MA-EGWP versus Medicare Plan G

[Irishgirlyc58]

I am hoping to gather opinions on my current dilemma regarding my medicare coverage.
I have been on MC with my former employer UHC advantage plan since turning 65 9/2023. The premium this year is $466. I was notified that it is going up to $600. My employer contributes $50-so my monthly cost is $550. This got me looking at options and now I'm trying to decide if the "extras" in the MA plan are really worth it. I'm just having trouble deciding on a few due to lack of experience with them.

Hospital days have no limit. I would pay zero costs for unlimited days. You can typically get a medigap plan G that covers the medicare days-approx. 90 and then and additional 365 days. How often do people stay in a hospital for that long? Does that ever happen? It seems to me to be a none benefit but I certainly could be wrong.
There is no 3 day hospital stay for admittance into a SNF. I read somewhere that this could be useful?

Podiatary services: 6 visits a year for treatment such as cutting or removal of corns, warts, calluses, or nail. Although I don't need this now-it seems like something that could be useful in 20 years.

Annual physical-meh. I'm not sure that's worth anything. I'm not sure I've ever had a "physical"

Prescription coverage seems to be very good. $10/$20/$35. An extensive formulary list and a supplemental list on medications not covered by medicare. Could be extremely useful.

Alternatively I believe I can get a plan G with some additional perks such as vision/hearing coverage for $170/month. Then I would still need to get a standalone plan D-which seems to be more of a crap shoot on coverage.

So am I nuts to even contemplate leaving the employer sponsored plan or am I nuts to not leave it? Do these additional benefits really pan out eventually or am I just throwing away my money. I don't mind paying for additional coverage if it actually is coverage and not just words on a document made to look like a benefit.

Opinions would be appreciated!

 

[Bigbass]

I went with MA-EGWP when I turned 65 earlier this year for the following reasons:

- Cost to me $0
- Annual max out of pocket $900
- No network restrictions
- If I decide to leave the plan, I would qualify for a special election period where I would have a 63-day window to pick up a supplement plan or other advantage plan with no underwriting or penalties. I was told this by three different sources, but of course, I won't know if this is correct until I actually try to make the switch.

But if I had to pay $500+ for my MA-EGWP, even with the 6 visits for Podiatry service and 84 home-delivered meals after hospitalization, I would still go with Plan G.

 

[Ian S]

I'm not really familiar with these plans but with standard Medicare Advantage as I understand it, you still have to pay your Part B premiums which for 2024 are $174.70 per month. Likewise with regular Medicare, you have to pay that same Part B premium. In your case, I assume that Part B premium is already included in your monthly payment. So, in addition to the cost of a G supplement and a Part D drug plan, you would have to add that Part D premium to compare. Part D drug plans can be changed annually and many of os currently have a Wellcare Part D plan that has no monthly premium. In addition, many commonly used drugs like a generic statin are also no cost. The increase in cost of your existing plan for next year seems excessive to me when compared to what it might cost you for traditional Medicare with a supplement plan G plus Part D.

 

[zl55lz]

If you drop your employer MA plan, is it final or can you get back on in the future or at least within a certain timeframe?

Is your MA plan through FEHB (federal)?

 

[Teacher Terry]

For that price I would drop the plan. I pay 330/month for plan G and parts b and D.

 

[aja8888]

For that price I would drop the plan. I pay 330/month for plan G and parts b and D.

This!^^^

 

[aja8888]

This!^^^

I just spent $350,000 of Medicare's money in the hospital (July) and had a stent put in my neck artery and a pacemaker installed in my chest, along with scores of expensive tests and doctor visits during and after my stay. I'm on Plan G and my OOP was somewhere around $230 (annual max deductible). I'm pretty sure if I was on an MA plan, I may not have been able to see all the doctors and surgeons I saw (12?) or if all the tests would have been covered.

 

[Irishgirlyc58]

But if I had to pay $500+ for my MA-EGWP, even with the 6 visits for Podiatry service and 84 home-delivered meals after hospitalization, I would still go with Plan G.

Right My first thought was -like I'd be able to find a podiatrist to do that.
I totally discounted their "healthy at home" perks-meals and transportation. I know from experience in my professional life in social services that these services are iffy at best.

I assume that Part B premium is already included in your monthly payment. So, in addition to the cost of a G supplement and a Part D drug plan, you would have to add that Part D premium to compare.

No, my Medicare Part B is taken directly out of my social security. It is over and above the premium for the MA plan. I am also subject to IRMAA for parts B and D due to my pension. So my total monthly cost for premiums would be just about $1,000. Everything would be covered except for minor cost for prescriptions but it seems like the same would be true with a plan G and D supplement.

If you drop your employer MA plan, is it final or can you get back on in the future or at least within a certain timeframe?

Is your MA plan through FEHB (federal)?

Once I drop the employer plan there is no going back.
It is through the county I retired from. I believe they actually self insure for this plan and use UHC as a third party administrator. The state requires that they offer some type of coverage for retirees and a contribution but not how much. They already reduced the contribution from $200 to $50.
My confidence level with this county is very low. I live here so I can say-they are a hot mess and have been for sometime.

For that price I would drop the plan. I pay 330/month for plan G and parts b and D.

Terry-do you just go with the cheapest part D plan that covers your prescriptions? It's hard to pick one not knowing if your health is going to change. 3 years ago I wasn't on any and now I have 3.

 

[Sarah S]

The hospital issue is rare but can happen. The 365 days are lifetime cumulative

The snf three day hospital rule being waived is definitely helpful

Podiatry and physical nice I suppose but I wouldn’t pay extra for that benefit

If the drug benefit is really good another plus

If you have a really excellent provider network and no prior authorization for procedures then I would strongly consider it. But it depends on your finances and also your personal and family medical history. Most people won’t have to worry about the hospital days. My family did

 

[Irishgirlyc58]

I just spent $350,000 of Medicare's money in the hospital (July) and had a stent put in my neck artery and a pacemaker installed in my chest, along with scores of expensive tests and doctor visits during and after my stay. I'm on Plan G and my OOP was somewhere around $230 (annual max deductible). I'm pretty sure if I was on an MA plan, I may not have been able to see all the doctors and surgeons I saw (12?) or if all the tests would have been covered.

Dang. I hope you are doing well after that ordeal.
I bet even with all of that you didn't spend over a year in the hospital! It seems to me that the extensive hospital days coverage is the "if Martians land" coverage.

Good point on the acceptance of the MA plan although it does seem that the employer sponsored ones are more likely to not be excluded. You just never know.

 

[aja8888]

Dang. I hope you are doing well after that ordeal.
I bet even with all of that you didn't spend over a year in the hospital! It seems to me that the extensive hospital days coverage is the "if Martians land" coverage.

Good point on the acceptance of the MA plan although it does seem that the employer sponsored ones are more likely to not be excluded. You just never know.

Thanks, I'm doing quite well after all of that punishment!

I spent 5 total days, two of them in ICU. The Pacemaker was installed as outpatient in one morning visit. That was no problem.

 

[Gotadimple]

So am I nuts to even contemplate leaving the employer sponsored plan or am I nuts to not leave it? Do these additional benefits really pan out eventually or am I just throwing away my money. I don't mind paying for additional coverage if it actually is coverage and not just words on a document made to look like a benefit.

Opinions would be appreciated!

Absolutely not! I retired from a health insurer and had their retiree MA plan for a few years. Over time, it turned out to be more expensive than what I could buy directly from a MA insurer. And your prescription co-pays are quite high - especially for tier 1 generics. Why? Because they have a limited retiree pool and as that pool of people ages they use more services. And the pricing on the retiree plan is now more expensive than a similar MA available to the public, or Traditional + Medigap G + Part D.

When you do your comparison, look in detail at the deductible and co-pays on the retiree plan compared to what you can buy directly (for MA plans). Likely you will find lower co-pays and deductibles on your retiree plan are than available on the open market - also adding to cost. Also consider your health and if you will pass screening for Medigap G plan. In that regard your state insurance commissioner can help with the assessment (called SHIP in most states, SHIBA in Washington and Oregon).

Then add everything up: Part B premium + MA Premium or Medigap Premium + Part D Premium + likely out of pocket costs (prescriptions + doctor visits + any applicable deductible) - for each plan you are interested in. It's not just a financial decision, but, what is covered may/will be different between carriers.

 

[aja8888]

Absolutely not! I retired from a health insurer and had their retiree MA plan for a few years. Over time, it turned out to be more expensive than what I could buy directly from a MA insurer. And your prescription co-pays are quite high - especially for tier 1 generics. Why? Because they have a limited retiree pool and as that pool of people ages they use more services. And the pricing on the retiree plan is now more expensive than a similar MA available to the public, or Traditional + Medigap G + Part D.

When you do your comparison, look in detail at the deductible and co-pays on the retiree plan compared to what you can buy directly (for MA plans). Likely you will find lower co-pays and deductibles on your retiree plan are than available on the open market - also adding to cost. Also consider your health and if you will pass screening for Medigap G plan. In that regard your state insurance commissioner can help with the assessment (called SHIP in most states, SHIBA in Washington and Oregon).

Then add everything up: Part B premium + MA Premium or Medigap Premium + Part D Premium + likely out of pocket costs (prescriptions + doctor visits + any applicable deductible) - for each plan you are interested in. It's not just a financial decision, but, what is covered may/will be different between carriers.

Very good post! Especially the last sentence.

As an example of what can happen, a good friend of mine has a Humana MA plan and all his doctors (Cardo, diabetes, foot, etc) are all part of the very large Memorial Hermann Hospital network here in Houston. Last year, on Jan 1, 2024, Humana and HM could not come to an agreement on the provider contract and parted company. So my friend lost access to all his doctors. If he had traditional Medicare with a supplement, he would have been able to keep seeing his regular docs since the hospital network takes regular Medicare.

 

[Dash man]

My father-in-law has an excellent union MA plan where he never pays anything. But if I were him, I’d still go on a Medicare Plan N or G. He had a battle with cancer, and while he’s gotten past it, he had to wait a number of times for approval for a PET scan or other procedures. With Medicare Plan N or G, there would be no waiting. With many cancers, speed is critical. Waiting for some administrator to approve a procedure is ridiculous.

 

[Irishgirlyc58]

Very good post! Especially the last sentence.

As an example of what can happen, a good friend of mine has a Humana MA plan and all his doctors (Cardo, diabetes, foot, etc) are all part of the very large Memorial Hermann Hospital network here in Houston. Last year, on Jan 1, 2024, Humana and HM could not come to an agreement on the provider contract and parted company. So my friend lost access to all his doctors. If he had traditional Medicare with a supplement, he would have been able to keep seeing his regular docs since the hospital network takes regular Medicare.

This is a real concern and sent me down a rabbit hole. My 95 yr old mom is a retired school teacher and gets her employer sponsored MA plan from a local school district. It is through Anthem Blue Cross and the doctors etc who my mom sees are in a health organization currently in contract negotiations. If they don't figure something out my mom is going to be really upset. She can't really make a trip to anywhere out of town, which would give us more options.

 

[Irishgirlyc58]

Also consider your health and if you will pass screening for Medigap G plan. In that regard your state insurance commissioner can help with the assessment (called SHIP in most states, SHIBA in Washington and Oregon).

I have a call into HICAP-SHIP in California. Hopefully I get a return call in the next few days.
Someone posted a link in another thread that in CA we can switch from MA to Medigap if the MA premium increases more that 15%. That should qualify me. Otherwise I think I am hosed because I am going to need a knee replacement in the future. It's well documented in my health records. It's from a surgery when I was 17.
Being able to switch is a big factor in making the decision. Otherwise I'm stuck.

I have done a spreadsheet! I will save $200-$300/month with regular Medicare/gap depending on the cost of the Plan D I choose. That's taking everything into consideration-premium, deductibles, my sanity.

 

[Irishgirlyc58]

With Medicare Plan N or G, there would be no waiting. With many cancers, speed is critical. Waiting for some administrator to approve a procedure is ridiculous.

This was my other concern when I originally went with my employer MA. I was hoping that employer plans were better but apparently they are not.

 

[MBSC]

...Otherwise I think I am hosed because I am going to need a knee replacement in the future. It's well documented in my health records. It's from a surgery when I was 17.
Being able to switch is a big factor in making the decision. Otherwise I'm stuck.

The underwriting look-back period varies from 2-5 years depending on the Medigap carrier. The knee should not be an issue if you were told about the replacement more than 2 years ago and have not recently received treatment.

Also, Blue Shield of CA occasionally has an "underwriting holiday" where they accept all Medigap Plan G applicants. I haven't seen anything for the remainder of 2024 but you should verify.

Blue Shield of California Has Fix for MA Enrollees Worried About Co-Pays

From page 13 of the earlier UHC link.

Medical Underwriting - Applicants who do not qualify for Open Enrollment or Guaranteed Issue will be underwritten and denied coverage for any of the following reasons:

Within the past two years, told by a medical professional that they may need any of the following that has not yet been completed:
- Hospital admittance as an inpatient
- Joint replacement

 

[Teacher Terry]

Right My first thought was -like I'd be able to find a podiatrist to do that.
I totally discounted their "healthy at home" perks-meals and transportation. I know from experience in my professional life in social services that these services are iffy at best.

No, my Medicare Part B is taken directly out of my social security. It is over and above the premium for the MA plan. I am also subject to IRMAA for parts B and D due to my pension. So my total monthly cost for premiums would be just about $1,000. Everything would be covered except for minor cost for prescriptions but it seems like the same would be true with a plan G and D supplement.

Once I drop the employer plan there is no going back.
It is through the county I retired from. I believe they actually self insure for this plan and use UHC as a third party administrator. The state requires that they offer some type of coverage for retirees and a contribution but not how much. They already reduced the contribution from $200 to $50.
My confidence level with this county is very low. I live here so I can say-they are a hot mess and have been for sometime.

Terry-do you just go with the cheapest part D plan that covers your prescriptions? It's hard to pick one not knowing if your health is going to change. 3 years ago I wasn't on any and now I have 3.

Yes that’s what I do because you can change part d yearly with no problem. Also see if your state has the birthday rule. It allows me to switch medigap plans but not sure if it works for MA .

 

[Irishgirlyc58]

Yes that’s what I do because you can change part d yearly with no problem. Also see if your state has the birthday rule. It allows me to switch medigap plans but not sure if it works for MA .

My state does have the birthday rule. You can switch to either an equal or lower plan in your birthday month. Unfortunately, it does not include MA. There was legislation proposed this year to change that but it failed. Darn it!

 

[FargoI]

Important considerations

- guaranteed issue. Only four states offer no underwriting for previous existing conditions

- MAP plans have extensive prior authorizations for anything expensive

- ability to go out of network with MA plans have material qualifiers such as caps on reimbursement equal to the MA plan allowable for the procedure, service or equipment. Patients are frequently under a misconception that they may pick any Medicare participating provider and have equivalent financial risk/exposure.

- many National Cancer Institute, "Centers of Excellence" do not participate in Medicare Advantage plans (check out MD Anderson, John's Hopkins, Dana Farber, etc).

- I urge you to research this thoroughly. Numerous high quality videos on you tube. Some by an individual named Danielle with "Boomer Benefits"

,- traditional Medicare coupled with Medigap insurance has been the gold standard for decades.

- Free silver sneakers, 14 meals after discharge from inpatient stay, x number of one way transports often turn out to be frills of little value to infirm 80 year Olds living in suburbs or rural areas as transportation has milage caps if it's even available. The meals... often are sub par to what many are accustomed to and clinical providers may have to certify necessity. What I'm really saying is do not depend upon glossy brochures, instead thoroughly read your plans Evidence of Coverage as it is the EOC that is the legally binding document... the glossy or summary documents- forgive the expression- are often thought of as makeup on an animal ( I cleaned the expression up so I not inadvertently insult anyone reading this post).

I worked in Healthcare for 40 years, including stints in hospital and physician billing. Additionally I am actively engaged in helping municipal retirees fight against employers forcing their retirees into MAP instead of honoring their hard earned, promised traditional Medicare supplemental insurance.

Hope this information is useful.

 

[Buckeye]

We switched to Plan G HD in May. I just started this year and husband's Plan N was premium getting too high for a policy we barely used in 10 years. We really just needed a backstop for something catastrophic and Plan G HD is that. We've saved about $1700 in premiums so far this year.

 

[Irishgirlyc58]

Important considerations

- guaranteed issue. Only four states offer no underwriting for previous existing conditions

- MAP plans have extensive prior authorizations for anything expensive

- ability to go out of network with MA plans have material qualifiers such as caps on reimbursement equal to the MA plan allowable for the procedure, service or equipment. Patients are frequently under a misconception that they may pick any Medicare participating provider and have equivalent financial risk/exposure.

- many National Cancer Institute, "Centers of Excellence" do not participate in Medicare Advantage plans (check out MD Anderson, John's Hopkins, Dana Farber, etc).

- I urge you to research this thoroughly. Numerous high quality videos on you tube. Some by an individual named Danielle with "Boomer Benefits"

,- traditional Medicare coupled with Medigap insurance has been the gold standard for decades.

- Free silver sneakers, 14 meals after discharge from inpatient stay, x number of one way transports often turn out to be frills of little value to infirm 80 year Olds living in suburbs or rural areas as transportation has milage caps if it's even available. The meals... often are sub par to what many are accustomed to and clinical providers may have to certify necessity. What I'm really saying is do not depend upon glossy brochures, instead thoroughly read your plans Evidence of Coverage as it is the EOC that is the legally binding document... the glossy or summary documents- forgive the expression- are often thought of as makeup on an animal ( I cleaned the expression up so I not inadvertently insult anyone reading this post).

I worked in Healthcare for 40 years, including stints in hospital and physician billing. Additionally I am actively engaged in helping municipal retirees fight against employers forcing their retirees into MAP instead of honoring their hard earned, promised traditional Medicare supplemental insurance.

Hope this information is useful.

This was very helpful. Thank you!
I actually did scrutinize the EOC and came to the conclusion that most of “benefits” would be almost impossible to access or I wouldn’t want them. Meals- no, I know too much about the pool of people who would come into your house for in home services and transportation- hard to get and many people missed their dr appointments.

I looked up the cost of the additional Rx the plan covers and the majority of them are under $20. A few between $50-$100 and 2 or 3 that were $200-$300- I don’t remember which ones.
I’ll take my chances.

I decided to leave the EGWP and go with Blue Shield plan G extra. The reasons stated above and also I called my former employers HR director and spoke with her about the increase.
She said that several people called because the cost is such a hardship for them.
The employer did not even bother looking for other less costly plans- something that would meet people’s needs without making them go broke.
I’m fortunate enough to have enough money that it was not a cost issue for me.
I was really concerned about not being able to switch to a medigap plan a few years down the road. Sure California has some protections but who knows if that will go away someday or if I just don’t meet the requirements.
It concerned me last year when I first signed up but I went ahead with it. I felt the same way this year and the 30% premium increase just put me over the edge on keeping it!

Only time will tell if I was wrong but I don’t think I am.
I can switch Plan G plans every year around my birthday but I think I’m going to really like the blue shield plan.

Thanks everyone for your input and words of wisdom about making this change. I really appreciate it!
I found out that a lot of people I know in real life on Medicare have no idea how Medicare, medigap, or MA plans work.

 

[zl55lz]

This was very helpful. Thank you!
I actually did scrutinize the EOC and came to the conclusion that most of “benefits” would be almost impossible to access or I wouldn’t want them. Meals- no, I know too much about the pool of people who would come into your house for in home services and transportation- hard to get and many people missed their dr appointments.

I looked up the cost of the additional Rx the plan covers and the majority of them are under $20. A few between $50-$100 and 2 or 3 that were $200-$300- I don’t remember which ones.
I’ll take my chances.

I decided to leave the EGWP and go with Blue Shield plan G extra. The reasons stated above and also I called my former employers HR director and spoke with her about the increase.
She said that several people called because the cost is such a hardship for them.
The employer did not even bother looking for other less costly plans- something that would meet people’s needs without making them go broke.
I’m fortunate enough to have enough money that it was not a cost issue for me.
I was really concerned about not being able to switch to a medigap plan a few years down the road. Sure California has some protections but who knows if that will go away someday or if I just don’t meet the requirements.
It concerned me last year when I first signed up but I went ahead with it. I felt the same way this year and the 30% premium increase just put me over the edge on keeping it!

Only time will tell if I was wrong but I don’t think I am.
I can switch Plan G plans every year around my birthday but I think I’m going to really like the blue shield plan.

Thanks everyone for your input and words of wisdom about making this change. I really appreciate it!
I found out that a lot of people I know in real life on Medicare have no idea how Medicare, medigap, or MA plans work.

Remember to also sign up for a Part D plan too, assuming you want one.

 

[Irishgirlyc58]

Remember to also sign up for a Part D plan too, assuming you want one.

Thank you. Yes I am signing up for Part D. I've been researching those-they were a lot harder than the gap plans to figure out which was best!
I've narrowed it down to 2-blue shield or AARP/UHC. The AARP/UHC plan seems to have a more robust formulary but I do know that they can be changed every year.