Can We Talk Medicare

Green Beans, when you are on Medicare Advantage you can change among such Plans during the enrollment period each fall from October 15 to December 7. These changes from one Advantage Plan to another or among different insurance companies offering Advantage Plans. There are also special enrollment periods that allow for changes when you move or your insurance company discontinues your plan.

The point is that if you want to change from Medicare Advantage to traditional Medicare with a Supplement MediGap insurance Plan, you must submit to underwriting and can be charged different rates based on your health status, age, smoking status, etc., and can be denied coverage by the company. So changes are not so simple in most cases.

There are four Guaranteed Issue times for A Medicare Supplement Plan; first, when you turn 65 and start Medicare, or at a later date move from an employer sponsored Plan onto Part B; second, when your Medicare Advantage Insurance Compay no longer offers the Plan you are on; third, when you move from your current CMS region to another region, and fourth, within 12 months of starting an Advantage Plan as a trial period you can go back to traditional Medicare and purchase a Supplement. At those points you can go to traditional Medicare and a Supplement without medical underwriting. You will basically get the Plan G with no discounts under the Guaranteed a issue rules.

An exception to this is that there are a very few states that override this by allowing you to switch from Advantage to traditional Medicare and a Supplement Plan on a guaranteed issue basis during the regular enrollment period each fall. By recollection, I think New York and California make such exceptions, but don’t quote me. When you look at Supplement Plan premiums in those areas they are usually much higher because of the additional adverse risk selection the companies must accept which drives up claims.

We have been hearing for years that fewer providers are accepting Medicare. That is actually true for Medicaid. Recent reports show that about 97% of physicians, clinics and hospitals participate in Medicare.

And as you point out, Advantage Plans and networks are very different. In Georgia going outside the Network on PPO Advantage plans generally double the out of pocket maximum. So instead of usually about $6,500 out of pocket for in Network, most plans double that to $12-14,000 out of pocket maximum for out of Network. And networks can be tricky. We have all heard of the person who goes to their in network hospital for surgery with their in network surgeon only to get a surprise billing from the out of network anasthesiologist. Attempts have been made to resolve the issue, but it can still persist. That is not an issue for traditional Medicare with a Supplement.

My wife is Medicare effective July 1. We just asked the agent about N and the quotient was higher than G. Go figure.

The other thing I hadn’t considered is we have a rather nice HSA that comes into play. The question then becomes would Advantage Plans deny coverage for scans that a gap plan wouldn’t.

Post Edited (Duck2) : 4/23/2021 12:34:50 PM (GMT-6)

JNF said, "In Georgia going outside the Network on PPO Advantage plans generally double the out of pocket maximum."

That has NOT been the case for me, in either of the PPO Advantage Plans I've use in Georgia.... and there are only 2 to choose from in my county, so no idea where you get generally double from.

Thanks for expanding on the times you can change plans - I didn't have the exact dates at my fingertips when I posted - just wanted to make the point that whoever said you could never change back was in error. Thought that was important for people to understand.

Cheers.

While we are on the Advantage Plan, there are a class of plans that may provide better benefits for some on the forum or members of their families. They are called the Special Needs Plans. They are based on the Advantage Plan and apply to very specific situations that allow the coverage to be more specific to the situation and may reduce overall cost compared to the regular Advantage plans. There are three such Plans:

Chronic Condition. C-SNP. There are 15 listed conditions that are chronic and debilitating and if a person has one or more they may qualify. Cancer, cardiovascular, stroke, HIV-AIDS, renal and liver failure, dementia, etc.

Institutional. I-SNP. This is for people in nursing homes, home confinement with in home nursing and some Long Term Care facilities. Where the person is basically confined and much of the care comes to them.

Dual Eligible. D-SNP. This is for low income seniors on Medicare and Medicaid. It pays premiums for coverage and Medicare B and helps offset deductibles and co pays.

To enter a plan you do not need to wait for a regular enrollment period, rather the enrollment period begins when you qualify for the plan.

For example, we are preparing for my mother in law to reside in a Long Term Care residence and nursing care is very likely in the not distant future. Part of the planning includes us assessing whether she will qualify for a I-SNP and what advantages it will provide. However, she can not go on the plan until after she is admitted. So far my search shows only one company in Georgia offering the plan. My initial assessment is that it would limit out of pocket expenses to $1,800 per year, which is great, but two of the specialists we have chosen for her are not in the network. So, we would have to search for specialists we have not dealt with.

Hal, you might have a post 65 retiree plan the integrates with Medicare. Just call the benefits people at your former employer. In such a plan you will pay the Medicare B premium as we all do, and you will be enrolled in Part A. The employer plan then becomes secondary to fill in the gaps is a way similar to a Supplement or Advantage plan. You will pay a premium for the coverage, but it is often less than what an individual would pay for similar coverage due to possible employer subsidies and the group buying power.

Duck, you should double check it. Use the link I provided and see what various companies are charging in your area. If G and N are the same cost from the same company, it would indicate either a great deal on a G or lousy deal on N. Which way is the agent trying to guide you? To the G? G is now the most comprehensive plan available, but as I stated earlier the concern is that it will probably have the greater premium increases in the future. The company I use is Mutual of Omaha, one of the leaders in the supplement plans. I have shown you the difference between G and N with them in my case, and it is significant.

TJ123 mentions using the VA as a backup. That was my plan too but when I applied to the VA I was turned down. Evidently I make too much money as a retired high school teacher. Who knew?

JNF said...
Duck, you should double check it. Use the link I provided and see what various companies are charging in your area. If G and N are the same cost from the same company, it would indicate either a great deal on a G or lousy deal on N. Which way is the agent trying to guide you? To the G? G is now the most comprehensive plan available, but as I stated earlier the concern is that it will probably have the greater premium increases in the future. The company I use is Mutual of Omaha, one of the leaders in the supplement plans. I have shown you the difference between G and N with them in my case, and it is significant.

If the agent is trying to steer, she is trying to steer to an advantage plan. The other thing I confirmed in IRS publication is you may not use HSA funds to pay for medigap plans. We have a considerable HSA account and it would make zero logic to go with a low deductible medigap plan.

No Bucks, but understand what “excess charges” are and the effect. Doctors that fully participate in Medicare agree to the Medicare reimbursement amount. This is defined as “accepting Medicare assignment”. Also Medicare then handles the claims process for these docs. The doc codes the claim to Medicare and they pay their portion and then presents the claim for payment to the applicable insurance company. That is by far the majority of docs.

A second level of participation keeps the doctor in the Medicare network, but at a lesser level of participation. First the doc receives 90% of the Medicare reimbursement amount and the the doctor can add an “excess charge” to the patient of 15%. So the doc gets a little bit more money, but must now file three claims, one to Medicare, one to the insurance company and one to the patient. Medicare does not do the claims processing as in the first case. This significantly increases the doc’s admin costs for claims filing, billing and chasing after money from three different sources.

So, for example, on a Medicare reimbursement of $50 for an office call the first situation the doc gets $40 from Medicare Part B and $10 from the insurance company for a total of $50 and gets streamlined claims handling by only filing one claim. In the second case the doc gets $36 from Medicare, $9 from the insurance company and bills the patient $6.75, for a total of $51.75. But the doc gets no administrative help from Medicare so their administrative costs go up.

In practice few doctors use this method. You can confirm through CMS you doc’s status and whether you would have any exposure to this cost. When I checked, all our docs are full participants. It is estimated that 95% of PCP docs fully participate and nearly as many specialists do so. Also, eight states prohibit “excess charges” including New York and Ohio.

Mumbo:

You addressed me and I have no idea what you are talking about.
It was pointed out that Medicare + Supplement was better than Medicare Advantage. I pointed out that in MY situation (PCA + disastrous spinal injury) my Advantage plan was great. Further discussion indicated that my plan might be different as it was a benefit of my retirement plan.

I thought we were having an interesting discussion that shed some light on this topic. Did I miss an argument somewhere... because you seem to be trying to start one.

Mel

Gym membership comes with some Advantage plans, but usually not in traditional Medicare with a supplement. I am a bit surprised the differential was so little for you between G and N. Our differentials for my wife is about $60 per month and for me about $67 per month.

Duck - I just took a look at AARP Ohio and they appear to have two G plans where I checked (Akron area). One is called G2 and has a limited network thus cheaper. It is amazing there are so many variations across the US of what we think is a standardized program. Did not know they could offer a supplement plan with a limited network.

I would opt for G only because of the co-pays associated with N which is just another couple of minutes wasted when checking in.

Duck and Mumbo, I still suggest you take a broader look and make sure you understand the differences. Looking at only one company isn’t efficient as there can be significant differences. That is why an independent agent/broker with access to all the different companies will provide you the best assessment.

Plan G is expected to have more significant premium increases in the future as F has experienced in the last several years and may negate the office visit copay potential. Even if G and N were equal in premium today, in just a few years it is expected that G will be considerably higher as it is now the default for guaranteed issue situations, thus giving N a long term advantage. Both the Medicare Modernization Act in 2010 and then MACRA in 2015 are having a profound effect in the Supplement marketplace. Shifting the guaranteed issue people from F to G will mean G future premium increases will mirror what F has experienced over the past several years.

And to clarify, the office maximum of $20 copay doesn’t apply to all visits, it depends on the coding. These are primarily for diagnostic and evaluation visits. It does not apply to visits for vaccines labs, scans, etc. Nor does it apply to telemedicine or online visits with your provider. This is a great way to avoid any copay when you don't need the doctor to physically touch or manipulate you. It does not apply to the annual Medicare Wellness visit which is essentially a physical exam. And neither the office nor the ER copay applies to Urgent Care facility visits. I went back to determine my copay exposure for 2019 and 2020 under N and it would only have applied to less than half a dozen visits over the two years. Thus I would have saved a good bit by moving to N earlier. And I my case, my new premium for N is now actually lower than what G was when I started Medicare 5 year s ago. Thus, I have negated five years of premium increases which were averaging nearly 10% a year.

Also I just read a report that indicates since 2017 the average premium rate increases have been Plan F 10% per year, Plan G 8% per year, and Plan N 3% per year.