My Internist of 11 years will not accept MediGap insurance anymore

I'm coming up on enrollment in Medicare in a few months, know nothing about it.  Can anyone give me an overview of the supplemental plans, and their advantages and disadvantages?

Medicare Advantage plans are PPO's, for those who don't know Preferred Provider Organizations.  They pay for the agreed services with doctors and other providers who have joined their plan.  So you are not covered for hospitals and doctors and other providers who have not joined the organization.  Sometimes a hospital has joined the plan but the doctors at the hospital have not. If you go there for emergency services, you may get a doctor that your plan won't pay.  I only discovered this after our insurance agent pushed up toward an Advantage plan. They usually include a drug plan.

Supplemental plans are Medicare.  The Supplemental part pays for YOUR obligation for care.  Medicare pays for 80% of the cost of all medical care covered.  Supplemental insurance pays the 20% that you would have to pay.  So your doctors are paid at the Medicare rate.  Most specialists accept Medicare.  Sometimes it is hard to find a Family Doctor who accepts Medicare (as you may know) because the reimbursement to them is very low.  You have to buy a separate drug plan whenon a supplemental.  

You will receive a large book to read about covered services, and there are insurance brokers who can help you get the coverage you want.  Ours kept promoting the cheapest insurance and we had to keep telling her we wanted the most comprehensive.   My choice is supplemental and a drug plan

I was diagnosed and the gynecologist wanted to send me to Cancer Centers of America.  My insurance didn't contract with them.  They also didn't contract with the gynecologist that could see me the next week.  I had to wait 3 months for an appointment. I never had children so didn't have a gynecologist.  If you have one, they will see you.  Just too many times I was told I couldn't on the Advantage plan.  We went in and switched.  The insurance person never did mention supplemental plans, it was my cousin who is a medical social worker, who was talking about them that got my attention.  Hope that helps.  

Medicare Advantage plans can also be HMOs in addition to PPOs. I am in an HMO here in the Tampa Bay area. There are entire practices here that will ONLY take Humana Gold 360 patients (that's my plan). I get back about $140 per month - that means they PAY ME $140 each month to take this plan. There is no charge to see my GP but a specialist costs me $25. All my prescriptions are free although my husband has to pay $135 every three months for one of his asthma inhalers. I also get $75 every three months to spend on over-the-counter health-related items in addition to gift cards for doing my preventative care, exercising and volunteering.

I do have to get a referral to see most specialists but we have not had a problem with that. I think with so many old people here in central Florida a lot of specialists accept this plan. 

When I'm in Wisconsin I can see a doctor there if I have a problem and can do two visits without prior authorization. If we were going to live part-time in Wisconsin and part-time in Florida, this plan would not work. But since I only spent three weeks in Wisconsin, I'm happy with my plan. Our son who works for Humana said the plan we have is the best Advantage plan Humana offers because so many doctors and hospitals accept it. Obviously, this plan wouldn't work for everyone but we sure are happy with it especially because we have our son to research coverage for us and give us all the ins and outs of the plan.

Good luck to you!! Right before we retired and left Green Bay, my beloved GP, Dr. Roth, sent me a letter telling me she was leaving private practice and was becoming a hospitalist. That woman saved my life and I was devastated that I was losing her. But, after quite a search, I found my Dr. Deepa and her PA, Kaila. If my cancer comes back, I may be singing a different song - LOL! Although quite a few of the people in my community have the same Humana Gold 360 plan. And it doesn't hurt that our Humana saleslady comes to our community coffees once a month, brings donuts, and will answer any question you have.

Good luck!!

Love,

Eldri

I wanted to chime in and say I do have a medicare advantage plan with a technical PPO.  However, there is no difference in payment between a PPO and a non-PPO provider.  This allowed me to get a second opinion at MSK in New York even though I live in Wisconsin.  I pay $50 to see a specialist and $10 to see my primary care Doc.  Before I went to New York I called my insurance who verified that I would be covered as long as the doctor in NY accepted Medicare.  So I believe if a physician accepts Medicare they have to accept Advantage or Gap plans.  While I do have a $4000 maximum out of pocket (that is the most I can pay in one year for services), my plan premium basically covers my gym membership which is included as a plan benefit.  (May not matter much now with Covid). I had a supplemental plan which went up with age and was over $200/mo without a drug plan before I switched.  I am not so sure that between that premium cost and a drug plan cost that I would pay less than $4000 year.  Before I got sick it was a no brainer.  I saw the doctor once a year for my annual exam and blood tests.  My one prescription is free.  So I think you need to weigh all the costs and benefits to see what works for you. I also agreed to this plan because I wanted to be able to go anywhere in the country for care.  My agent had a chart that showed all the differences between various plans that as helpful.  Now I want a good dental plan but none seem worth it.

zsazsa1 said:

I'm coming up on enrollment

I'm coming up on enrollment in Medicare in a few months, know nothing about it.  Can anyone give me an overview of the supplemental plans, and their advantages and disadvantages?

Medicare is not as confusing as it seems at first. The most important thing to understand is the difference between original Medicare and Medicare Advantage. Medicare Advantage is managed care by insurance companies with a financial interest in you using as little care as possible.

The insurer in original Medicare is the federal government. Original Medicare does not cover all the costs of care, and you would need to buy supplemental plans to cover what original Medicare does not. Typically, people buy a general Medigap plan and a drug plan. Hands down, you would want to buy a Medigap Plan G, as Plan F is no longer available except to people who were eligible to enroll in Medicare before 2020. Every state has really good information online about the companies that offer the various plans in that state, including the price. Choosing a drug plan is more complicated as there are big variations in price and formularies. However, there are many tools online that help you figure out which drug plan offered in your state is best for you. The tools allow you to enter in the drugs you take, and then see the cost of those drugs in each company's formulary.

Insurance companies work hard to sell people on Medicare Advantage, and at first it looks like a good thing, because it is cheaper. Healthy people often love Medicare Advantage until something serious happens and they cannot see the physician they want or go to the hospital they want; instead they are required to stay within their plan's managed care network. It's really a crap shoot, because the best MD and the best hospital system may be in the network. But they may not. And the insurance companies can, and do, change who is in their Medicare Advantage plan networks.

People who choose to enroll in Medicare Advantage can change to a different Medicare Advantage plan during open enrollment every year. But there is a complication if someone wants to switch. When you sign up for Medicare for the first time, the companies that sell Medigap plans must sell everyone a plan at the same price without medical underwriting -- th only thing they are allowed to factor in is age. Someone who wants to buy a Medigap policy because they are switching from Medicare Advantge can be subject to medical underwriting and charged a prohibitive price. 

I believe that there are many women on the board who are happy with their Medicare Advantage plans. In general, though, advocates for people with disabilities or chronic illnesses like cancer advise them to stay away from Medicare Advantage. Here is a  link that describes the differences and includes some cautions about Advantage plans, including conclusions by the HHS Inspector General that Advantage plans inappropriately deny necessary care at high rates. https://www.cancercare.org/blog/choosing-the-right-medicare-program-when-you-have-cancer

ps. While I'm sure there are many good agents, I know many people who were streered into Medicare Advantage without understanding that they were signing up for managed care. I'm old enough for Medicare, but stayed with my work insurance as original Medicare premiums are linked to income to encouarge people who are still working to stay with their private insurance if they make over a certain income. In all my years of dealing with Medicare and Medicaid advocacy, I never knew that. : ) 

I'm in the Philly area and my insurance expert advises me against any advantage plan. I experienced when I had my dietetics practice that many providers were not in network with the advantage providers. I've had traditional Medicare and the f medigap plan and everything has been paid for...even a 2 hour ambulance ride. Medicare part D sucks though. Good luck. 

BluebirdOne said:

Thanks for the info, Cheese.

First off, I hope you will do well with the K/L. Fingers and toes crossed. My experience with my G plan was similiar. I paid a total of $27.00 for my cancer care, never had an issue with getting any treatment or drug. I am a terrible cynic, but when the doctor's letter speaks glowingly about what is an obviously inferior plan (for me because I live in two states and might receivecare from 3 separate locations) I take a hard look at their motive for forcing me and all of her patients into managed care. In the end, we have a profit driven health care system that patients have to navigate. The suggestion and I quote "In summary, I am doing this because I firmly believe it is in the best interests of my patients", is laughable, in fact my husband heard me gasping and laughing in the next room. Moving patients to a system where they limit the patient's choices NEVER serves the patient well. I expect that she will get some sort of bonus for every patient they sign up, and higher reimbursements from the insurance company. I also expect that the Doctor Group will pressure many other docs in their group to put forth lies about the coverage. As a parting insult, they said that if you do not like the Medicare Advantage plan you can switch back to Medicare Gap/Supplemental, which was true, they forgot to mention that if you do that you will be subject to underwriting, just like any patient. There is no underwriting when you initially select your MediGap Plan at age 65. So people like me with at least 6 pre-existing conditions including cancer, would be charged accordingly to switch back. I think I am more upset that they are trying to force people into a plan that makes them more money, rather than what is good for the patients, and it is so easy to see through the gaslighting pretense that patients will be better off.  If they tried, they couldn't make this whole mess more complicated. So I will be looking for a different internist. 

xxoo

Denise 

 

We use a broker, and she helped us transition from an Advantage plan to supplemental by switch us to AARP Advantage and then 3 months later switching to supplemental.  It is very complicated but I will say this.  Medicare reimburses primary care at a rate lower than the cost to the doctor himself.  Overhead is now about 70% for them, and any medical supplies or un named services make it even higher.  And when my husband was practicing Medicare reimbursed doctors at 50%or 60% of the charge.  At 70% cost to the doctor, for all the new computer mandates, and new IT employees and electronic billing, and regulations it can COST a provider to see medicare patients.  Specialists are reimbursed at a much better rate.  This is why we have a developing shortage of primary care physicians.  When Medicare was invented, the government told doctors they could supplement the lowe charges paid by Medicare, by charging private patients more.  Maybe this is what your Internist is referring to.  It is very frustrating but I have worked in two single payer systems as an RN.  They have their own problems.  None of them are perfect.

Forherself said:

Main difference

Medicare Advantage plans are PPO's, for those who don't know Preferred Provider Organizations.  They pay for the agreed services with doctors and other providers who have joined their plan.  So you are not covered for hospitals and doctors and other providers who have not joined the organization.  Sometimes a hospital has joined the plan but the doctors at the hospital have not. If you go there for emergency services, you may get a doctor that your plan won't pay.  I only discovered this after our insurance agent pushed up toward an Advantage plan. They usually include a drug plan.

Supplemental plans are Medicare.  The Supplemental part pays for YOUR obligation for care.  Medicare pays for 80% of the cost of all medical care covered.  Supplemental insurance pays the 20% that you would have to pay.  So your doctors are paid at the Medicare rate.  Most specialists accept Medicare.  Sometimes it is hard to find a Family Doctor who accepts Medicare (as you may know) because the reimbursement to them is very low.  You have to buy a separate drug plan whenon a supplemental.  

You will receive a large book to read about covered services, and there are insurance brokers who can help you get the coverage you want.  Ours kept promoting the cheapest insurance and we had to keep telling her we wanted the most comprehensive.   My choice is supplemental and a drug plan

I was diagnosed and the gynecologist wanted to send me to Cancer Centers of America.  My insurance didn't contract with them.  They also didn't contract with the gynecologist that could see me the next week.  I had to wait 3 months for an appointment. I never had children so didn't have a gynecologist.  If you have one, they will see you.  Just too many times I was told I couldn't on the Advantage plan.  We went in and switched.  The insurance person never did mention supplemental plans, it was my cousin who is a medical social worker, who was talking about them that got my attention.  Hope that helps.  

I have a medicare advantage plan through the Texas Teacher Retirement System. So far, all of my specialists and my family practice doctor take this insurance.  All of my procedures and medication have been covered with the exception of acupuncture. I've only been on it for a short time, though, so I can't say how I will fare over the long term. I will say, it is not less expensive than other plans I looked into, but does seem to have better coverage. Prior to having this, I had a PPO. I have experienced emergency room doctors and hospitalists who did not take my insurance, which I found out after the fact. I appealed to the insurance company and they covered me at the in-network rate since I really didn't have a choice of providers in the hospital.