How does Medicare work?

[littleb]

I assume from many articles and posts that you pick a Medicare plan from different carriers and options from PPO to HMO.

If you pick a plan other than a HMO do you have coverage over state lines?

I am not inquiring about emergency care.

 

[Corporateburnout]

I assume you're talking about policies to supplement your basic coverage of parts A and B.

Medicare Advantage which is similar to an HMO is restricted to your area and you need referral in most cases to see other doctors within the network. Some plans do cover emergency services outside your area.

Medicare Supplement is accepted by any doctor who accepts Medicare anywhere in the US and some policies have international coverage as well.

 

[littleb]

I assume you're talking about policies to supplement your basic coverage of parts A and B.

Medicare Advantage which is similar to an HMO is restricted to your area and you need referral in most cases to see other doctors within the network. Some plans do cover emergency services outside your area.

Medicare Supplement is accepted by any doctor who accepts Medicare anywhere in the US and some policies have international coverage as well.

Well I guess you can tell I know nothing about Medicare. So if you travel you need to buy Medicare Supplement in order to go to out of area doctors and hospitals.

Thanks

 

[braumeister]

Well I guess you can tell I know nothing about Medicare.

Medicare is not really as complex as many people think.

Here is a basic outline:
What's Medicare?

 

[meierlde]

If you go original medicare you get parts A (hospital) part B (physicians and out of hospital treatment) and part D prescription drugs. The part B applies to any physician who accepts medicare. However after the deductable part B pays 80% of the medicare amount. Medigap pays the 20% part B does not as well as other items. Note medicare does not pay anything for travel outside the US. (except along the routes to and from Alaska from the lower 48). Medigap is standardized the various forms are the same for any carrier paying essentially the same benefits. Only medicare advantage has the narrow networks of traditional insurance. Note because medicare patients are such a large part of the business of hospitals most hospitals take part A patients.

 

[calico1597]

I'm new to Medicare this month, happy 65th to me tomorrow. Medicare covers 80% of most medical expenses. A supplemental insurance (also known as Medigap) picks up the other 20%. If you're a snowbird you don't want the Medicare Advantage Plan, it's too restricting, requiring you to use drs in your home area. Medicare nor supplemental policies does not cover hearing aids, eye exams or glasses, or dental work. Separate policies are available for eye and dental. You will also need to purchase a policy for a drug plan (known as part D), also not covered by Medicare or the supplemental.

 

[CRLLS]

First few months of Medicare for DW. What surprised me is that traditional Medicare Part A and Part B (not including Part D or a Medigap) is as good or better than our old company plan not counting medications and certainly better than our ACA plan. So far, any DR (including specialists and anesthesiologists) and any Hospital we have seen accept Medicare Assignment.

DW purchased an FHD supplement plan which has a ~$2150 deductible. That starts AFTER the negotiated Medicare rates. For example, for our Supplement to pay anything, our BILLED amount has to be over $20K (ish). For this example, I assume that Medicare negotiates a 50% reduction in the bill taking it to $10K. Then Medicare pays their 80%. leaving us $2K out-of-pocket before the supplement takes action. At that, we still have not met our deductible. If you are relatively healthy, don't be fooled by thinking you need a lot of coverage by the Supplement plan you choose. The Medicare system is pretty good by itself.

We are still trying to figure out our Part D (Drug plan). They are covering some items before we have met that separate deductible. Go figure.

No matter where you are in the USA, make sure you ask the Dr if they accept Medicare assignment and you will be golden.

Standard Medigap Plans C, D, F, G, M, and N provide foreign travel emergency health care coverage when you travel outside the U.S. Foreign travel emergency coverage with Medigap policies has a lifetime limit of $50,000.

 

[meierlde]

A bit more if you go into the hospital that is part A your hospital bill will have a total that will be zeroed out and replaced with the diagnosis related charge that medicare uses for hospital bills (this happened with my mother). There is a deductible of about 1300 associated with part A also but most medigap policies cover this deductible. Actually for part B charges you see an amount allowed which is the max medicare will pay for whatever was billed.
On your part d are the drugs in question generic drugs? Some plans cover generic drugs with no deductible, so that for example with the Human Wal-Mart plan a generic that might cost $10 for a 3 month supply now costs 3 (which is significanly better than my old employers plan)

 

[fritz]

I assume from many articles and posts that you pick a Medicare plan from different carriers and options from PPO to HMO.

If you pick a plan other than a HMO do you have coverage over state lines?

I am not inquiring about emergency care.

I'm new to Medicare this month, happy 65th to me tomorrow. Medicare covers 80% of most medical expenses. A supplemental insurance (also known as Medigap) picks up the other 20%. If you're a snowbird you don't want the Medicare Advantage Plan, it's too restricting, requiring you to use drs in your home area. Medicare nor supplemental policies does not cover hearing aids, eye exams or glasses, or dental work. Separate policies are available for eye and dental. You will also need to purchase a policy for a drug plan (known as part D), also not covered by Medicare or the supplemental.

Welcome to the confusing world of Medicare. I went on it last year and it was difficult at best to get straight answers (and tread carefully with supplemental and advantage insurance sellers).

I chose traditional Medicare (Parts A, B & D) with a supplemental insurance policy for the part B 20% coverage (your portion that has no cap). This works well for me (eventually us) as we travel, and winter along the gulf. As long as the hospital/doctor accept Medicare, the supplemental insurance will have a difficult time not covering the 20% of your portion (given only some deductibles, as spelled out in each Medigap plan). Medicare frowns on insurers not following the rules, and supposedly has the power to pull any insurer from offering Medigap policies.

All supplemental/Medigap insurance policies are supposed to be identical "standardized" per their group (A, B, C, etc) so the only difference is the price. The best price policies might not be offered by an insurance agent as not all insurance companies use (pay commissions) to agents. I personally found that agents I spoke to did not offer me what I needed and pushed what they made the highest commission on - Medicare Advantage was the big push).

The best current Medigap policy is "F" as it covers 100% of all part "B" Medicare (your 20% portion), and offers 80% coverage of foreign travel (up to plan limits - currently $50,000). FYI - this Medigap plan is scheduled to go away in 2020. I believe "F" is the most popular choice to date, and apprx. 80% of Medigap customers are in plan "F". You can sign up for it, but realize that after 2020 - the pool of insured will be shrinking and increases will most likely be higher for those in it or choosing it before 2020.

I would consider "G" as a suitable alternative. The deductible not covered in "G" that is covered in "F" is the part "B" Medicare deductible (currently $166.00 annually 2015). The price difference (premium costs) could make it worth your while to choose "G" over "F". "G" is not scheduled to go away...

There is also a High Deductible "F" for those willing to pay up front ($2200 for 2017) before regular "F" kicks in (and it is not going away when regular "F" does in 2020).

I didn't consider any Medicare Advantage plans per reasons stated above, and also because we currently deal with BCBS in an HMO for the wife with the ACA. Don't want any wars (in network vs. out of network and ever changing deductibles) when it comes time to utilize coverage. From what I've read and what others have said - Medicare Advanatge policies do offer extra benefits, but with caveats...

I use High Deductible "F" (cost is $32.50/mos. from Globe Life) and no Medicare part "D" due to being in the VA. VA qualifies for Medicare part "D" coverage (and I could go on part "D" in the future w/o any penalties for not sighing up at 65 because of it). Wife will be traditional Medicare (A, B, and D) with Medigap supplemental coverage "G".

You should have received a booklet from Medicare "Medicare and You 2017" if you're turning 65 soon. There is another publication they offer "Choosing a Medigap Policy:" Public library in our area offered a Medicare 101 intro, but it was run by an insurance agent... You could also contact a Senior Services Center in your area (look online) for assistance.

 

[meierlde]

BTW my megacorp allows a spouse under 65 to stay with the retiree policy, while the ex employee who is over 65 is moved to medicare. The actually moved from their own medigap policy to a private exchange accessing the medigap policies etc. This did reduce the cost $100 per month, since the company refunds what was their contribution to their private medigap plan. (The part D is better than the drug plan they used before also, and the post 65 drug plan was better than the per 65 drug plan)

 

[littleb]

Thanks everyone for the detailed answers. This information is for a family member.

 

[audreyh1]

That 20% uncapped copay without a supplement plan may not seem like much, until you are facing cancer treatments.

 

[Another Reader]

I'm SO not looking forward to Medicare. I pay almost nothing in co-pays for my pre-Medicare retiree health plan, although the premium is high. However, when I add up all the Medicare premiums plus the Medigap policy, it's not much less that what my share of the current policy premium is. Fewer choices and lower reimbursements smell like a lot less service and quality for the same price.

 

[AllDone]

I'm SO not looking forward to Medicare. I pay almost nothing in co-pays for my pre-Medicare retiree health plan, although the premium is high. However, when I add up all the Medicare premiums plus the Medigap policy, it's not much less that what my share of the current policy premium is. Fewer choices and lower reimbursements smell like a lot less service and quality for the same price.

Doesn't your retiree health plan cover your Medigap premium? That's the usual arrangement.

More than 95% of doctors and almost all hospitals take Medicare, so you don't have to worry about fewer choices. There are a couple of specialties that may not accept Medicare in isolated areas -- if you're the only dermatologist in town, you can make plenty of money on a cash basis doing "aesthetic" dermatology -- but most people won't run up against that kind of limitation.

 

[meierlde]

That 20% uncapped copay without a supplement plan may not seem like much, until you are facing cancer treatments.

If that is a concern the high deductable plan F is a possiblity, its premium is far lower than the regular plan f.

 

[Another Reader]

Doesn't your retiree health plan cover your Medigap premium? That's the usual arrangement.

More than 95% of doctors and almost all hospitals take Medicare, so you don't have to worry about fewer choices. There are a couple of specialties that may not accept Medicare in isolated areas -- if you're the only dermatologist in town, you can make plenty of money on a cash basis doing "aesthetic" dermatology -- but most people won't run up against that kind of limitation.

Many of the better doctors here do not take new Medicare patients because the reimbursements are too low. The retirees get a medicare exchange where most of the policies are Advantage policies and the subsidy is small. I would rather pay for the policy I have now than be stuck in this morass of a program.

 

[CRLLS]

That 20% uncapped copay without a supplement plan may not seem like much, until you are facing cancer treatments.

True. And that (and other catastrophic events) is the major reason for having the Supplement policy IMO. But when compared to a generic Corporate plan, Medicare is pretty good standing by itself IMO. That is until one on Medicare reaches what would have been max out of pocket on the corp plan. There is no Maximum on Part A or Part B. For general medical coverage, Medicare is much better than any ACA plan I have had and do have. I, for one, am welcoming the time when I can get Medicare Parts A, B and D.

But correct me if I am wrong. I'm thinking procedures/radiation etc fall under Part B or Part A. Is that right? Does Chemo fall under Part D? Not having been there, I was just wondering......

 

[REWahoo]

But correct me if I am wrong. I'm thinking procedures/radiation etc fall under Part B or Part A. Is that right? Does Chemo fall under Part D? Not having been there, I was just wondering......

Interesting what you can find on the intertube: https://www.medicare.gov/coverage/chemotherapy.html

Chemotherapy

How often is it covered?

Medicare covers chemotherapy if you're a cancer patient who's a hospital inpatient or outpatient, as well as if you're a patient in a doctor's office or freestanding clinic.

Who's eligible?

All people with Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance) are covered. Part A covers hospital inpatients, and Part B covers hospital outpatients and patients in a doctor's office or freestanding clinic.

Your costs in Original Medicare

You pay a copayment if you're a hospital outpatient.

You pay 20% of the Medicare-approved amount if you get your treatment in a doctor's office or freestanding clinic. The Part B deductible applies.

 

[audreyh1]

True. And that (and other catastrophic events) is the major reason for having the Supplement policy IMO. But when compared to a generic Corporate plan, Medicare is pretty good standing by itself IMO. That is until one on Medicare reaches what would have been max out of pocket on the corp plan. There is no Maximum on Part A or Part B. For general medical coverage, Medicare is much better than any ACA plan I have had and do have. I, for one, am welcoming the time when I can get Medicare Parts A, B and D.

But correct me if I am wrong. I'm thinking procedures/radiation etc fall under Part B or Part A. Is that right? Does Chemo fall under Part D? Not having been there, I was just wondering......

No, the chemo, as it is administered in a doctor's office or clinic, falls under part B. When it's $30,000 a treatment, as it was for my MIL, you're looking at a $6,000 copay each session! Without Medigap the costs balloon.

 

[imoldernu]

We have been totally pleased with our Medicare Supplement experience for the past 18 years.
Small, but important point for us. Though our original supplement plan was from a state where we had previously lived until 4 years ago, we have continued to leave it there, and have had zero problems.

 

[ABQ2015]

I'm SO not looking forward to Medicare. I pay almost nothing in co-pays for my pre-Medicare retiree health plan, although the premium is high. However, when I add up all the Medicare premiums plus the Medigap policy, it's not much less that what my share of the current policy premium is. Fewer choices and lower reimbursements smell like a lot less service and quality for the same price.

I'm starting to share your concerns. As a federal retiree, I can keep my federal health insurance in addition to Medicare. I thought this would be a big plus as far as being accepted by a doctor as a new Medicare patient or being able to go to the Mayo Clinic, if needed, as it would work like regular insurance. But the more I read about it, my federal health insurance is mostly good for paying the 20% co-pays or co-insurance similar to Medigap and is limited by law to paying up to the prescribed Medicare amounts for services - at most it can pay a doctor about 15% more.

And it is recommended that I purchase both the federal health insurance and Medicare Part B for which I will pay the higher premium rates. So I will be paying more for health insurance as a retiree than as an employee despite having "employer" health insurance.

 

[Lakedog]

I'm starting to share your concerns. As a federal retiree, I can keep my federal health insurance in addition to Medicare. I thought this would be a big plus as far as being accepted by a doctor as a new Medicare patient or being able to go to the Mayo Clinic, if needed, as it would work like regular insurance. But the more I read about it, my federal health insurance is mostly good for paying the 20% co-pays or co-insurance similar to Medigap and is limited by law to paying up to the prescribed Medicare amounts for services - at most it can pay a doctor about 15% more.

And it is recommended that I purchase both the federal health insurance and Medicare Part B for which I will pay the higher premium rates. So I will be paying more for health insurance as a retiree than as an employee despite having "employer" health insurance.

My understanding is that you do have the option not to sign up for medicare if you prefer to keep the FEHB plan as is. I am a few years away so haven't looked into that closely but I may consider it since I am on a HDHP with HSA that I could continue contributing to beyond age 65 if I do not sign up for medicare.

If you do sign up for medicare, going with one of the least expensive FEHB plans is often recommended since most of them cover the majority of what medicare does not.

 

[Fedup]

FEHB BCBS basic and Medicare premium B is about $200 something for a single. But you pay no fee going to the doctors. But I think the savings will be later when you're much older than 65. Plus less headaches. No worries about who pays what.
But from what I've read even with these two plans, you might have some conditions that require more money out of pocket.
I originally thought of not getting Medicare B from what I've read from other forum but my husband's doctor refused to accept BCBS, that's our plan, so we had to sign up for Medicare B at almost the last minute. I'm glad we did because of less worry in the future.

 

[rodi]

I'm SO not looking forward to Medicare. I pay almost nothing in co-pays for my pre-Medicare retiree health plan, although the premium is high. However, when I add up all the Medicare premiums plus the Medigap policy, it's not much less that what my share of the current policy premium is. Fewer choices and lower reimbursements smell like a lot less service and quality for the same price.

I'm in the opposite camp. My husband started Medicare at the beginning of the year. After a lot of reading, questions asked and answered here, etc, we went for the f- plus and part d in addition to Medicare a&b. The monthly premiums are about $300 less per month, the deductible is far lower and only applies to the 20% not covered by Medicare b.

I guess the difference is we didn't have retiree health insurance and had a hdhp from the exchange. I can't wait till I go in Medicare for lower premiums for better, more comprehensive, insurance.

 

[mickeyd]

One piece of Medicare not mentioned yet is it's relationship with retired military members and spouse. At age 65 they must enroll in Pt A and B, like others, and pay the appropriate premium. They are then kicked off of Tricare Prime and enrolled in Tricare-for-life ( no cost to the individual or spouse.) This acts as a free medi-gap-like plan that pays all that MC does not pay.