What's the Dope on Medicare Advantage vs Medigap?

In My Humble Opinion
1

So my parental units have hit that age. They are now eligible for Medicare, and apparently almost everyone over 65 gets part A courtesy of the taxpayers. At the present time, both are in good health.

So, apparently, they have to pay ~$100 a month for medicare part B. Why is it a separate deal? Who knows. So there’s still Part D, and they’d also like dental coverage.

Or (they have received a few high pressure phonecalls from salesmen on commission), there’s Part C, where apparently they can get private insurance that is taxpayer subsidized for a monthly premium of about $100 in addition to the part B premiums. Some of these part C plans have dental and drug coverage. However, they are all from insurance companies that run networks and make their living denying claims.

So there’s apparently 10 government allowed “flavors” of Medigap coverage. There are as many Medicare Advantage plans as there are private insurance companies to offer them - a literal blizzard of choices.

How can my folks cut through the noise and get something that has a maximal likelihood of being a wise decision?

Honestly, car buying is a lot easier than this. If you just want something that will reliably get you around, there’s a couple of manufacturers that *consistently *score the highest marks for reliability. Can’t go wrong with a mainstream Honda or Toyota model, for the most part. Go used so you make sure you are buying into one of the model years that didn’t have latent problems, and pay only about 30-40% of the new sticker price.

2

No answer here, but I’m interested in this information, too. Is there any site with good, unbiased information, and hopefully reviews, of all the different options and providers out there?

Now, if there only was an “Over the Hill” forum on the SDMB. :slight_smile:

J.

3

While I doubt that they will steer you towards or away from any specific vendors, I believe AARP has some resources on their website that might help you understand the options better. Here in San Francisco I was also able to take advantage of an unaffiliated non-profit where you can go and have a person explain it all to you.

However, once you have decided on either medigap or advantage coverage, in my short and limited experience, you still have to do all the legwork yourself to get quotes and compare coverage vs. what you pay for it.

For myself I picked medigap, for a couple of reasons: 1) the one you said about advantage plans, basically they are all HMOs and personally I am so over having one of those; and b) when I priced out the medigap plans the prices were too close to matter, so I could just pick one.

The good news is that if you don’t like what you pick, you can change it the next year.

4

Part of this depends on where you live. For example 0% participate in Medicare Advantage in Alaska and 51% participate in Minnesota (national average is 30%)

5

AARP around here will always steer you to United Health Care plans. They have decent plans, but are just one of a couple of dozen carriers available.

Medicare.gov has web tools to help you figure out what is available to you in your area. Some counties have great plans and one right next door won’t.

A reputable ins agent that offers several lines could help, too. Ask for local referrals.

6

Independent is a search term you’ll want to use to find a local agent. If an agent works for a specific ins company, they will hard sell you on their line. An independent agent can be contracted with many ins carriers, and can find a good fit for you.

.

7

Foggy, but I think there is a difference in the amount that’s paid between the two plans. Like the dr or hospital has to take what Medicare pays in the Medigap plan, but not in the Advantage plan. Something like that.

I have 3 very cheap prescriptions, so I end up paying more for the drug coverage than I spend. I’m still pretty healthy but that could change quickly, so I willingly pay the extra.

The dental covers a percentage of two annual cleanings; part of the cost of a crown; and the rest I haven’t paid attention to. But it’s cheap, less than $25/mo for me.

Haven’t investigated vision coverage.

I’ve had BCBS all my adult life, so I went to the local office for advice when I became Medicare eligible. They did all the paperwork for me.

8

I researched this last year and concluded that Medigap was best for me.

Advantage programs are run by insurance companies who are paid to provide and administer Medicare services for the government. My conclusion was that they can make the plans free or low cost AND profit from this in at least three ways :

  1. The government pays them roughly 12% more than it would cost to do it themselves. (Cutting this in the future is a possibility)
  2. The insurance company can insist on reviewing a treatment before approving it.
  3. Limiting the services to HMOs or networks of providers.

On the other hand, a Supplimental/Gap policy simply pays for any service (or extra charge) after you meet the deductible. My doctor and I make the decisions on treatment with no outside organization involved and no extra cost to the taxpayer.

It is very important to get a Gap policy in the first six months of eligibility - after that they can deny you if they think you are a poor risk. If you decide you don’t like MediGap, you can switch to Advantage but not vice versa.

I chose a high deductible F plan to be able to both predict a maximum yearly cost if I become ill AND minimize my monthly outlay while healthy.

9

My husband and I both retired through the state of Illinois. Because he worked for a university for over twenty years, he has prepaid a portion of his Medigap and so will get it at a reduced rate. The state has decided all university retirees will now get Medicare Advantage, so if he decides he really wants Medicare he has to forfeit the gap insurance, or he can go to a Mdicare Advantage program and get part of it paid for.

I retired as a teacher, not university employee, and retired teachers now have to get Medicare Advantage instead of Medicare. When I turn 65 and have to choose, I wll have to decide if one has a financial advantage.

Are your parents under any constraints like that?

10

Also, if I am understanding the whole thing, it’s not Medicare Advantage vs Medigap, it’s Medicare Advantage vs Medicare + Medigap. Medicare Advantage combines the two.

11

I have a Medicare Advantage plan.

It has a limited choice of providers; I chose a network affiliated with a teaching hospital. The doctors I see are all American-trained and board-certified in their specialties; many of them teach or publish.

I pay only the equivalent of the Part B premium (c. $105/mo). There are fixed (generally not percentage) co-pays for some things, but no deductible. There is an annual $3400 out-of-pocket limit.

Everything mandated for basic Medicare is covered.

My plan includes Part D (prescription drug coverage). Thirty- to ninety-day supplies of Tier 1 & 2 generics from their mail-order pharmacy carry no co-pay.

It also includes (no additional cost) a few other goodies: two dental exams and one eye exam per year, a “Silver Sneakers” membership, which I use for a local “Y” (pool, exercise center, fitness classes), a monthly OTC allowance (pays for my supplements and a bunch of non-prescription stuff), and some less-likely-to-be-used benefits.
About a year-and-a-half ago, I got a not-good cancer diagnosis. The doctors have been throwing pretty much everything they have at it. The insurance administrators have not kicked about anything that has been submitted as “medically necessary”, including expensive items like PET scans and an exotic chemotherapy technique (“isolated limb infusion”).

Am I getting the latest and best? My oncologist wants to hold off on immune therapy until the FDA approves an in-the-pipeline combination drug-therapy he thinks will be best for me. They are doing two studies of my type of cancer at the clinical center where I am being treated; he’s the contact for both of them.

The billing & payments administration has been rocky, but that is the case with Medigap policies as well.
So I’ve been satisfied with my choice.

You need to cost out what is covered and how much you pay in addition to your monthly premium. A higher premium may get you less out-of-pocket total, or just a wider choice of providers. If you’re considering something not “medically necessary”, like a facelift, Medicare Advantage may not be the option for you.

If your preferred providers, or a good network, is available on a Medicare Advantage plan in your area, you’ll definitely get a lot of bang for your buck.
Added to answer some of the OP’s questions:

Part A is hospitalization; Part B is medical services (like doctors). Medicare Advantage plans often have add-on options for additional dental, optical, and hearing services. The official (Federal government) Medicare site has ratings of plans, but the break-out is important; the items rated vary in importance.

12

There are Medicare Advantage plans that are PPOs, but they cost more than HMOs (& aren’t offered everywhere).

In my experience 2 of the biggest things beneficiaries have trouble understanding provider network and service areas. With a Medicare Advantage plan you have provider who’s specifically in-network with that plan; it’s not like a Medigap plan were you can use any provider who accepts Medicare. Most Medicare Advantage plans won’t cover out-of-network providers unless it’s either an emergency or the provider got prior approval from the plan before seeing the patient. Even for plans that do have out-of-network benefits the beneficiary will most likely end up paying more than they would if they used in in-network provider or just had Original Medicare.

As for the service are; Medicare Advantage plans (like Part-D Rx plans) have a defined geographic service (which my be an entire state, or only certain counties within a state). With Medigap plans you may be allowed to keep the same plan if you move out of the area you were living in when you original bought it. People do not realize this, and often find out for the first* time when they call in to do a change a address and get told the plan has to disenrol them effective the last day of the month (and yes I just had to have this conversation with some women’s power-of-attorney on Friday).

I would recommend going with Medigap and a stand alone Part-D plan if I wasn’t legally prohibited from doing due to not being a licenced insurance agent.

*This along with nearly everything else people claim they were never told about is in the Evidence of Coverage documents that few people bother to read.

13

The take on it from the health policy professors I know who study this stuff: Medicare Advantage is sometimes appealing and a good deal for younger, healthier Medicare recipients, but as you get older/sicker, the coverage of Part B + a Medigap policy becomes a better deal (and many Medicare Advantage providers do things to encourage older, sicker patients to get off their plans).

When I did an internship in a nationally-ranked cancer center, I did a lot of projects that were payer-specific and required me to do large searches of patient records. It was rare to find a patient who kept Medicare Advantage more than a year after their diagnosis (because of the open enrollment rules that limit when enrollees can switch). So it seems that Medicare recipients are generally agreeing with the assessment of the academics.

14

Looks like it’s been 6 years since the last post here. Has anything changed?

My spouse has the choice between a Medicare Advantage plan with zero monthly premium (and doctor in network) and a Medicare Supplement Plan G with $167 monthly premium. The Medicare Advantage plan seems like the obvious choice - am I missing something?

15

Your timing is excellent: see this thread for an exhaustive discussion on the current situation, from an expert.

16

Yes. The Advantage plans are an advantage only to stockholders and executives in the insurance company. You can die waiting for them to authorize treatment. There’s an adage—you get what you pay for. It applies here.

Read all of the thread by @JohnT. Excellent, clear explanation and advice. Also in that thread is a site for the SHIP in every state-a government agency that offers assistance in selecting the best plan. After you read all of @JohnT get in touch with yours. Your life might depend on it.

https://www.shiptacenter.org/

17

Glad y’all like the thread! Feel free to promote it elsewhere as well! :slight_smile: :slight_smile:

18

If I recall what my SHIP/SHIBA rep told me correctly, they also benefit the government. With someone like me who has Medicare A/B (with or without a Medicare Supplement plan), Medicare is the primary insurer and pays up front; with someone who has Medicare Advantage, the policy issuer is the primary insurer and Medicare picks up the cost on the back end. Since some (all?) private insurers are motivated to keep costs down, there are potential cost savings to the government as well.

But it’s worth it to have The Greatest Health Care System in the World™.

19

FWIW, my parents with with a Medicare Advantage plan, and have always seemed to be OK with it. No problems with claims or hassle, etc. I think it’s through Aetna.

The OP should do his/her own research. If you want a MedSupp plan, you have 6 months. The clock will be ticking.

20

A new report is out that Medicare Advantage plans deny approval to medically necessary procedures:

Repeated at:

Report is at:

https://oig.hhs.gov/oei/reports/OEI-09-18-00260.pdf