Why I use Medicare Advantage, and I'm happy.

[FD1000]

(OM) Original Medicare is a great option for many people. I have plenty of money and decided to explore (MA) Medicare Advantage by myself. Finding details is a very complex subject because the "experts" are mostly unprofessional, massage the truth, and many times don't know themselves.
In my zip code, metro Atlanta, there are over 60 MA options. Only several meet my criteria, which is to be able to see all the best doctors and go to the best facilities. In my case, only Aetna and Humana can do it.
I selected OM in the first 7 months at age 65, then switched the next year to MA.
The first MA was with Aetna. Aetna canceled it after one years. This allowed me to go on OM without tests, but I selected a new MA, Humana Gold Choice H8145-069 (PFFS). I have saved at least $6K per year compared to OM.
Premium of OM supplement + Part D = $3000. MA = 0
Prescriptions: I have a tier 3 drug that I had to pay about $1900 + others under OM = $2000. Under MA is about $100-200.
Dental $2500
Vision eye check + glasses/contacts are about $500. I used it in 2025
Free LA Fitness(Silver Sneakers) = $360
Over-the-Counter (OTC) $250 per quarter = $1000. I used it to buy many things, including the latest Fitbit.
If you add the above, it comes easily to over $6-7K.
This means that the above money is invested, as I do with all my money.
Let's use $5K savings * 20 years at a modest performance of 6% = $200K

My max out-of-pocket at in/out of network is $6700. This looks scary, but in the real world it isn't when I used it.
Two years ago, I had a $35K surgery. I paid the deductible of just $370.
Two months ago, I had another surgery at $40K, and I paid only $415. This time the surgeon and the hospital were out of network, but my deductible is the same. It means I can go to other states too.

In big metro areas, MA can be a very good choice if you select the right one. In most cases it's not an HMO, although I read that Kaiser is a good choice. Several friends in Kaiser can't use the best doctors and specialists in my area. PPO should be your choice. In my case, PFFS (Private Fee-For-Service) is even better with more flexibility to use other states, a low same deductible for in/out of network, and much lower out-of-pocket costs.

From what I read, I found out that:
1) The people on OM always tell you that OM is the best choice. It's not true.
2) Most MA are below par IMO, but several of them are excellent if they are available in your zip code.
3) They also scare you with MA; you may be in trouble and have to pay thousands out-ot-pocket, my 2 surgeries proved it wrong.
4) Another scare is that if you are sick, you can't join OM. That's true in some cases but not all. Several states let you change to OM every year regardless. In my case, cancellation of my MA, allowed me to join OM without tests.
5) Many people who have enough select the easy OM choice. That's fine. I have plenty, but I'm a number guy; in my case it is clear to me that my choice is going to save me thousands over the years. I discuss my MA with a local broker that have used these type of MA, he has almost 1000 clients for about 20 years, some with multiple complicated and expensive surgeries, and the most that anyone paid was $1500 annually out of pocket. I have several friends that have used him for over 15 years.
6) I also found out you can buy stand-alone coverage for certain deductibles. In my case, if I stay in the hospital, I will pay $390 daily for the first 5 days, then zero for the rest. I could buy insurance that will pay me $500 per day for 5 days at about $40 per month. I passed on that. There are insurances that will cover your max-out-of pocket for $55-70 monthly. They are all much cheaper when you look at the total picture.

 

[euro]

Good for you if it works out for your needs. My biggest issue with MA is that many procedures require preapproval. To me, this is an nonstarter - an insurance representative make medical decision for me? No thanks.
Maybe you found a way to get around pre-approvals? If so, again, good for you!
It looks to me like you are, as you say, a numbers guy who enjoys maximizing the bottom line "on principle", not necessarily based on need (since you say, you have plenty of resources). That's cool too! People play credit card games for the same reason.
Personally, I see MA as a decent option for people who have very limited means and just can't afford regular MC. I don't think it is a horrible option, but for me, it doesn't make sense. I pay more for IRMAA than for B, D and medigap, so why worry about the extra premium cost? But again, that works for ME - you must do what works for YOU.

 

[FD1000]

Pre-approval is another one among several things that many claim it's a problem.
I have seen the best doctors in my area, they ordered several procedures, from simple tests to MRI and all the way to surgeries and I was never denied.
I also have several friends in the top 2-3 MA and they are very happy too.
This is why I said select a good flexible PPO with great options. If you can't find one, select Original.
The key of course is your zip code.
Selecting Original blindly is not always great because many never looked at other options.

 

[OldConch]

Good for you if it works out for your needs. My biggest issue with MA is that many procedures require preapproval. To me, this is an nonstarter - an insurance representative make medical decision for me? No thanks.
Maybe you found a way to get around pre-approvals? If so, again, good for you!
It looks to me like you are, as you say, a numbers guy who enjoys maximizing the bottom line "on principle", not necessarily based on need (since you say, you have plenty of resources). That's cool too! People play credit card games for the same reason.
Personally, I see MA as a decent option for people who have very limited means and just can't afford regular MC. I don't think it is a horrible option, but for me, it doesn't make sense. I pay more for IRMAA than for B, D and medigap, so why worry about the extra premium cost? But again, that works for ME - you must do what works for YOU.

Good for you OP! We have lots of friends and acquaintances that seem very happy with their MA.

DW started a $66/month HD F plan about 5 years ago and my plan is to select a $59 HD G plan as soon as I'm eligible later this year. She hasn't even come close to meeting her deductible each year. That includes 2023 when she had surgery for a shattered wrist and surgery to remove a melanoma. She was able to choose her doctors and the insurance company had no say in the matter.

It's great to have options and one-size certainly doesn't fit all.

 

[aja8888]

I got to choose the surgeon that replaced both my hips over 15 years using the Anterior procedure, the most innovative one out there. He is one of the best in the world doing hips and he doesn't take MA.

I could go on.

 

[Graybeard]

I've had nothing but MA plans for 10 years. I'm pretty healthy and don't see doctors very often. Some MA plans have all sorts of bells and whistles and many have a zero premium. But these plans can change from year to year so you need to look at whether your doctors and meds are in the network. I prefer a PPO vs an HMO but have used both. You also need to see if your meds are in the formulary. Many come with dental, vision, drug coverage and an over the counter allowance per quarter. I have no need for hearing. Other than that, I find MA easy to use and it costs nothing and is shocking how much it covers and how little I have to pay but these plans vary by zip code so someone in the town next to me may not have the same plans offered to them as I have. It is important you use someone that is paid by CMS so they have no reason to shift you from 1 plan to another, these folks are experts that will look at your needs and suggest a MA plan for you.

 

[aja8888]

One of the biggest complaints I hear is that many MA plans don't like to authorize PT in a lot of necessary cases. Or if they do, they limit the PT time. I think I read that here somewhere.

 

[bada bing]

Original Medicare plus supplement is the best option from the standpoint of access to care. That can not be disputed. Depending on area, you may have access to MA that approaches the access of OM. Or maybe not. Or maybe not in the future. You'll save some money on premiums with MA. You risk greater uncovered expenses for that savings.

Like the decision over claiming age for SS, we all look at and prioritize different aspects of the choice. If you have a MA that works and makes you happy, good all the way around. Your numbers as far as cost don't pan out for the options available to me and the access you cite isn't what happens here either. I suspect that my situation is closer to average than yours. But all that matters is my options are.

Anyone paying attention to the news knows that Medicare options have challenges. In particular, MA plans are going through a lot of flux. With a MA plan, you have no guarantee of future coverage with your choice. With OM plus supplement you do, albeit with some price uncertainty. What plan are you going to be on at age 85 ? You don't know. With OM you have a lot more certainty.

 

[Pluperfect]

Nobody's mentioned skilled nursing facilities, and how Advantage plans are known for limiting the length of stay they approve.

I have a friend who had a stroke last weekend. He was in the hospital for a few days and then got transferred to a rehab hospital. I don't know if where he is is considered a skilled nursing facility, but I'm so thankful he has Original Medicare plus an F supplement so he doesn't have to worry about anything.

 

[Koolau]

I think the issue that some folks have run into is that MA w*rks - until it doesn't. IOW for most things, it's fine but for other things which you might think are critical for your situation, MA might not w*rk and you won't find out until the need arises.

Not at all trying to talk anyone out of MA. As I said, it does w*rk for many people. The issue arises when it doesn't w*rk and you may not pass underwriting to switch to MC.

YMMV

 

[marko]

I think the issue that some folks have run into is that MA w*rks - until it doesn't. IOW for most things, it's fine but for other things which you might think are critical for your situation, MA might not w*rk and you won't find out until the need arises.

Not at all trying to talk anyone out of MA. As I said, it does w*rk for many people. The issue arises when it doesn't w*rk and you may not pass underwriting to switch to MC.

YMMV

+1. I have Medicare and a $385 quarterly BCBS supplement. After paying over $1200 a month EACH for HCI before Medicare, the $385 quarterly is "practically free" IMO.

I've just crossed the $200,000 mark on my prostate cancer issue. My only OOP has been a whopping $94, (ninety four dollars) likely due to some coding glitch that I wasn't interested in spending time pursuing. Everything else was paid for. I must say, I'm a little amazed.

I have no idea how I'd fare with another plan...maybe it'd be the same, maybe I'd be in trouble, but I'm happy and thankful for where I am. If it ain't broke.....

 

[Flieger]

+1. I have Medicare and a $385 quarterly BCBS supplement.

I've just crossed the $200,000 mark on my prostate cancer issue. My only OOP has been a whopping $94, (ninety four dollars) likely due to some coding glitch that I wasn't interested in spending time pursuing. Everything else was paid for. I must say, I'm a little amazed.

I have no idea how I'd fare with another plan...maybe it'd be the same, maybe I'd be in trouble, but I'm happy and thankful for where I am. If it ain't broke.....

What is your BCBS supplement? Is that one of the "letter" plans, or in addition? Thanks!

Flieger

 

[harllee]

If you plan to move into a Continuing Care Community the type of Medicare plan you have is a consideration. At the CCRC where I live they take traditional Medicare and Supplements but only certain Medicare Advantage plans. ( They do not take Medicaid).

 

[Jerry1]

This is why I said select a good flexible PPO with great options. If you can't find one, select Original.
The key of course is your zip code.

OP - at least you’re being honest. I personally wouldn’t touch an MA plan but, in the right area with the right plan, I’m sure you can do well. You’re in a particularly good area to have so many different plans. Many people are lucky to have a couple options to choose from and those tend to be highly restrictive - mostly due to the limited size of the network. I’m glad you found something that works for you.

 

[VanWinkle]

Thanks to OP for the post, it proves a point that there are good MA plans out there and not everyone needs to be on a costly supplement. It is an individual choice and can make sense whether MA or a supplement.

 

[gauss]

OP,

I think the majority of the audience of this board, are aligned with the strategy of delaying things now for even better things down the road. We don't get to be ER by spending our full paychecks.

This concept plays into why I would not personally get involved with an MA plan. Sure you might save money in the short term or get some bonus items, but what happens down the line 20 years from now?

I've seen first hand what happens when my mother died due to the insurance company denying rehab after sending her home with high flow oxygen and dementia after a bout of covid in 2021. The hospital staff all agreed that she should not be going home like that but the insurance company ( Big Nonprofit Blue) kept denying after we appealed.

So sure, MA might be great in the short run, just realize what you're trading off -- your future wellness.

Not a trade that many will take here.

-gauss

 

[VanWinkle]

OP,

I think the majority of the audience of this board, are aligned with the strategy of delaying things now for even better things down the road. We don't get to be ER by spending our full paychecks.

This concept plays into why I would not personally get involved with an MA plan. Sure you might save money in the short term or get some bonus items, but what happens down the line 20 years from now?

I've seen first hand what happens when my mother died due to the insurance company denying rehab after sending her home with high flow oxygen and dementia after a bout of covid in 2021. The hospital staff all agreed that she should not be going home like that but the insurance company ( Big Nonprofit Blue) kept denying after we appealed.

So sure, MA might be great in the short run, just realize what you're trading off -- your future wellness.

Not a trade that many will take here.

-gauss

Medicare also denies some hospitalizations due to the type/need of treatment. If Medicare denies, Medigap does also. That's when we all hope we can pocket pay for treatment.

 

[marko]

What is your BCBS supplement? Is that one of the "letter" plans, or in addition? Thanks!

Flieger

AFAIK Massachusetts only allows one plan. Different providers but no options like G or others. Other states offer more options, but yes, I believe it is like a "letter" plan.

 

[anethum]

Two friends, both with traditional Medicare + Medigap, each developed a different rare disease. Both were able to seek new, highly successful treatments from renowned specialists at two different world-class facilities outside of the area where each lived. This was possible thanks to traditional Medicare. Both responded extremely well to their treatments.

MA may be great, until it isn't. Nobody knows in advance when or if they may need world-class medical care. My health is not something I'm going to gamble with.

 

[Flieger]

Two friends, both with traditional Medicare + Medigap, each developed a different rare disease. Both were able to seek new, highly successful treatments from renowned specialists at two different world-class facilities outside of the area where each lived. This was possible thanks to traditional Medicare. Both responded extremely well to their treatments.

MA may be great, until it isn't. Nobody knows in advance when or if they may need world-class medical care. My health is not something I'm going to gamble with.

Is it 100% known they would not have been able to get the treatment if on MA? Just curious how one would know?

Flieger

 

[aja8888]

Is it 100% known they would not have been able to get the treatment if on MA? Just curious how one would know?

Flieger

There is "treatment" and then there is finding the best surgeon or practitioner in the field of medicine you need the specialized care from. Don't think that anyone on the doctor "list" is the same as the next guy!

My BIL needed a heart transplant at age 74 and I doubt very much if an MA plan would have authorized that at his age. Good thing he had traditional Medicare with a Sup plan. He got the best surgeons in Houston to do the transplant and is doing well 9 years later.

 

[Closet_Gamer]

This is down the road for me, but I’m interested in the topic.

If you enroll in MA for a year and don’t like it, is there anything that prevents you from going back to traditional Medicare the following year?

 

[Qs Laptop]

Is it 100% known they would not have been able to get the treatment if on MA? Just curious how one would know?

Flieger

They received treatment outside of their respective Medicare Advantage area. The two specialists were almost certainly not in any of the provider networks in their area.

Isn't it a simple matter of checking on the doctor network within the Medicare Advantage plans available in the area to see who they are allowed to receive treatment?

 

[aja8888]

They received treatment outside of their respective Medicare Advantage area. The two specialists were almost certainly not in any of the provider networks in their area.

Isn't it a simple matter of checking on the doctor network within the Medicare Advantage plans available in the area to see who they are allowed to receive treatment?

Around here, greater Houston, Texas, the entire Houston Memorial Herman hospital system (several large locations) failed to finalize a contract with Humana for their MA plans causing thousands of MA plan holders in the Humana system to lose their doctors.

 

[Flieger]

They received treatment outside of their respective Medicare Advantage area. The two specialists were almost certainly not in any of the provider networks in their area.

Isn't it a simple matter of checking on the doctor network within the Medicare Advantage plans available in the area to see who they are allowed to receive treatment?

Maybe it is, but I am not Medicare age yet and am researching. Thanks.

Flieger