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  • Medicare Advantage vs Medigap

    I have been on SSDI for 18 months and am 56 years old T4 paraplegic. Soon I will be on Medicare and will need to choose between Medicare Advantage and Medigap as a supplement to Medicare. Was wondering which of these you find is the best and pros/cons of them.

  • #2
    Go to the AARP site. There is good information there about relative merits of plans, but any way you slice it it is very complicate, with many "what ifs" build in. Since it is impossible to answer the "what ifs", our choice is a bit of a guessing game.

    https://www.aarp.org/health/health-i...tcmp=AE-HP-LL1

    In addition, all states have a helpline where someone will attempt to help you sort out your information and what fits you best.

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    • #3
      Personally I would never get a Medicare Advantage Plan.

      They purport to save you money or offer other benefits above and beyond traditional medicare, but they can only do so by providing inferior services or coverage. Many providers do not accept these plans.

      Comment


      • #4
        Originally posted by funklab View Post
        Personally I would never get a Medicare Advantage Plan.

        They purport to save you money or offer other benefits above and beyond traditional medicare, but they can only do so by providing inferior services or coverage. Many providers do not accept these plans.
        I believe they are called "Medicare Advantage" plans because once you switch to them you realize the advantage that traditional medicare has over these private plans...

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        • #5
          I can't get Medigap in Virginia. Only available for 65 and over population. I choose an Advamtage plan for one important reason: stop loss.

          Its saved me over $8,000 this year alone. The 20% co-pay traditional Medicare has can be enormous.

          My annual max OOP with the Advantage plan is $2,500. My Medicare 2019 20% OOP would have been ~$8,000, and nothing really big happened. Traditional has no max. It costs you what it costs, with Zero stop loss. My Advantage OOP for 2019 was only ~$650. Heaven forbid you have to be hospitalized on traditional Medicare. 20% of a huge number is still a big number.

          Benefits for me actually got better. No doctor changes required. Dental, drugs, vision, mental, chiropractic, etc all included for same I was paying traditional. E.g. A (bladder control) drug I'd been wanting to try was not covered by Part D and was $600 a month. Advantage Plan: $35 monthly copay for same drug.

          Ive yet to encounter a situation where Advantage plan has not worked in my Advantage. (2 years and counting). They even covered my latest wheelchair much better. (Just a few hundred for a chair and smart drive instead of a thousand.)

          Only thing I don't like is needing to get referrals sent for all my specialists but that took like 20min and the referral authorization lasts 12 months.

          All that said, Medicare + Gap is better, IMO, but it more than doubles the monthly premiums and isn't available in every state for folks on Medicare under 65. Advantage is no more premiums, unless you want to upgrade, which is another benefit: buying better coverage if you want better coverage. Traditional Medicare is take it or leave it.

          My .02
          "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

          "If you only know your side of an issue, you know nothing." -John Stuart Mill, On Liberty

          "Even what those with the greatest reputation for knowing it all claim to understand and defend are but opinions..." -Heraclitus, Fragments

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          • #6
            Doesn’t traditional part A cover 100% of hospital costs?

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            • #7
              Originally posted by funklab View Post
              Doesn’t traditional part A cover 100% of hospital costs?
              No. 80%. And B is what pays for outpatient physician visits, PT, OT, etc.

              If you go with Medicare Advantage, you are really going with an HMO. Physician and hospital choice may be non-existent or very limited. Be sure to look at their DME coverage too...it may be less than traditional Medicare.

              If you go with a Medigap plan, be sure it is one that also includes Medicare Part D (medication coverage); otherwise you will have to also chose and pay for a D plan. That is a Medicare requirement.

              (KLD)
              The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

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              • #8
                In Alabama.
                I have BCBS for Rx and to cover the 20% with no deductible or co pay. Meds cost $4-$24 depending on the med.
                Cost is $135 for Rx and $380+ (I think) = $500+ which = 1/4 of my SSD (after Medicare takes $ from SSD).
                Premium price hurts and takes a big chunk of my SSD.
                I got a new power chair this year so my supplemental coverage was basically free for this year (compared to what I would have paid OOP with out it).

                I've looked on "My Medicare" website to compare plans, hoping for a cheaper premium. Made my head hurt trying to decipher all the info.
                I'm trying to not go call ins. companies because of bad side effects. They share your phone #. Last time I called to check around, I was attacked by telemarketers for 5 years (3-10 calls a day, 1 or 2 on weekends). I have it down to no calls to max 4 a day occasionally. Afraid to rock the boat but would like a cheaper price.

                Adding to the confusion, all states are different with different plans and costs.
                Last edited by Gearhead; 11-01-2019, 07:57 PM. Reason: addition
                Attack life, it's going to kill you anyway
                Steve Mcqueen (Mr Cool)

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                • #9
                  I have a good advantage because the company running my plan also runs 100% of the hospitals in my region and ~75% of the group practices and other facilities. Every doctor I've ever gone to is a member of their network. Most are affiliated business wise too.

                  There aren't any Advantage plans with worse coverage than Medicare, even for DME, between Anthem, Humana, Sentara and United, that I can find.

                  I thought by law they had to be at least as good.


                  Originally posted by SCI-Nurse View Post
                  No. 80%. And B is what pays for outpatient physician visits, PT, OT, etc.

                  If you go with Medicare Advantage, you are really going with an HMO. Physician and hospital choice may be non-existent or very limited. Be sure to look at their DME coverage too...it may be less than traditional Medicare.

                  If you go with a Medigap plan, be sure it is one that also includes Medicare Part D (medication coverage); otherwise you will have to also chose and pay for a D plan. That is a Medicare requirement.

                  (KLD)
                  "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

                  "If you only know your side of an issue, you know nothing." -John Stuart Mill, On Liberty

                  "Even what those with the greatest reputation for knowing it all claim to understand and defend are but opinions..." -Heraclitus, Fragments

                  Comment


                  • #10
                    I have had Humana Medicare Advantage plan for probably since I got on Medicare. It has worked out great for me and when My mom and Dad were still alive it worked out great for them. They were paying a lot for the medigap coverage. They never had to change doctors nor have I and I really have no complaints. I had a Bladder stone removed this past March and my co-pay for that was $400 that was it. I had no other cost for that procedure. I only take one med and I started geting it through Good RX because with Good RX it was about half what my co-pay was through Insurance. I think if you have a lot of medications you can run into problems with the Advantage plans but from my own personal expereince it has been just fine for me. You will really have to do your homework to figure out which is best for you

                    Comment


                    • #11
                      Originally posted by funklab View Post
                      Doesn?t traditional part A cover 100% of hospital costs?
                      Depends on length of stay and state insurance regulations. For short stays, yes. There is always a deductible (2019 ~$1,500 per "spell of illness"/admittance for a condition. Admissions for multiple issues means multiple $1,500 deductibles. Once for each diagnosis code being treated, per admission, essentially.) Long stays get up around $300-$400 per day co-pay. More in some states. It's not a flat 20% co-pay for Part A like it is for part B, but even some out patient part B services (chemo, radiation, outpatient surgeries, etc) still can be HUGE bills. My Dad racked up nearly $50k in Medicare copays over just a couple years recently.
                      "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

                      "If you only know your side of an issue, you know nothing." -John Stuart Mill, On Liberty

                      "Even what those with the greatest reputation for knowing it all claim to understand and defend are but opinions..." -Heraclitus, Fragments

                      Comment


                      • #12
                        Originally posted by Oddity View Post
                        Depends on length of stay and state insurance regulations. For short stays, yes. There is always a deductible (2019 ~$1,500 per "spell of illness"/admittance for a condition. Admissions for multiple issues means multiple $1,500 deductibles. Once for each diagnosis code being treated, per admission, essentially.) Long stays get up around $300-$400 per day co-pay. More in some states. It's not a flat 20% co-pay for Part A like it is for part B, but even some out patient part B services (chemo, radiation, outpatient surgeries, etc) still can be HUGE bills. My Dad racked up nearly $50k in Medicare copays over just a couple years recently.
                        Wow.

                        Comment


                        • #13
                          Originally posted by Tetracyclone View Post
                          Wow.
                          Yeah. That's why 'stop loss' risk management was so important to me. There is a lot of confusion as to what a "spell of illness" exactly means (that's the language used in the Medicare claims processing manual) and it's not perfectly consistent claim to claim, as far as I understand. E.g. I've heard from some folks who've had multiple admissions for what was adjudicated as a "single spell of illness" who've only paid the $1,500 once, and another who had a single admission for multiple illnesses get charge it twice. It's about as clear as mud to me.
                          "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

                          "If you only know your side of an issue, you know nothing." -John Stuart Mill, On Liberty

                          "Even what those with the greatest reputation for knowing it all claim to understand and defend are but opinions..." -Heraclitus, Fragments

                          Comment


                          • #14
                            I enrolled in my Medigap policy during a special window of time that has closed, and over the years my premiums go up and up. So, I used to call around for something more reasonable (I was barely using my pricey Medigap policy), and the only alternatives offered me were Medicare Advantage. I was getting close to signing up, but called around to a couple more agents just in case. The last guy I reached, it was late Friday afternoon, closing time.

                            He was talking to me about the Medicare Advantage plan I was considering, and at one point he dropped the sales speak. His voice changed. "Spitz, don't do this." Then he laid out the reasons why I, with a progressive condition, could get caught behind the eight ball. Losing my choice of providers and facilities. Being constrained by formularies if I needed newer treatments. Most likely losing coverage when away from my primary address, which is a concern in our lifestyle. He went on for a few minutes. It was a very sobering. I wish now I could recall more exact details.


                            Meanwhile though my Medigap provider will keep trying to buck me off. Who knows what will happen? Go Bernie.
                            Hotel list: Hoyer-friendly beds, low and adjustable-height beds

                            Blog: https://thewheeledwonder.wordpress.com/

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                            • #15
                              I talked with Medicare today about a bill I received in the mail. The bill was about a claim from 2 1/2 years ago. My beef, 2 1/2 years and I was just now getting this surprise bill about a claim denied 2 yrs 5 months after it was originally submitted. .
                              I was advised to talk to SHIP (don't know what that stands for). This is a medicare affiliated office with many local locations. After I receive protest form (in about 15 days), I will call and visit them.
                              I need help writing the protest (hand function).
                              Supposedly Medicare gurus work there and they also can advise which supplement policies are best for me or you.
                              Ph # for SHIP 800-243-5463 Call for a location near you.
                              Attack life, it's going to kill you anyway
                              Steve Mcqueen (Mr Cool)

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