Medicare Advantage vs. Medigap vs. ?????

[Dtail]

Oh I remember now! He doesn't have to pay anything for his MA plan. He pays for Part B, and then they refund part of that premium to him. Oops, sorry, my mistake.

See? I told you I am no good at understanding insurance.

That's fine.
You are good at avatar creativity.

 

[W2R]

That's fine.
You are good at avatar creativity.

That's a lot easier for me. I actually HATE health insurance and "insurance-ese" or "legal-ese" with a passion. I truly hate it. It makes me sick to my stomach to even think about it. I know a lot of other people can relate to that.

So anyway that is why I say I can't do it. I suppose if I was motivated I'd figure it all out eventually, maybe? I'll never know because I'm not. I just know that everybody says the federal retiree health plans are good so I stick with that.

 

[steelyman]

I think a confusing factor is that not all Medicare supplement/Medigap and Advantage plans are equal. You can’t draw broad conclusions from comments on the Internet.

 

[rk911]

I think a confusing factor is that not all Medicare supplement/Medigap and Advantage plans are equal. You can’t draw broad conclusions from comments on the Internet.

the medicare supplement plans are standardized, not sure if the premiums are. we didn't shop as we wanted to stay with Blue Cross. the MA plans may not be standardized.

 

[RobbieB]

I think a confusing factor is that not all Medicare supplement/Medigap and Advantage plans are equal. You can’t draw broad conclusions from comments on the Internet.

Yeah Baby! I draw no conclusions from anonymous people on the internet.

 

[rk911]

https://www.medicare.gov/supplements-other-insurance/how-to-compare-medigap-policies

 

[MBSC]

Yes, that's one of the disadvantages of MA. If you need an expensive drug, injected or by IV in a hospital, even if it is covered, you have to pay coinsurance of 20%, with NO CAP. Talking about Part B drugs, administered by IV or injection, in the hospital.

Part B drug coinsurance does count toward the MA plan's MOOP. The cost sharing of covered Part A and Part B services must count toward the MOOP.

Maximum Out-of-Pocket Responsibility (does not include Part D drugs): The most you pay for copays, coinsurance and plan deductible for the year.

Some cancer services under Medicare Advantage plans require up to 20% coinsurance from you. You will pay this until you reach the plan’s Out-of-Pocket Maximum. That maximum can be as high as $6700 per calendar year in the network, and even higher out-of-network.

Cancer medication that you receive in a doctor’s office or clinical setting will fall under Part B, which will pay 80%. If you have a Medigap plan, it will pay the other 20%. On a Medicare Advantage plan, you will usually pay 20% up to the plan maximum. These Part B drugs are often IV infusion chemotherapy drugs or anti-nausea medicines.

Reference: https://boomerbenefits.com/medicares-coverage-for-cancer/

Medicare Advantage plans have clearly defined out-of-pocket limits for what would be covered under Part A and Part B of original Medicare.

Reference: https://www.fool.com/retirement/general/2016/04/09/9-drugs-that-cost-medicare-a-fortune.aspx

Medicare Managed Care Manual
Chapter 4 - Benefits and Beneficiary Protections
Section 50.1 – Guidance on Acceptable Cost-sharing

Maximum Out-of-Pocket (MOOP) and Combined Limits on cost-sharing:

All MA plans (employer and non-employer) – including HMOs, HMOPOS, local PPO (LPPO), Regional PPO (RPPO) and PFFS plans – are subject to a mandatory maximum out-of-pocket (MOOP) limit on enrollee cost-sharing for all Part A and Part B services. In addition, both RPPO and LPPO plans are required to have a combined limit on cost-sharing that is inclusive of both in- and out-of-network cost-sharing for all Part A and Part B services. The MOOP dollar limits are set annually by CMS and include all cost-sharing (i.e., deductibles, coinsurance, and co-payments) for Part A and Part B services, although an MA plan may also include supplemental benefits as services subject to the MOOP.

Source: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/mc86c04.pdf

MA plans have the option of requiring medical providers to use 'step therapy' with Part B drugs. Original Medicare does not require step therapy for Part B drugs but instead lets each medical provider establish their own policies, if any.

Medicare Advantage and Step Therapy for Part B Drugs
CMS is finalizing regulations similar to the policy implemented for 2019, under which MA plans could implement step therapy for Part B drugs as a recognized utilization management tool.

Full article: https://www.cms.gov/newsroom/fact-s...and-part-d-drug-pricing-final-rule-cms-4180-f

 

[John Galt III]

^^^ Thanks, MSBC !!

 

[fh2000]

I am in Southern California. I have 10 more months to sign up for Medicare. From my zip code for 2020, out of 53 Medicare Advantage plans, there is only one PPO.

I am now looking into either Kaiser Advantage plan, or go with a Medigap plan. All our doctors accept Medicare from what I can see, so that might make my decision easier.

 

[meleana]

Medigap plans are the best way to go. They are portable across the country and they are accepted by any doctor that accepts Medicare patients. If apply for a Medigap plan from the get go, then there is no prexisting limit underwriting. And if you get a G plan you will have very little out of pocket expense. Not so with Advantage plans.

Plus, an Advantage plan you sign up for one year might not exist the following year.


Just make sure you also sign up for Part D if you go with a Medigap plan because you will be penalized down the line if you didn't first do so and then change your mind.

 

[explanade]

I am in Southern California. I have 10 more months to sign up for Medicare. From my zip code for 2020, out of 53 Medicare Advantage plans, there is only one PPO.

I am now looking into either Kaiser Advantage plan, or go with a Medigap plan. All our doctors accept Medicare from what I can see, so that might make my decision easier.

What is the difference in premiums?

Medigap would be more but depends if you think the difference is worth having access to a wider network of doctors.

 

[pb4uski]

DW turns 65 in March so I started doing research on this today.

I stumbled into Boomer Benefits. Their videos seemed very well done and very clear. I talked for about 20 min with one of their CSRs and she seemed very knowledgable and gave me some good information. I'm interested in other's experience with Boomer Benefits, but I was impressed overall. Thoughts?

It looks like between Part B, Part D and Medigap-Plan G we'll each be paying about $343/month compared to the $267/month for our current ACA catastrophic coverage. I'm ok paying the extra $76/month or $912/year in exchange for a $198 deductible vs a $8,150 deductible.

We're going with Medigap rather than MA because we snowbird so the portability is useful to us spending a lot of time in two different parts of the country.

 

[REWahoo]

I'm interested in other's experience with Boomer Benefits, but I was impressed overall. Thoughts?

Do a search on the forum and you'll find a lot of comments/recommendations. Never heard anything but positive feedback about them. DW and I used them last year to change Medigap plans and they were great to work with.

 

[fh2000]

What is the difference in premiums?

Medigap would be more but depends if you think the difference is worth having access to a wider network of doctors.

I looked up my zipcode from Medicare.gov. Kaiser Senior Advantage (HMO) has $0 premium with $4000 in-network out of pocket max (MOOP). Most of the Advantage HMO plans has $0 premium. Some with MOOP as low as $900.

For Medigap plans, I find many websites require phone number from me before they give the quote, so I skipped them. Two websites do provide pricing lists: Medicare.gov, and ehealthmedicare.com. But they are different and not comprehensive.

I looked up Anthem Blue Cross Plan G ($454), and Blue Shield California Plan G ($113). Seems like there is a big difference. If Blue Shield California Plan G is still available when I apply, I might go with them since I am currently on their ACA Bronze HSA PPO plan.

 

[ucfparents]

Please help with understanding MA vs Medigap. From a strictly worse case scenario view unless I am missing something, I cannot understand why anyone would choose a MA over a Supplement. I am a few years away but am doing some pre-budgeting. Please tell me what if anything I have wrong.

Let's assume in round numbers I have a $20k heart procedure. The way I understand it, if I have Plan G, I would pay a $200 premium each month, my Part B deductible and G would cover the rest, so in this example my "cost" would be $2598 max and that is all I would pay for the entire year plus Part B premiums.

Now if I had a MA, I would pay my Part B premiums, copays and coinsurance up to the MOOP which could be $6700. So, for the same procedure an MA would cost $5k more?

Do people with MA budget the MOOP each year as a cushion and if they have a year with low medical expenses they have a splurge fund? I would rathe budget $2598 per year than $6700, so I knew what possible costs I would have each year with no surprises. Do I have this correct? If not, please straighten me out, this is very confusing.

 

[SumDay]

Now if I had a MA, I would pay my Part B premiums, copays and coinsurance up to the MOOP which could be $6700. So, for the same procedure an MA would cost $5k more?

Do people with MA budget the MOOP each year as a cushion and if they have a year with low medical expenses they have a splurge fund? I would rathe budget $2598 per year than $6700, so I knew what possible costs I would have each year with no surprises. Do I have this correct? If not, please straighten me out, this is very confusing.

We have some neighbors who went with MA because they paid 0 premiums, they get a pair of glasses each year, and dental check-ups. Last year he got throat cancer, and while he is now cured and they were pleased with his care, it cost them around $10K, as they had to pay OOP for every scan, chemo, doctor visit, etc. They're regretting their MA decision.

 

[ucfparents]

We have some neighbors who went with MA because they paid 0 premiums, they get a pair of glasses each year, and dental check-ups. Last year he got throat cancer, and while he is now cured and they were pleased with his care, it cost them around $10K, as they had to pay OOP for every scan, chemo, doctor visit, etc. They're regretting their MA decision.

That is what I was kind of thinking that people choose MA based on low premiums and take their chances that they won't use a lot of health care during the year. Me personally, I would rather pay $200 a month and know that I wouldn't have a big bill should something happen.

As for the MOOP, before I learned more about Medigap, my yearly budgets until death included the MOOP for an MA updated each year. I hope people on MA do this also so they are not hit with unexpected bills.

During an informal survey on the golf course recently, people said they had Supplements, but when they gave details like $0 premiums, they get an eye exam etc., it is clear they had an MA

 

[Chuckanut]

The only thing my Medigap plan lacks that the MA plans have is Silver Sneakers. And since I am not a gym rat, I don't miss it that much.

The only OOP I worry about is OOPS! as one fall can wipe out the good health of an older person in New York Minute.

 

[pb4uski]

Please help with understanding MA vs Medigap. From a strictly worse case scenario view unless I am missing something, I cannot understand why anyone would choose a MA over a Supplement. I am a few years away but am doing some pre-budgeting. Please tell me what if anything I have wrong.

Let's assume in round numbers I have a $20k heart procedure. The way I understand it, if I have Plan G, I would pay a $200 premium each month, my Part B deductible and G would cover the rest, so in this example my "cost" would be $2598 max and that is all I would pay for the entire year plus Part B premiums.

Now if I had a MA, I would pay my Part B premiums, copays and coinsurance up to the MOOP which could be $6700. So, for the same procedure an MA would cost $5k more?

Do people with MA budget the MOOP each year as a cushion and if they have a year with low medical expenses they have a splurge fund? I would rathe budget $2598 per year than $6700, so I knew what possible costs I would have each year with no surprises. Do I have this correct? If not, please straighten me out, this is very confusing.

+1 I can't understand it either... the differences in portability is an issue for us since we snowbird. Though I can see where MA might be attractive to people who are pretty healthy and very budget minded and are willing to take a chance on the deductibles and co-pays and generally stay in the same locale.

I suspect that there will be many MA users who chose MA because it is more affordable budget wise and may live to regret it... but not my circus and not my monkeys.

 

[kaneohe]

The only thing my Medigap plan lacks that the MA plans have is Silver Sneakers. And since I am not a gym rat, I don't miss it that much.

........................

what 'gap plan do you have. I had AARP UHC plan F in the past and they had it for many yrs. Last yr plan G didn't have it but AARP UHC must have go an earful for taking it away. This yr , not Silver Sneakers, but called something else I can't remember but essentially the same........free membership in some local gyms.

 

[CardsFan]

+1 I can't understand it either... the differences in portability is an issue for us since we snowbird. Though I can see where MA might be attractive to people who are pretty healthy and very budget minded and are willing to take a chance on the deductibles and co-pays and generally stay in the same locale.

I suspect that there will be many MA users who chose MA because it is more affordable budget wise and may live to regret it... but not my circus and not my monkeys.

I agree. We don't snowbird like some, but being out of state for a month or more is not unusual.

I have a retiree lunch group twice a month. Though we retired from the same place, due to mergers, sales and spin-offs over the years, we have retired from 7 or 8 different companies.

Several of the older folks had company retiree supplement plans. Apparently, some of the companies have really jacked-up the prices, and reduced benefits. Several folks have gone with MA plans, because "they are free, compared to the $1,000/month we were spending with the company plan". I don't think some even looked at the Medigap plans! And these are smart folks. Chemical engineers!

Maybe they picked the right plan, but maybe not (several are approaching, or over, 80).

Plan G for DW and me, starting this year.

 

[CRLLS]

I have some friends that are on MA. They claim their premiums are zero. I baited them a bit and asked if that includes the Medicare premium cost. They said they just pay zero, and they get optical and dental etc. Zero? Really? They sipped the Kool-Aid for sure.

 

[pb4uski]

So do you think that Part B is being withheld from their SS check and that is why they think that they are paying zero?

https://www.ehealthmedicare.com/med...zero-dollar-premium-medicare-advantage-plans/

 

[MichaelB]

Please help with understanding MA vs Medigap. From a strictly worse case scenario view unless I am missing something, I cannot understand why anyone would choose a MA over a Supplement. I am a few years away but am doing some pre-budgeting. Please tell me what if anything I have wrong.

Let's assume in round numbers I have a $20k heart procedure. The way I understand it, if I have Plan G, I would pay a $200 premium each month, my Part B deductible and G would cover the rest, so in this example my "cost" would be $2598 max and that is all I would pay for the entire year plus Part B premiums.

Now if I had a MA, I would pay my Part B premiums, copays and coinsurance up to the MOOP which could be $6700. So, for the same procedure an MA would cost $5k more?

Do people with MA budget the MOOP each year as a cushion and if they have a year with low medical expenses they have a splurge fund? I would rathe budget $2598 per year than $6700, so I knew what possible costs I would have each year with no surprises. Do I have this correct? If not, please straighten me out, this is very confusing.

Earlier posts in this thread highlight some of the reasons people choose MA.

Many members here chose MediGap over MA (me included) but MA may be a viable option for some individuals, despite posts to the contrary.

 

[ncbill]

Here's another reason to avoid MA plans...possible Hospice complications:

https://www.bogleheads.org/forum/viewtopic.php?t=278349