insurance is regulated by the states, so that may very well have some impact on this particular scenario...as Bob's post illustrates.

[Rich Engelhardt]

Insurance is regulated by the states, so that may very well have some impact on this particular scenario...as Bob's post illustrates.

Bingo - it most certainly does have an impact.
What's good in one zip code is a disaster waiting to happen in another.
When I log onto my Medicare planner site - I'm given the choice between choosing my current county (Summit) and - the state of West Virginia.
Just for grins and giggles - I chose WV once - just to check things out.
Totally different.