Very much this. Especially because at this point, many people may be switching from family-friendly docs who see a lot of kids and younger adults to eldercare GPs. Get a doc you trust, then be sure they are in your plan’s network.
My PPO is associated with a large clinic, and I can’t see a specialist without approval of my PCP, which I agree is a good thing. Mostly I see specialists inside the clinic, but I can go outside if necessary, so I think I have the best of both worlds.
My PCP is an excellent diagnostician, and I’ve been seeing him long enough that he knows I’m not a kvetch. As I mentioned they weren’t under any MA plans when I started Medicare which is why I didn’t go that route. Never have regretted it.
I am fearful that in the context of the statement of the op quoted above, my pushbacks above may have resulted in our op stepping back. My great apologies if so @JohnT. Your insights and knowledge provided in this thread are appreciated.
Lol, no big deal because you didn’t really repudiate anything I said:
- One should always be in an Med Avantage plan if they can’t afford a Med Sup plan and should never rely on Original Medicare.
- A PPO client is perfectly free to ask for referrals as well. It’s just not required, and those ‘I know my body’ types do like the freedom of seeing a specialist directly if they wish.
I’m just over 3 years away from turning 65 and am starting to really pay attention to this topic. We’re in a slightly better position financlally than many, because we’ve been on a high-deductible plan the past few years, have maxed out our HSA contribution. and have used relatively little of it - AND my company put aside money in an account that can, if I meet certain criteria, be used to pay Medigap premiums.
Despite all this I can see how we could blow through most of our resources relatively quickly if anything really bad happened. Family members were wiped out when the wife developed multiple myeloma (there was more to it than just that, but the medical bills really did them in).
For giggles, I looked at monthly premiums for type F, and for G (high deductible), both of which have a lot of stuff covered. I looked in my ZIP code (124-334 for F and 25-57 for G), my in-laws’ ZIP (168-378 and 42-56) and my daughter’s ZIP in Vermont (236-339 and 56-121). Relatively close overall, except for the really low value for F here (and high for F in Vermont), and the much higher upper value for G in Vermont.
All of them said something about “locked in at a lower rate, the younger you are when you choose that plan”. Does that really mean that whatever the premium is when you lock in, will truly never go up even with cost of living? Or just that it won’t get jacked up if you get sick?
And I have read somewhere that all plans with the same name have to offer identical benefits. Why the huge variance in prices then?
As far as I can tell this is because each company can choose their own way to set premiums. There are three ways , and in all three systems , premiums can go up over time due to inflation.
Community rating means everyone pays the same premium and it won’t change because of your age.
Issue-age rating means your premium is based on how old you are when you sign up. The price doesn’t go up as you get older based on your age - but if you first buy a policy at 70, your premium will be higher than your 65 year old neighbor’s.
Attained-age rating means your premium goes up as you get older. These tend to be attractive to younger buyers, as the premiums are lower than the other two types but they become more expensive later.
And look carefully at the benefits - I only know anything about this because a year or two ago my mother called my sister and I freaking out because her premium was going up something like $300/month. Turns out she had a plan that covered excess charges- but she didn’t need that coverage as she lives in a state that prohibits excess charges. So we found another plan with exactly the same coverage minus the excess charge coverage - much less expensive.
With Apologies to Ayn Rand
It is said that catastrophes are a matter of pure chance, and there were those who would have said that every person trapped in the Medicare system were not guilty or responsible for the thing which happened to them.
Sandra, 69, was a Tulsa OK nurse her entire life who complained about taxes and kept voting for Republicans because they said they would keep her taxes low. When she retired, she was surprised to find out that dental and vision are covered so poorly by Medicare and the other plans. Upon being told that a dental plan would cost $47.95 month and cover $2k of work, she got mad and said she “deserved” free dental.
David, 72, sat in his Jacksonville house, his knee aching. He wanted to call the clinic, but knew there would be a $45 copay and then the medicines prescribed might not even be on his new plans formulary. He knew it was because all the Blacks drained the benefits and didn’t leave anything for him, and he tells every person who calls his phone about Medicare exactly what he thinks about that.
Winthrop, 84, was a professor of economics who taught that individualism was the way, that collective measures were doomed to fail, and who’s highest professional attainment was a White House dinner during the Bush Administration where the topic was his paper supporting the privatization of social security. Unfortunately, Winthrop’s mind started to go at 73, with his family taking his social security and medicare cards 3 years later, after he signed up for a Medicare Advantage plan, therefore losing his university retirement benefits.
Jim, 47, campaigned on reducing social security and medicare taxes during his undergrad days because the numbers showed the programs wouldn’t be around for 30 years and why should he have to pay for it? Now, 4 years disabled, on Medicare and Medicaid, he gets fantastic benefits through his UHC D-SNP and still campaigns and votes for smaller government and the fight against socialism.
Juanita, 72, never cared about politics, figured they were all crooks anyway, voted as her husband Rigoberto voted, which was usually Republican except for that one time they voted for Obama. 'Berto died a couple of years ago and since then it’s been hard, real hard. They voted for Trump in 2016 and Juanita will never understand why the world is so hard, but she accepts that it is and she has no control over it.
Leonard, 78, was a reporter for the Denver Post who wrote hard-hitting articles on Hillary Clinton back in the 1990s. He was a liberal and wanted socialized medicine, but he wanted to appear “fair” and “balanced” and, for some reason, chose her as his target, finally convincing himself to vote for Trump in 2016. He is now wondering where he is going to get $2,000 for a hearing aid.
Ruth, 87, spent 60 years voting for men whom she knew nothing about so they could run a government whom she was taught to disdain and is having to parse out her diabetes medications because she can’t afford $47 for Januvia.
Believing and voting as he did that “the government which governs best governs least”, Tom wants to know why he has to pay $195 for a MRI when he “worked and paid into the system for 45 years” and is bitter because the system he is faced with is far more complicated than the system he dealt with at work.
Jane, 74, a retired schoolteacher who lost her retirement benefits out of a misplaced sense of competence in the insurance field, spent the last 10 years of her career turning class after class of teens into sullen voices, telling them their only value was that of which they would be paid for, that their dreams were of little value and that they had better “face the real world” as she has.
The pain from his sciatica flare-ups slowly increasing, 66yo Roger’s greatest disappointment of the past 10 years was when John McCain voted thumbs-down to save that communist-loving Obama’s precious medical plan. Had that Obamacare had been overturned, Roger’s taxes would be lower and he would have a cheaper medical plan. He knew it!
Thelma had a son who worked in the Trump administration, a job whose nature she avoided asking, just knowing it had something to do with immigration. Thelma told herself that it didn’t matter, that it’s only those others that they hurt, then she cut her amlodipine tablet in half, knowing her social security wasn’t coming in for another 9 days.
Ricardo still believed as Rush said, that the worst thing you could hear was “I’m from the government and I’m here to help”. Ricardo was OK, though, as he was of Mexican citizenship and went to Mexico whenever he needed medical attention, not trusting our crazy, insanely expensive and complicated system. Living in Laredo made this easy, except that one time he broke his leg and had to drive himself across the border.
These clients, more, for there was not a person among them who did not share the same beliefs, actively working them into reality, and not a single one of them understood that they… in their own small way… have created the hell in which they’re living.
Today, listening to the tales of misery spoken by people who obviously helped create the social underpinnings of this system, I couldn’t help but think of the ending passage to Chapter 7 (pages 566-568 in my mass market edition) of Ayn Rand’s Atlas Shrugged, one of my desert island books. Obviously not a SDMB instant classic, I enjoy her Calvinistic ability to lay blame on those who consider themselves blameless and, listening to white conservative after white conservative demand socialism and, many times, for ‘someone to care’, I felt inspired to write the above pastiche. Hope you enjoyed.
Okay, JohnT, tell me what I need when I get there. Right now I’m nearing 60. I’ve been such an infrequent user of healthcare services that I never worried about my insurance although I have insurance through work which is thorough and comprehensive. But the minute I can get healthcare outside of my job, I’m retiring.
I live in TN. I have a fair bit of money in the bank, own my farm and a rental house outright and have no debt. I’m used to paying for insurance. All those $0 plans make me skeptical, because nothing in life is free. I’m healthy - I take a thyroid pill, that’s it. And those are dead cheap. I go to the doctor about every 18 months, because they hold my thyroid med hostage until I come in. I’ve literally gone decades between doctor visits. However, my family is riddled with cancer - 3 of my 4 siblings had cancer before they were 60. My mother had it twice, including while she was pregnant with me. My father was a non-smoker who died of lung cancer.
Do I want an Advantage plan, or a Supplement plan? Do I want a pay to play plan? Do all the work for me!
StG
Do it yourself!
The above is a link (should be editable) to a quick and dirty plan comparison model I made. This doesn’t include ALL costs, just the more common ones. Enter the information in blue, taking note of whether you are being charged per day or per stay on the hospital portion, and see where you think you’ll come out.
There are two tabs, the calculator and an example. Feel free to copy this into your own spreadsheet.
Thanks, JohnT. My problem is, I can’t calculate # of specialist visits and hospitalizations. Going by my current medical history, I’ll see a specialist once every 10 years and maybe the same for hospital visits. But that’s unrealistic, because presumably at some point my health will decline.
StG
Yeah, it can be difficult to estimate the future.
Just make a guess. If you think you will end up in the hospital 1 time evey X years for a total of Y days:
-
If the plan charges per visit , then put the answer to 1/x in the # of visits. 1 visit every 3 years is .333
-
If the plan charges per day, then put Y/X. So 9 days over 3 years is 3 days.
Don’t forget to change the $ amount, of course!
Don’t forget that hospitalization is not nearly the only cost to be worried about. My wife had $50K of retinal surgery and was in the hospital one night, and that only because the operation went so late they didn’t want to release her to me. I’ve had a few reasonably expensive procedures and haven’t stayed a night in the hospital for over 30 years.
Same principle applies, but anyone estimating medical costs should take this into account.
Yeah, feel free, anyone, to add to the model. My point is that when you run the numbers on even the basic items (like doc visits, hospital stays, MRI’s) you will see that $0 is, in no way, ‘free’.
But once all those costs on the MA plan = that ‘max out of pocket’, that’s where you stop paying on medical & hospitalization and the plan pays 100%.
Another thing to consider is cashflow. We picked the old Medigap plan F pay all copays plan because the extra monthly cost was not painful to us, but paying a big chunk of copay would be psychologically painful if not financially painful.
I haven’t done the calculation but I wouldn’t be surprised if we were behind in terms of total payments, but we’re ahead in the pleasure of not paying a penny out of our pockets for a knee replacement.
My daughter does behavioral economics so I’m sensitive to this way of looking at things.
Lol, there’s only so much spreadsheetin’ I’ll do for free!
And to a point earlier in this thread: even those struggling on that Med Supp payment are happier, on average, than those who are not struggling on the MA plan.
Just talked to a guy who, in the space of three minutes, dropped both a Christopher Columbus and a John Holmes reference.
WHICH OF YOU WAS IT??? 
Tales from the Pit
Betty had a Med Supp + Prescription, $288. Coulda switched to a Medicare Advantage plan with a MOOP of $3,900, but when I explained the differences to her, she… like all the rest… happily decided to keep her MS plan. She likely would’ve been ok switching to a MA plan because her $3,456 premium cost was not too far from a couple of plans $3,800 MOOP. But that last # isn’t guaranteed for the rest of her life while most of the $3,456 was, so she kept her $3,456 expense. However Betty is one of those cases where… if her premium keeps increasing… the MA world may be cheaper than the MS world. It happens.
Ladies and gents, if there’s one thing you can learn from Betty’s situation, going with a flat-rate plan will be more expensive at first, but may be wiser in the long run. Betty’s plan is designed so her premiums increase for the rest of her life, which really sucks as it will force her into the MA space. Don’t do this.
Alfred calls. CPA, mentions his accounting skillz in the first minute of the call so it makes things much easier for me - I can throw out #'s & calculations with the best of them. Now, Alfred may have been a CPA, but he is completely and utterly lost in the world of Medicare Advantage plans. Alfred was going on about copays and how he receives documents from the hospital which aren’t really bills and on and on and so I let him get some of the venom out until he winds down.
Then I start speaking:
“OK, Alfred, I’m so glad you’re a CPA because I’m a numbers guy like you and knowing we speak the same language is going to make this SO MUCH EASIER for the both of us. So I’m going to get you out of the weeds so you understand the few key metrics you need to understand when choosing MA plans.”
“The first key metric is “Maximum Out of Pocket”, MOOP, which limits the amount you can pay for copays, deductibles, etc. And a MOOP of $3,000 is definitely not the same as a MOOP of $7,550, and this is the first number you can control, up to an extent.”
Clarity began to ensue. “What about drugs?”
“That’s the other major expense you can control. Drug prices are very sensitive to pharmacy and plans. Drugs which are $0 at CVS may be $47 at Walgreens. Also, some plans are just much better at handling drug costs than others. For example, one client had an annual drug cost range of $304 on one plan to $54,000 on another because of nothing more than how the two plans handled his drugs at his selected pharmacy. And there are drugs which will be covered by some plans and not others. Lastly, you don’t have to have your drugs at the same pharmacy - some people have some drugs at CVS and some at Walgreens because those drugs are cheaper at their respective locations.”
“Holy fuck that’s complicated! But what about the rest? Copays? MRI’s? Hospital visits?”
“Those are important and should be looked at, but the fact is that everything you pay towards those expenses, excepting drugs, count towards the MOOP. So if you really want to minimize your copays, first minimize your MOOP, then look at the individual copays., But yes, if lower copays are more important than lower hospital costs, then once you look at the metrics above, look for those minor differences which mean a lot to you.”
“I wish someone would have explained this to me…”
Had a great call. When I mentioned to him that he is signing a financial contract which imposes obligations upon him, obligations which could be capped, that’s when the light went off. He got it. He understood that all we were doing is rearranging deck chairs, that eventually most of the #'s would come out the same and his worry about copays, etc was largely for naught.
Marilynn:
‘I have had two knee replacements which haven’t cost me a cent and I listen to my friends talk about copay this and coinsurance that which is something I never have to think about, so I made it very clear to my children that they are never to take me from my plan even if my mind goes and they make the decisions.’
Marilynn, it goes without saying, has a Medicare Supplement plan.
So, how should I shop for a Medicare Advantage plan?
When shopping for a Medicare Advantage plan, assuming you don’t qualify for a chronic illness plan or are not on Medicaid, here is the hierarchy of expenses you should look for:
- Drugs. Drugs are usually not an issue, but if you take some rare ones, your drug costs can easily exceed your Max Out of Pocket. I’ve seen some plans with covered drugs which ran over 25,000/year. Also, pharmacy selection *matters*, and it can be drug-dependent. Do not hesitate to split your prescriptions between differing pharmacies to save .
When shopping for MA plans, be sure to have your prescription drug list ready to go and if the agent says “we don’t need that” or if they don’t take the time to enter the meds so they can then tell you their projected cost, find another organization that can do this operation and use those people instead.
Because you NEED to know this.
-
Max Out of Pocket - I’ve talked about this enough, but if you’re reading this sentence and somehow didn’t read all the rest, this is the calendar-year maximum you can spend on covered medical expenses out of pocket before the plan picks up 100% of all medical/hospital expenses for the rest of the calendar year. MOOP’s range from $900-$7,550. (If you have a MA plan with a $900 MOOP available, that’s likely a better deal than a MS plan.)
-
Hospitalization. Wide variability in how plans charge you hospital copays. Some plans will be “$295/day for days 1-6, $0 for days 7-90” others will be “$700 per stay.” The flat rate plans end up being the equivalent of 2-3 days of the per-day plans. Choose your poison.
-
The other financial items… copays, coinsurances, ambulance, ER and Urgent Care… those things trend towards a range:
Copays: $0-$60
Coinsurance: 20%
Ambulance: $250ish
ER: Either $90 or $120
Urgent Care: $0-$60
MRI’s: $0-$265
And because they stay within those ranges, and because all the above (including hospitalization) counts towards your MOOP, the best thing you can do to minimize expenses on the above list is to minimize your MOOP. It’s really that simple.
Except…
Non-Financial Considerations
Obviously there are non-financial considerations you need to consider:
- Are my doctors in-network? Any competent organization will be able to tell you if your docs are in-network prior to reviewing plans. If they cannot, find a new insurance company.
Now some people are really attached to their doctors, some are not. But this is an important non-financial consideration because…
-
Am I currently undergoing a treatment plan? If you are currently undergoing a long-term treatment plan (say oncology or you have a hip replacement scheduled) which has been approved by the insurer, I strongly recommend not changing insurance plans until the treatment plan is fully over. Of course, if you’re going broke, then a plan change may be what’s needed.
-
Am I happy with my plan? Honestly, if you’re happy with your current plan, no need to change.
Therefore, when selecting a MA plan, here, in order, is what you want to look at:
-
An agency who has systems which can calculate your plans actual drug price AND tell you if your doctor is in/out of network. Once you find this (PM me because guess what I can do!), then:
-
Non-financial considerations, especially ongoing treatment plan considerations.
-
Drug costs
-
Max Out of Pocket
-
Everything Else
Again, thanks for the advice. I found that looking at Plan D plans was similar. I used to go to a local pharmacy, but found that CVS was a lot cheaper, even for relatively cheap generics. And it was open 24 hours. And it was closer. It’s a shame to not support the local guy, but it could mean real money if I got prescribed something expensive.
The Medicare site is pretty good at letting you enter a bunch of pharmacies and seeing the difference in costs for the drugs you enter.
BTW, when you say MS plans don’t increase premiums, I assume you mean due to aging. My premiums increase - not by much - but I assume the same amount as everyone else in the pool regardless of age.
If you know of any plans where premiums don’t increase, I want it!!!