topic Re: Need Advice on Medicare and Medicare Advantage in Community Chat

Need Advice on Medicare and Medicare Advantage

donniesmom — Sat, 09 Mar 2019 18:50:31 GMT

Hi--I am trying to navigate the confusing maze of Medicare. I basically understand Original Medicare but am not sure about Medicare Advantage. I read that Medicare Advantage is like an HMO or PPO. Does anyone have Medicare Advantage and would you recommend it? This is just so confusing and overwhelming! Thank you in advance for your help.

Re: Need Advice on Medicare and Medicare Advantage

Group 5 minus 1 — Sat, 09 Mar 2019 18:58:27 GMT

Why,oh why are you asking us?

Re: Need Advice on Medicare and Medicare Advantage

Kachina624 — Sat, 09 Mar 2019 19:00:15 GMT

Medicare Advantage plans vary widely; there seems to be no two alike making it impossible to generalize or make sweeping statements about them. The best thing to do is evaluate a policy you're considering and see if it meets your needs.

Any Medicare question posted here has a plethora of misinformation . Please don't take information posted as the gospel truth.

Re: Need Advice on Medicare and Medicare Advantage

chessylady — Sat, 09 Mar 2019 19:06:56 GMT

I have Medicare Advantage through Kaiser Permanente which was my provider through my employer. I have the same doctor and same coverage I have had for many years. I am very healthy, have had no surgeries so I can't speak to that. I like it but you will have to make your own choice.

Re: Need Advice on Medicare and Medicare Advantage

NickNack — Sat, 09 Mar 2019 19:12:43 GMT

Your insurance company would probably have someone who could talk about this with you, or you could go to medicare dot gov for help. There is lots of information posted on their website. Don't trust anything you read on this board. It varies widely from person to person in what their opinion is.

Re: Need Advice on Medicare and Medicare Advantage

donniesmom — Sat, 09 Mar 2019 19:10:35 GMT

hollysunshine--I am asking to get advice from people who may have something of value to offer. The same reason most of us come on to these blogs to ask questions and get other people's opinion. People can either offer their advice or simply move on to another post.

Re: Need Advice on Medicare and Medicare Advantage

Dragonflyveb — Sat, 09 Mar 2019 19:35:43 GMT

I went through the same thing. There are so many companies, and within those companies, several versions of plans. And then, they vary by state. And they don’t put the premiums on their websites.

That being said, an Advantage plan has their own list of providers in their network. A supplemental plan does not.

My best advice is to first check if your area has a Council on Aging. They can explain the options. My consultation was free.

Once I did that, I asked around with my retired friends to find an agent to help me pick a plan. Be sure to find an agent that is not affiliated with any company. If you go to someone representing say, Anthem, they will only review Anthem policies.

I hope this helps. It was so confusing, I thought my head would explode!

Good luck,

Dragonfly

edited to add...also, I was told that if I wanted to switch plans after the initial signup, the companies require medical info and they can charge more or even reject you for previous conditions, hypertension, asthma, etc. I don’t know if that’s just my state, but it is a good question to ask!

Re: Need Advice on Medicare and Medicare Advantage

Carmie — Sat, 09 Mar 2019 19:16:34 GMT

There are two different types of Medicare Advantage Plans. One type is a PPO Plan. With this type of plan, you can go to the doctors of your choice. If they are in your PPO Network, you will have less out of pocket or even zero out of pocket that you pay for services. You will pay more out of your pocket for out of network providers, but you do have coverage. PPO Advantage Plans work okay if you travel in the US and get sick.

The second type is an HMO plan. With this type of plan, you MUST chose a doctor from their list who will act as a gatekeeper for all of your medical services. You will need referrals to see a specialist or get any types of services. Most of them will NOT cover any services without the referral unless it is a medical emergency. These HMO plans usually cost less per month than a PPO Advantage Plan. They are miserable plans to have if you travel anywhere in the US and get sick. They are made for people who stay close to home...remember that gatekeeper?

Both types of plans usually include RX drugs, perhaps some dental and vision coverage too...along with a gym membership ( silver sneakers) and hearing aid coverage. Not all Advantage plans include all of this, but most include some of it.

I am Medicare eligible in May. I have just about 25 years experience in Healthcare insurance, so I am pretty much an expert in Medicare insurance.

I prefer Advantage PPO's to HMO's. They are easier to navigate and understand. One nice thing about Advantage Plans is that if you choose a plan you don't like, you can change to another one during open enrollment for the next Jan. 1st.

If you choose Original Medicare and get a supplement, you cannot change your supplemental plan. It's pretty much a life long thing, but you can switch to an Advantage Plan during open enrollment.

If you choose Original Medicare and a supplement...always chose an RX plan at the same time, or else you will be greatly penalized if you don't.

Once you choose an Advantage Plan, If you change your mind and decide you want Original Medicare, you can switch, but if will be next to impossible to get a supplement.

if you are still confused or have any other questions, just ask.

Re: Need Advice on Medicare and Medicare Advantage

CinNC — Sat, 09 Mar 2019 19:18:01 GMT

I was able to go to a class thru my local Office of the Aging......it was put on by the NC Dept of Insurance so they weren't selling anything.

For my state (North Carolina), the Advantage Programs are based on how many physicians in the county are have joined. Their recommendation was that if you travel a lot, you would be better off w/traditional Medicare rather than an Advantage program. If you end up hospitalized and the facility/physicians are not in your Advantage program, then it would be considered out of network and you could be responsible for the entire bill. So, in part, it would depend on your lifestyle.

I'm turning 65 in May and have to select my plans. It's such a nightmare and I know where you're coming from.

Re: Need Advice on Medicare and Medicare Advantage

Kachina624 — Sat, 09 Mar 2019 19:29:43 GMT

@Carmie. I have an Advantage Plan that is neither a PPO or a HMO. I can go to any provider that takes Medicare anywhere. I never have a co-pay or deductible. I have not paid one cent out of pocket since I've been on Medicare even though I've had major surgery.

As I said above, with these Advantage Plans, as soon as you think you understand them, somebody will come up with an exception. Mine is exceptionally good and only available through the employer from whom I retired.

Re: Need Advice on Medicare and Medicare Advantage

Carmie — Sat, 09 Mar 2019 19:30:41 GMT

@CinNC You are correct in the fact that if you do a lot of traveling in the US, a traditional Medicare plan with a supplement is best.

If you travel out of the country Medicare does not cover any foreign bills. That goes for cruise ships too. There are supplemental plans that will partially cover at 80% for foreign claims.

Advantage HMO's are horrible for travelers, but some PPO's are not too bad. You have to carefully read the Advantage Plans. They are all so different and not carved in stone like Traditional/ Original Medicare and the supplements.

Re: Need Advice on Medicare and Medicare Advantage

donniesmom — Sat, 09 Mar 2019 19:37:58 GMT

CARMIE--wow! thank you so much for your detailed response. You helped clear up the Medicare Advantage part especially the difference between HMO & PPO's. Another poster couldn't understand why I asked this question on this forum. This is why!! Because wonderful people like yourself and others that answered me are willing to take the time to help others. Obviously, I know it's up to me to make a decision but it's wonderful to see that people can be so kind to take the time to help. Your many years in the healthcare field has certainly helped me. Thank you and many blessings!

Re: Need Advice on Medicare and Medicare Advantage

donniesmom — Sat, 09 Mar 2019 19:39:42 GMT

Many thanks to you all for your help and advice. It helps to hear different points of view. Blessing to you all!

Re: Need Advice on Medicare and Medicare Advantage

Carmie — Sat, 09 Mar 2019 19:43:05 GMT

@Kachina624 @As soon as I read your first paragraph, I knew you had an Advantage Plan through an employer. Your employer is self insured. Employers are allowed to have different Advantage Plans than can be offered to the public.

My sister was on a Advantage Plan through her deceased husband's employer, and it was super wonderful, Then two years ago, they changed to an awful plan. She pays $90 a month and it covers nothing in full anymore.

Group insurance is a completely different category than what is being sold to the public. Not even in the same league.

Re: Need Advice on Medicare and Medicare Advantage

tipsy — Sat, 09 Mar 2019 19:48:57 GMT

@Carmie thanks for your input! I am Medicare eligible in May also. I got my Medicare A & B card. I have TriCare for Life & will keep that as my secondary. I still need to find out about RX coverage. I don't think I need Medicare Part D. The TriCare number I call for that is a nightmare. It's a nightmare because it's a recording & they ask questions for you to answer but there is no option for the information I want. It is VERY frustrating!

Re: Need Advice on Medicare and Medicare Advantage

Mom2Dogs — Sat, 09 Mar 2019 19:56:47 GMT

@Carmie wrote:
There are two different types of Medicare Advantage Plans. One type is a PPO Plan. With this type of plan, you can go to the doctors of your choice. If they are in your PPO Network, you will have less out of pocket or even zero out of pocket that you pay for services. You will pay more out of your pocket for out of network providers, but you do have coverage. PPO Advantage Plans work okay if you travel in the US and get sick.

The second type is an HMO plan. With this type of plan, you MUST chose a doctor from their list who will act as a gatekeeper for all of your medical services. You will need referrals to see a specialist or get any types of services. Most of them will NOT cover any services without the referral unless it is a medical emergency. These HMO plans usually cost less per month than a PPO Advantage Plan. They are miserable plans to have if you travel anywhere in the US and get sick. They are made for people who stay close to home...remember that gatekeeper?

Both types of plans usually include RX drugs, perhaps some dental and vision coverage too...along with a gym membership ( silver sneakers) and hearing aid coverage. Not all Advantage plans include all of this, but most include some of it.

I am Medicare eligible in May. I have just about 25 years experience in Healthcare insurance, so I am pretty much an expert in Medicare insurance.

I prefer Advantage PPO's to HMO's. They are easier to navigate and understand. One nice thing about Advantage Plans is that if you choose a plan you don't like, you can change to another one during open enrollment for the next Jan. 1st.

If you choose Original Medicare and get a supplement, you cannot change your supplemental plan. It's pretty much a life long thing, but you can switch to an Advantage Plan during open enrollment.

If you choose Original Medicare and a supplement...always chose an RX plan at the same time, or else you will be greatly penalized if you don't.

Once you choose an Advantage Plan, If you change your mind and decide you want Original Medicare, you can switch, but if will be next to impossible to get a supplement.

if you are still confused or have any other questions, just ask.

@Carmie (See you words in red) out of curosity why is it difficult to get a supplement plan if you decide to cancel an Advantage Plan?..and is it that pretty much across all 50 states?

I will be eligilble next year and plan of speaking with an insurance person locally but like to know as much info going in...thank you.

Re: Need Advice on Medicare and Medicare Advantage

Carmie — Sat, 09 Mar 2019 20:00:19 GMT

@tipsy Medicare Part D is RX coverage. It is important that you choose RX coverage within 3 months of your Medicare Part B effective date. If you do not, you will be penalized and it will cost you more for the rest of your life.

You need to find out if Tricare for Life includes pharmacy services. If it does, you do not need Part D. If it does not, you would need to buy a Plan D.

I know that TriCare is a military insurance plan, but unfortunally, I don't know the eligibility requirements or plan coverages.

Re: Need Advice on Medicare and Medicare Advantage

conlt — Sat, 09 Mar 2019 20:01:35 GMT

I am a health care provider and I will tell you what I see with clients who have Medicare Vs. Medicare advantage. You are correct that the advantage plans are run by private insurance companies. With that being said, they are there to make money. I would choose Medicare and a supplement plan over a Medicare advantage plan and here is why: I am the administrator of a skilled home health company and we usually see pretty sick patients with the average age being around 80. With Medicare our services are covered at 100% the RN, or therapy visits the patient, formulates a care plan in conjunction with the MD and then we see the patient according to that care plan covered at 100% for our services. Every week I deal with advantage plans and it breaks my heart with what I see. Yesterday an elderly couple came to our office, they had our address that was given to them by Humana to get a walker (we don't sell or provide equipment). She was holding onto things and desperately needed a walker. She was on a Humana Medicare PPO. We searched the Internet for the place that she was supposed to be and we sent the couple off without knowing where this company was. I don't think that it exists, I have been working in health care here for 38 years.

Several times a week, my company receives referrals on advantage plan patients, some we can take but the plan usually limits the visits that we can do despite what the clinician's assessment says.

These plans say they cover what Medicare covers, and they cover those categories but they limit care and expensive care costs the patient more out of pocket. . Yesterday one of our referrals had a $15800 deductible. Many have a 50% copay for our services, whereas Medicare pays at 100%. The elderly are often "swooned" into these plans, promising to cover the same as Medicare but many times the plan does not deliver, especially the HMO's. They may work fine if you are healthy, but just get sick and needy and see what they don't cover.

The best plan, in my opinion, is regular Medicare, Part F (if they still have it supplement) and a Part D prescription plan.

Re: Need Advice on Medicare and Medicare Advantage

conlt — Sat, 09 Mar 2019 20:14:50 GMT

I forgot to mention another thing about advantage plans, I live and work in Florida and we get many of out-of-state visitors, some who get ill while here. I have received referrals on patients who have an advantage plan that is only good in certain states. We had 1 recently who's insurance only covered him the the state of Maryland. Again, if we can get authorization from the insurance company, then we can see them. If not, then we cannot and the person goes without care. We recently had a referral on a patient who had a plan where there were not local providers. We tried to do a letter of agreement with the advantage plan but the insurance company would not specify a rate to pay us so we could not complete the agreement. So we had a patient, who needed care, who could not obtain care. Dealing with these issues on a weekly basis, really opened my eyes to how people are lulled into advantage plans by free lunches, silver sneakers gym memberships, etc. Their offerings are not worth it when the patient gets ill and can't access needed care.

Re: Need Advice on Medicare and Medicare Advantage

Carmie — Sat, 09 Mar 2019 20:14:57 GMT

@Mom2Dogs It is almost impossible to get a supplement because insurance companies are allowed to charge more for insurance that you purchase outside of your 6 month Medicare enrollment date....(three months before and three months after your Medicare Part b effective date)

Some companies won't allow you to enroll for Pre x conditions and the ones that do, charge fees so high they will make your head spin.

example: I called United Health Care to downgrade a supplement Plan H to a Plan C for a family member. Plan H is not needed if you live in PA or one of the other states where the provider cannot bill you for the Medicare excess fee. The broker did not explain this when the plan was purchased.

I was quoted a price that was 2x's higher for Plan C which is a less comprehensive plan than Plan H. So, we stayed with the higher plan for less money. They can charge more for downgrading too.

Yes, it is the same in all 50 states. There are some government rules to allow people with certain diseases and health problems to switch and pick up a supplement without penalty, but most people would not fall into that.

So, yes you can buy a supplemtal Plan, but the average person would not be able to afford the premiums. It is legal.

IMO, it is done to keep healthy seniors from choosing a lower plan when they are healthy, then switching to a more comprehensive plan when they are older and sick.