Medigap (traditional) vs. Medicare Advantage
- Thread starter UK82
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MA plans are capitated plans, i.e. insurers receive a fixed fee from CMS, per member. In other words, your MA insurer gets paid the same amount whether you go to the doctor a lot or not at all. So the incentive for your PCP is to closely manage, i.e. reduce, the amount of care you get.
I'm still several years away from 65, but can you elaborate on that a little more. What I'm confused about is the last sentence. Why would your primary care physician be incentivized to control care because Anthem or United get a fixed payment whether or not someone goes to the doctor? I can see why the insurer would be incentivized to manage the amount of care, but I am confused why the PCP would be incentivized to do it.
It depends on the doctor of course, but the PCP gets the fixed fee regardless of the amount of times he/she sees the patient and how long they spend with the patient. The incentive can be to not give the patient the amount of time/care they need.
Started with an Advantage plan - and if you’re perfectly healthy, no dental or vision issues, then you’re good.
However if there are any issues and I found this with my dental, then supplemental might be your best option.
However if there are any issues and I found this with my dental, then supplemental might be your best option.
Thanks you for that. One additional question. Is the PCP limited to the fixed amount, or can they still bill insurance for office visits, tests, etc.? If they are limited to the fixed amount, then I can definitely see where they are incentivized to manage the amount of care.
My grandmama is 96 and on a supplemental plan. I don't remember off the top of my head what she pays a month for it, but she never gets a bill when she goes to the doctor or for her prescriptions. Its all just covered for her.
Difference is that with the Advantage plan, Medicare is out of the picture and the plan pays what it pays.
With the supplemental, you present both Medicare card & supplemental card. Expenses are submitted to Medicare first and then supplemental for what Medicare doesn’t cover v
Advantage is a scam, don't get. Most ppl don't know what they're signing up for. It's not a supplement...its the coverage and you forfeit the red white and blue Medicare.
I'm not Medicare age, but worked in Healthcare for awhile so someone that's had it can maybe explain better. But advantage covers meds I believe where with Medicare you have to get part D, but they make up that cost on things like length of stay what services they pay for, etc. Ex: 80 year old and fall and break hip i believe medicare will give you 30 days, advantage might give you 7. And there's a pre authorization on everything. So if you really have no problems- advantage may not be bad option.
Medicare pays 80%. A separate supplement, not advantage, from a carrier will cover the 20%.
I hate government, yet I'm suggesting the govt option. That's how ass garbage advantage is.
I'm not Medicare age, but worked in Healthcare for awhile so someone that's had it can maybe explain better. But advantage covers meds I believe where with Medicare you have to get part D, but they make up that cost on things like length of stay what services they pay for, etc. Ex: 80 year old and fall and break hip i believe medicare will give you 30 days, advantage might give you 7. And there's a pre authorization on everything. So if you really have no problems- advantage may not be bad option.
Medicare pays 80%. A separate supplement, not advantage, from a carrier will cover the 20%.
I hate government, yet I'm suggesting the govt option. That's how ass garbage advantage is.
This is my understanding.
Medicare A, “Original Medicare”, is what everyone gets when they turn 65. You do have to apply. It pays towards your hospital expenses.
Medicare B is optional and pays towards doctor expenses.
Medicare D is optional and pays towards drug costs.
Medicare G is optional and pays towards deductibles and copayments.
Medicare C, “Medicare Advantage” bundles A, B, D, and G and may have vision and dental coverage.
Your preferred provider may not participate in all Advantage plans and I believe you have to have routine care in your home state if you have a second home in another state. I believe physicians don’t like advantage plans because they try to limit patients access by more paperwork and squeeze them harder on reimbursements all in the name of controlling costs which for the insurance company equals more profits.
Part A is the same for everyone including Advantage plans with the premium coming from your social security. Premiums for A and D are means tested based on your AGI from your return when you were 63.
There is lots of information from the government about the different plans on the social security website, there are toll free government hotlines in each state with people who are supposed help, and you will be bombarded by postcards from various salespeople and insurance companies.
It seems a crime that it is so complicated especially for people who are getting to the age where figuring out something new and making a good choice is difficult.
Ultimately you have decide do you want go with the government’s alphabet soup of plans with the inefficiencies of an uncaring big bureaucracy or the private sector that sees you as a potential profit center until you’re not.
I chose an Advantage plan offered to me through my wife’s former employer. It seemed to have a good balance of not too high premiums but lower deductibles and copays. It also was the path of least resistance and fewest choices and decisions.
Medicare A, “Original Medicare”, is what everyone gets when they turn 65. You do have to apply. It pays towards your hospital expenses.
Medicare B is optional and pays towards doctor expenses.
Medicare D is optional and pays towards drug costs.
Medicare G is optional and pays towards deductibles and copayments.
Medicare C, “Medicare Advantage” bundles A, B, D, and G and may have vision and dental coverage.
Your preferred provider may not participate in all Advantage plans and I believe you have to have routine care in your home state if you have a second home in another state. I believe physicians don’t like advantage plans because they try to limit patients access by more paperwork and squeeze them harder on reimbursements all in the name of controlling costs which for the insurance company equals more profits.
Part A is the same for everyone including Advantage plans with the premium coming from your social security. Premiums for A and D are means tested based on your AGI from your return when you were 63.
There is lots of information from the government about the different plans on the social security website, there are toll free government hotlines in each state with people who are supposed help, and you will be bombarded by postcards from various salespeople and insurance companies.
It seems a crime that it is so complicated especially for people who are getting to the age where figuring out something new and making a good choice is difficult.
Ultimately you have decide do you want go with the government’s alphabet soup of plans with the inefficiencies of an uncaring big bureaucracy or the private sector that sees you as a potential profit center until you’re not.
I chose an Advantage plan offered to me through my wife’s former employer. It seemed to have a good balance of not too high premiums but lower deductibles and copays. It also was the path of least resistance and fewest choices and decisions.
My office specializes in Medicare plans.
There are differences in the plans that can only be deciphered as what is best by individuals needs and ability to pay.
There are differences in the plans that can only be deciphered as what is best by individuals needs and ability to pay.
If you want MA and the commercials sound great then an insurance company decides what amount they pay your doctors. You pay the rest. Much like plans run by your employer. I plan to start with traditional Medicare in a couple years and no longer deal with insurance companies. The only way to truly understand the gaps in coverage is to see what happens afaic.
I get medical bills all the time. There are 3 standard plans under Medicare: A, B, and D. For some reason the government farms out administering the plans to private insurers. I'm not sure of the name of my insurer. It switched a few years ago, and I simply don't remember. I just hand some care provider my card.
Medicare A takes care of 80% of your typical doctor/hospital bill. Medicare B takes care of 80% of the rest. And Medicare D is the prescription drug portion. The individual geezer pays some % of their income for each plan they choose to take part in. Retiring meant I quit looking at money. I should be more alert and attentive, but I'm not. (Commercial voice: Don't Be Like DreadLox.)
I'm in pretty good health but I'm old so I see more doctors and take more medicine than I used to. There's a theoretical maximum out-of-pocket dollar amount per year, but I never seem to get near there. Knock wood. I used to use Pharmacy X but they had a disagreement regarding their reimbursement amount from the insurer. So I switched to Pharmacy Y. I was shocked at how much cost difference there was between pharmacies. (Pharmacy Y is much cheaper than Pharmacy X) Lesson: don't assume everybody charges the same.
This is a very important decision. Changing plans down the road, unless because of a qualifying event within your current plan, may require overall health evaluation and premiums, if even accepted, might be extremely costly. You really want to make the best decision possible during your original Medicare enrollment period.
Watch (zoom sessions linked below) or (better yet) attend a MEDICARE SIMPLIFIED presentation. It is the absolute, very best advice I can give you and there is absolutely no cost or obligation to attend their FREE educational seminars that are extremely informative.
The biggest and most critical point, as best I can remember from enrolling 6 years ago ...
If your Doctor and/or Healthcare Provider accepts Medicare, then they HAVE to accept your supplemental plan. Doctors and providers DO NOT HAVE TO ACCEPT Advantage plans. Advantage plans can be a particular problem when you might require medical attention outside of your local and immediate network area.
Fwiw ... My wife and I have UNITED HEALTHCARE, PLAN G, supplemental coverage under the AARP group plan.
Watch (zoom sessions linked below) or (better yet) attend a MEDICARE SIMPLIFIED presentation. It is the absolute, very best advice I can give you and there is absolutely no cost or obligation to attend their FREE educational seminars that are extremely informative.
The biggest and most critical point, as best I can remember from enrolling 6 years ago ...
If your Doctor and/or Healthcare Provider accepts Medicare, then they HAVE to accept your supplemental plan. Doctors and providers DO NOT HAVE TO ACCEPT Advantage plans. Advantage plans can be a particular problem when you might require medical attention outside of your local and immediate network area.
Fwiw ... My wife and I have UNITED HEALTHCARE, PLAN G, supplemental coverage under the AARP group plan.
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The biggest difference are Advantage often gives you more stuff like eye glasses, and dental, but they have restrictions like you can only use doctors from a PP network, you have to have referrals to see a specialists and some won't cover you if you are outside you home area. Medigap doesn't have those restrictions.
I have Medigap with CIGNA and have been fine with it, never an issue.
I have Medigap with CIGNA and have been fine with it, never an issue.
I don't see how it's to the advantage of the MA provider to reduce your care so that you're not as healthy & thus need even more care tomorrow. Why do they want you hospitalized? Senseless thinking as I see it.
Also, my MA requires a copay and an out-of-pocket to a certain amount. So PCP gets the copay when I show up & not if I don't.
My former employer's sponsored MA plan may be unique in that I have no doctor restrictions.
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