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

[zl55lz]

If I were trying to save money on healthcare premiums, and I had no pre-existing conditions, I might go with Medicare Part C, but only if I had solid plans to move states (change residence) in a few years. You have 11 months to switch without underwriting anyway. And then if you had a health issue that wasn't handled in a world-class way, you move (run the planned residence switch), and get traditional Medicare with a supplement plan without underwriting. You do get guaranteed issue if you move out of your Part C's geography, right?

By the way, I think "Part C" is the best way to refer to these plans. It's more accurate to think of the plans as getting a "C" grade, than saying they hold an "Advantage" over traditional Medicare

Can I change my Medigap policy?

Find out if you have a right under federal law to switch or drop Medigap policies, or check with your State Insurance Department.

www.medicare.gov

I found the above info at medicare.gov regarding guaranteed issue rights. Click on the link "What are guaranteed issue rights?" near the top. It covers situations when one can switch to Medigap with guaranteed issue rights.

 

[youbet]

I am on traditional Medicare and DW is in a MA plan. I would have preferred for her to have chosen traditional Medicare, but not my choice. So far her MA plan has been fine. Her annual costs are less than mine, her drug coverage is better than any of the Part D plans I've had over the years and the selection of docs and facilities available to her is very good.

She has gone through bunion surgery, rotator cuff surgery, spinal surgery, a colon resectioning and a bout of breast cancer which required surgery, chemo and radiation to achieve remission. She's used the plan a lot over the past decade+.

I'm still skeptical. So, I noodled the consequences of her switching back to traditional Medicare without being able to pass underwriting for a supplemental policy. I wondered if paying the 20% of the allowable rate that traditional Medicare doesn't pay would be within our reach . The answer seems to be yes.

For example, if you ran up a 2 million buck bill (rack rate) fighting cancer, traditional Medicare would likely allow around 25% or 0.5 million. (My guess at their allowable rate.) They'd then pay 80% of that or $400k. That would leave you with $100k to pay.......... a number easily within our reach.

Armed with that knowledge and the fact that, like many folks on this forum, paying the 20% of the allowable rate of a multi-million dollar medical bill is within reach without disrupting RE, I decided to stop fretting about it. Again, if it were up to me, I would have put her on traditional Medicare from the get-go. But that isn't the case. But knowing I could put her on traditional Medicare (if that seemed like the best path to follow for her issues - whatever they may be in the future) and have a high probability of being able to afford the 20% makes me feel less stressed about it.

As an aside, I'm surprised at the several posts on this thread where less than optimum care was accepted for a loved one just because of insurance issues.

 

[Flieger]

For example, if you ran up a 2 million buck bill (rack rate) fighting cancer, traditional Medicare would likely allow around 25% or 0.5 million. (Their allowable rate.) They'd then pay 80% of that or $400k. That would leave you with $100k to pay.......... a number easily within our reach.

I don't get this. Isn't there a MOOP associated even with MA plans?

Flieger

 

[Ian S]

I don't get this. Isn't there a MOOP associated even with MA plans?

Flieger

He's talking about going with traditional Medicare without a supplement. There is no MOOP for the 20% co-insurance for Part B without a supplement.

 

[youbet]

He's talking about going with traditional Medicare without a supplement. There is no MOOP for the 20% co-insurance for Part B without a supplement.

Yes

 

[MBSC]

I'm still skeptical. So, I noodled the consequences of her switching back to traditional Medicare without being able to pass underwriting for a supplemental policy. I wondered if paying the 20% of the allowable rate that traditional Medicare doesn't pay would be within our reach . The answer seems to be yes.

For example, if you ran up a 2 million buck bill (rack rate) fighting cancer, traditional Medicare would likely allow around 25% or 0.5 million. (My guess at their allowable rate.) They'd then pay 80% of that or $400k. That would leave you with $100k to pay.......... a number easily within our reach.

... But knowing I could put her on traditional Medicare (if that seemed like the best path to follow for her issues - whatever they may be in the future) and have a high probability of being able to afford the 20% makes me feel less stressed about it.

Your profile says you are in Chicago. If so, BCBS-IL has year-round guaranteed-issue Medigap plans if the Advantage plan leads you down this path. The premiums are high (~$400/mo), but less than $100k. This is different from the Illinois "Medigap Birthday Rule" that all carriers must follow.

"2025 Medicare Choices

Guaranteed Issue Policies from a Guaranteed Issue Company

For persons aged 65 or older and NOT in their Open Enrollment Period or any Special Enrollment Periods there is still an option to get a Supplemental plan. In Illinois, we have one Medicare Supplement insurer that offers policies to anyone over the age of 65 in ANY health condition, throughout the year at the same premium rate as anyone in the same policy class. That company is Blue Cross Blue Shield of Illinois.
NOTE: BC/BS also has some plans with underwriting."

Page 12: https://ilaging.illinois.gov/content/dam/soi/en/web/aging/ship/documents/medicare-choices.pdf

If you enter your zip code and age on the BCBS-IL website, look for "guaranteed issue plans". The 'Secure' Medigap plans are lower premium, underwritten policies.

 

[bada bing]

He's talking about going with traditional Medicare without a supplement. There is no MOOP for the 20% co-insurance for Part B without a supplement.

There are several wrinkles for going OM without supplement. The co-pays would be all eligible HSA expenses for those with HSA balances. In my case, I'm on OM with the UHC plan G supplement. A fall back for me, if something catastrophic happened to the supplement market, would be just OM with no supplement. I have about $100K in HSA balance, with a lot of it not covered by anticipated eligible expenses. I also have $90K in HRA credit in the retiree medical program from my former employer. For my situation and desires, OM without supplement would be preferable to the C plans available to me. I'm a resident of Alaska. The C plans available to me are particularly crappy and I definitely don't want to be fenced into a local network.

 

[sengsational]

Can I change my Medigap policy?

Find out if you have a right under federal law to switch or drop Medigap policies, or check with your State Insurance Department.

www.medicare.gov

I found the above info at medicare.gov regarding guaranteed issue rights. Click on the link "What are guaranteed issue rights?" near the top. It covers situations when one can switch to Medigap with guaranteed issue rights.

That was less than crystal clear, but I did some more reading and I came away with my suspicion confirmed: moving to somewhere where your current Part C does not operate triggers a "Special Enrollment Period", at which point, you can choose traditional Medicare. You have guaranteed issue rights for up to 63 days after your old policy ends. BUT you don't get to buy the most comprehensive Medigap plans under this guaranteed issue scenario. Specifically, you can't get G or N plans as a guaranteed issue. You can get L, covering 75% of what Part B doesn't pay, or K, covering 50% of what Part B doesn't pay. Those have max out of pocket, so you still are protected from really bad financial outcomes, but not protected as well as G or N.

 

[MBSC]

... BUT you don't get to buy the most comprehensive Medigap plans under this guaranteed issue scenario. Specifically, you can't get G or N plans as a guaranteed issue. You can get L, covering 75% of what Part B doesn't pay, or K, covering 50% of what Part B doesn't pay. Those have max out of pocket, so you still are protected from really bad financial outcomes, but not protected as well as G or N.

Plans M & N are not on the federal GI list. You have GI rights to either F or G depending on if you became Medicare eligible before or after 1/1/2020.

Some states (NY) and carriers (UHC/AARP) are more consumer friendly and include 'N' on their GI lists.

"You have the right to buy...Medigap Plan A, B, C*, D*, F*, G*, K or L that’s sold by an insurance company in your state.

*Note: Plans C and F are no longer available to people new to Medicare on or after January 1, 2020. However, if you were eligible for Medicare before January 1, 2020, but haven’t yet enrolled, you may be able to buy Plan C or Plan F. People new to Medicare on or after January 1, 2020, have the right to buy Plan D or G instead of Plan C or F."

Can I change my Medigap policy?

Find out if you have a right under federal law to switch or drop Medigap policies, or check with your State Insurance Department.

www.medicare.gov

 

[RetMD21]

Part B drugs are not subject to the $2000 Part D MOOP. You would pay the plan's 20% coinsurance until you hit the $6700 MOOP for covered Part A/B services. See page 60 of the Evidence of Coverage for Humana FFS plan H8145-069 below.

https://www.humana-medicare.com/BenefitSummary/2025PDFs/H8145069000EOC25.pdf

I don't know where you looked to find Part B drug pricing, but original Medicare and MA plans use the Average Sales Price (ASP) files located here:

ASP Pricing Files | CMS

The quarterly ASP Pricing Files are grouped by the year in which they are effective. For more information on how ASP is reported, and what drugs and biologicals are included in the ASP Pricing Files, visit the ASP Reporting page:

www.cms.gov

Examples:

Pegaspargase - $28,424.05 approved amount (18.41% OM coinsurance = $5232.87) each injection.

Axicabtagene ciloleucel - $533,076.47 approved amount (18.015% OM coinsurance = $96,033.73)

Afamitresgene autoleucel - $770,620.00 approved amount (20% OM coinsurance = $154,124.00) per therapeutic dose.

My oncology colleagues told me about issues with deciding which drug to give based on MA plans. For example, they might have thought that the expensive new drug was better but the MA plan might mandate that they try the older cheaper drug first. They had to get prior approvals. I don't think they disclosed the details to the patient. MA is of course mandated to provide coverage equivalent to OM but with broadly similar drugs they can have policies that favor cheaper drugs. There is an appeal process but the burden falls on the doctor and is potentially a big time sink.

 

[sengsational]

"You have the right to buy...Medigap Plan A, B, C*, D*, F*, G*, K or L that’s sold by an insurance company in your state.

I think we mostly agree, but as I understand it, and I could be reading it wrong, but I walked away thinking guaranteed issue rights require insurers to offer Plans K, or L, but most insurance companies will also offer Plan F or G (depending on which side of the 2020 date the customer is on), even though not required to do so.

The whole point is that if you are desperate enough to move residences, you CAN get back into traditional Medicare with guaranteed issue supplemental coverage. I'm not sure how realistic that is, though.

Doctor: Sorry to inform you that you're going to need a bajillion dollars worth of infusions.

You: Do you know a good moving van company?

 

[Graybeard]

Also remember the maximum OOP is $9,350 for MA plans in 2025.

While they may charge less this year, OP's MA plan (& any other) could switch to charging the maximum OOP every year, starting in 2026.

No idea where you get that, I just checked and my MA OOP for 2025 is $6,750. 2024 was $5900.

 

[Ian S]

This Part C vs traditional Medicare discussion has been interesting. I started on Medicare almost 9 years ago. I opted for the AARP F plan and kept that until they offered the G plan and then I switched. Been with that ever since. At the time MA plans seemed limited especially with respect to networks. Could I get an MA plan cheaper now? Probably but I'm at that point in life where I really don't like the idea of checking every bill that comes in all year long or dealing with insurance companies that may delay needed treatments. And what happens if I decline so much physically or mentally that my much younger (by 16 yrs) husband gets the MA hassles thrown on his shoulders? I'm also only 100 miles from Mayo Clinic and I have the option of being treated there if I wish as they accept traditional Medicare. Finally, we're in a position where we can afford the costs of Medicare and G supplement easily. I realize that it's a personal decision to make for everyone and I've made mine.

 

[Texas Proud]

I have not read the whole thread so this might have been thrown out...

Not all MA plans are good (mentioned by OP)... and some places do not have any good plans (assumption based on reading)... so even if you have a good plan now it does not mean that you will in 3, 5, 15 years... and heck, you might move to a place that has zero good plans...

Regular medicare and a gap plan is good everywhere... the only negative is if you can get a Dr appt... I just called to get an appt for a colonoscopy and the preconference is late July and they are booked until mid Sept... and will not book me until I get the consult... I could go somewhere else but Dr has done a number of family members and is good so I will wait..

 

[RetiredAt55.5]

Regular medicare and a gap plan is good everywhere... the only negative is if you can get a Dr appt... I just called to get an appt for a colonoscopy and the preconference is late July and they are booked until mid Sept... and will not book me until I get the consult... I could go somewhere else but Dr has done a number of family members and is good so I will wait..

I think, in general, that's an advantage of a traditional supplement plan if you REALLY need to see a specialist sooner you have a wider universe of specialists to choose from (not limited to what's in a MA plan's network).

This is pre-Medicare for DW, but when she broke her wrist she really needed to see a specialist sooner to diagnose and perform a procedure, before the wrist started to heal itself with the bones out of alignment. As it ended up, we used a specialist in our HMO's "tier 3" so it ended up costing us more than if we used a preferred specialist in their tier 1. The tier 3 specialist could see us sooner so that's what we chose.

 

[youbet]

Your profile says you are in Chicago. If so, BCBS-IL has year-round guaranteed-issue Medigap plans if the Advantage plan leads you down this path. The premiums are high (~$400/mo), but less than $100k. This is different from the Illinois "Medigap Birthday Rule" that all carriers must follow.

"2025 Medicare Choices

Guaranteed Issue Policies from a Guaranteed Issue Company

For persons aged 65 or older and NOT in their Open Enrollment Period or any Special Enrollment Periods there is still an option to get a Supplemental plan. In Illinois, we have one Medicare Supplement insurer that offers policies to anyone over the age of 65 in ANY health condition, throughout the year at the same premium rate as anyone in the same policy class. That company is Blue Cross Blue Shield of Illinois.
NOTE: BC/BS also has some plans with underwriting."

Page 12: https://ilaging.illinois.gov/content/dam/soi/en/web/aging/ship/documents/medicare-choices.pdf

If you enter your zip code and age on the BCBS-IL website, look for "guaranteed issue plans". The 'Secure' Medigap plans are lower premium, underwritten policies.

Well thanks MBSC. Despite the fact I'm on a BCBS supplemental plan, I was unaware that a guaranteed issue plan was available from them.

 

[ncbill]

No idea where you get that, I just checked and my MA OOP for 2025 is $6,750. 2024 was $5900.

Should have noted it is the maximum allowable.

 

[Koolau]

I have not read the whole thread so this might have been thrown out...

Not all MA plans are good (mentioned by OP)... and some places do not have any good plans (assumption based on reading)... so even if you have a good plan now it does not mean that you will in 3, 5, 15 years... and heck, you might move to a place that has zero good plans...

Regular medicare and a gap plan is good everywhere... the only negative is if you can get a Dr appt... I just called to get an appt for a colonoscopy and the preconference is late July and they are booked until mid Sept... and will not book me until I get the consult... I could go somewhere else but Dr has done a number of family members and is good so I will wait..

I had the same kind of "wait" when contacting the colonoscopy doctor directly (only it was like 6 months). I contacted my PCP and he said "Let me handle it." I got in in 5 weeks.

 

[sengsational]

..and the preconference is late July and they are booked until mid Sept...

I'd bet that doctor is on the Part C list for too many insurance companies, and probably works for a megacorp owned practice. So the green eyeshades run the company, not the doctors. Find a doctor that doesn't sign-on with the MA plans. It's not easy any more, but you still might be able to find a doctor that is still his own boss.

 

[RetiredHappy]

I had the same kind of "wait" when contacting the colonoscopy doctor directly (only it was like 6 months). I contacted my PCP and he said "Let me handle it." I got in in 5 weeks.

Yep. My concierge doctor generally is able to get me into the top specialists within a week.

 

[Texas Proud]

I'd bet that doctor is on the Part C list for too many insurance companies, and probably works for a megacorp owned practice. So the green eyeshades run the company, not the doctors. Find a doctor that doesn't sign-on with the MA plans. It's not easy any more, but you still might be able to find a doctor that is still his own boss.

Not sure about who he contracts with, but he is in a small specialty group... 4 Drs total... I think my big problem is I am a new patient...

I am fine with the wait as DW is going to be traveling soon to see her mother...

 

[Graybeard]

Should have noted it is the maximum allowable.

ncbill, I just called my MA provider and asked what maximum allowable means. Your comment sounds like that is a bad thing but I am not sure what your point was. I was just told once I have paid $6750 out of pocket everything is covered for the remainder of the year at 100%. $6750 is not a lot when talking about medical costs so a $100k OOP expense is 100% covered after I have paid $6750 which is not a lot to me. Just for reference, so far this year I have paid out of pocket a whopping $143. I'm pretty healthy so I'd be surprised if I even got to $250 this year OOP but if there was a big expense, my cost is capped at the $6750 and to me that seems pretty good. I'm confused if you think that is a bad thing and if so why.

 

[RetMD21]

ncbill, I just called my MA provider and asked what maximum allowable means. Your comment sounds like that is a bad thing but I am not sure what your point was. I was just told once I have paid $6750 out of pocket everything is covered for the remainder of the year at 100%. $6750 is not a lot when talking about medical costs so a $100k OOP expense is 100% covered after I have paid $6750 which is not a lot to me. Just for reference, so far this year I have paid out of pocket a whopping $143. I'm pretty healthy so I'd be surprised if I even got to $250 this year OOP but if there was a big expense, my cost is capped at the $6750 and to me that seems pretty good. I'm confused if you think that is a bad thing and if so why.

He might have got the number in this link. $9350 is the maximum out of pocket allowed by Medicare. Insurers are free to set lower limits. Maximum out-of-pocket limit - Medicare Interactive

 

[FD1000]

I think, in general, that's an advantage of a traditional supplement plan if you REALLY need to see a specialist sooner you have a wider universe of specialists to choose from (not limited to what's in a MA plan's network).

This is pre-Medicare for DW, but when she broke her wrist she really needed to see a specialist sooner to diagnose and perform a procedure, before the wrist started to heal itself with the bones out of alignment. As it ended up, we used a specialist in our HMO's "tier 3" so it ended up costing us more than if we used a preferred specialist in their tier 1. The tier 3 specialist could see us sooner so that's what we chose.

My OP was clear: stay with the best 5% of MA. In my case, never an HMO = limited.
I can see any doctor, including specialists, directly in/out of network for just $20. Several other MA I like can also see most/all doctors they like directly because most are in their PPO. These plans are inferior to mine because out of network, you will pay a certain percentage. I was on one my first year, but all my doctors were within the network.
So again, several big metros have great MA that cover many doctors. If you checked and they don't, select OM.
These metros likely will continue to have that.

IMO, there is no way more people will switch to MA, which has already happened, and they will get worse every year, while OM will stay great and premiums will stay the same. At some point, after lots of complaints, they may change the system and kick out the bad apples.

Maybe it's not the same, but someone who looks for a great, reliable vehicle starts at Toyota. Do I care about the bottom 5? No. I never looked at the bottom 5. The key is to educate yourself.

 

[Texas Proud]

Well, there is another thing that swayed me to not go MA.... and you point it out with your last post... picking Drs in network even if you can see them without a PCP... when I was on ACA ALL of the providers had Drs listed in their network who was NOT in.. when my PCP moved and I tried to get another it took me weeks of calling and getting told they did not take 'THAT' insurance...

Again, if it works for you and you like it that is great... if it saves you money even greater... I just do not want to get stuck having to be in MA with the possibility of not getting a good plan since I can afford a gap plan easily...