I’m a new agent & I want to know EVERYTHING about ALL of these plans before I even attempt to sell & service any plans. You are one of my favorite Medicare agents thank you so much for being honest & explaining these plans so well!
Yes. New agent here too. I initially struggled with why MA is better than supplement or vice versa. There are a handful of content creators that really frown upon MA plans. but at least in our area (St Louis) the MA market is very competitive with MOOPs
@@craigabt1808 thank you for watching! There are pockets of the country that are REALLY hard to ignore some Advantage plans. We love Supplement plans, but the fact is that many people cannot afford them and another group of people do not want them. Every situation is different. Thank you for watching!
The main con, which allows all of the "pros" is the hurdle of prior authorization. These advantage plans receive funding by the govt and they turn a profit by denying you care via this authorization process, not by being more efficient at delivering care. In fact they make a ton of money off these plans which is why they push them so hard. As a physician I can tell you multiple times per week I receive denials from advantage plans. Sometimes I'm successful in changing that decision but a fair amount of the time I'm not. This never occurs with traditional medicare. Additionally, if you do need a test/procedure/imaging study/etc this can be done the next day. With the advantage plans the authorization process can take weeks delaying care and prolonging suffering. If you can afford a medicare supplement it is almost always a better decision. The only time an advantage plan is likely better is if the financial burden of a supplement plan is too large and you assume you will never be significantly sick. The sad reality of anyone pushing these advantage plans is that they are paid everytime they convince someone to sign up for one. This is probably true of the gentleman in this video as well. So I caution everyone, buyer beware.
Appreciate you watching and adding your perspective. Would caution about making judgements like that. Our group does not push Advantage plans and we have several videos that outline how they really work. There are several cases against physicians committing fraud against Medicare because they know Original Medicare will pay. Extra, unnecessary tests and procedures are added to get more dollars. Would it be fair to say that you, as a physician, probably do this and people shouldn't trust physicians even though we know nothing about you except that you are a physician? Doesn't seem like a decent way to treat people. We would rather hope that you are ethical like the VAST majority of physicians we know trying to do right for your patients and not one of the bad apples that cheat the system for profit. We welcome all opinions. We agree with your assessment of how some Advantage plans have the prior authorization hurdles, can be difficult to work with, and deny care. Just careful with character judgements.
No character judgements were made. I didn't question your ethics or morals. Your comments did that for me. I was simply highlighting for the viewers the important fact that many people promoting these plans do so for profit. In contrast, you did make a character attack against me and imply I defraud Medicare. Based on what, I have no idea. Also, you seemed to make an argument in favor of Advantage plans as a way to prevent fraud. I assume then, you are not aware of the dozens of lawsuits against these plans by whistleblowers, the govt, etc. for improper coding regarding the level of health issues of their subscribers? So these plans, which were sold as being more efficient, are instead costing tax payers untold billions. Given you have never had the "pleasure" of arguing for weeks with one of these plans about a necessary treatment for your patient, only to be denied because of their own unique company policy, I would assume you would show some humility. Even worse yet, is having to be the person to explain to the patient why their treatment was denied and bearing the brunt of their anger, frustration, sadness and despair. This is an ever growing cause of physician burnout and something insurance agents never have to deal with. Instead, you choose to cast aspersions and change the focus of the debate, which is the fact that these plans have many drawbacks and are universally worst for most.
A lot of copy pastes happening, but it is important. In a different way, we do address the prior authorizations and denials with our clients who, in turn, are patients of providers like yourself. Our conversations, while difficult, do not compare in difficulty to yours as the physician counseling your patient in the high-stress environment of healthcare. The unfortunate part of this comment string is that I think we both agree on the crux of the issues. We both agree that prior authorizations and the managed care aspect of Advantage plans are a drawback to these plans and a matter to look at and make sure it improves, which from what we see and experience, is happening. Is it where it should be? No, but we, along with agents in this community are advocating for the same thing you are. Our whole point in the caution against character judgements was the implication made that we are pushing our clients into Advantage plans - at their detriment - for a higher 1st-year commission that comes with Advantage plans, which we disclose in this video and others. Our business model, just like your practice, would not be sustainable if we were pushing people into inappropriate plans. We do not accuse you of Medicare fraud. It is the exact opposite. It would be foolish of us to accuse you or any other provider of fraud solely based on the fact that you are a physician because we heard that there are physicians out there who do those practices. The way we phrased it, which is the downside of comments made through a keyboard, was meant to show how unfair it would be to make such a blanket statement with no information about how you run your practice or treat your patients. Same thing here. To assert that we are pushing people into Advantage plans, having never sat down and seen the at-times-hours long conversations we have with our clients about their health, finances, risk tolerance, and plans available to them prior to their decision, seems equally unfair. There are agencies out there who put people on a plan and hope to never speak to them again. We aren't that agency. And to your excellent point in your most recent comment, the additional hours of conversations and phone calls that we have with our clients and the insurance carriers to help and push where we can with those prior authorizations and denials - happens every day. When we see that you are a physician, our first thought and assumption is that you are amazing at what you do and are a help to your patients, NOT the fringe, worst-case scenario. Genuinely hope we can work together on these issues, not separate.
This is a great video. If you are looking for a Medicare Advantage Plan, which I am, this is the best most simple explanation on what these plans cover, and who would benefit from them. I for one, have found my answers to several questions that I had about them. Many of these videos are pushing more towards supplemental plans which pays higher commissions. I went ahead and subscribed to this channel. Thanks for the great info.
I think you have it backwards. Advantage Plans pay much higher commissions to brokers than Supplement Plans. That's been talked about on many UA-cam videos by brokers themselves.
The big thing y0u didn’t emphasize is that you need approvals for many treatments under Medicare advantage that you don’t have for supplements. I had prostate cancer and a supplement. I was able to get robotic prostatectomy whereas a friend who 6 months later came down with prostate cancer was told under his “advantage” plan that robotic surgery was experimental and not covered. He had many problems. Similarly, the local Medicare advantage plan in our area didn’t cover modern cataract surgery (phacoemulsification) until some 20 years after it came into existence. The “advantage” plan interprets the rule to cover what Medicare covers as prostate surgery is prostate surgery or cataract surgery is cataract surgery and they don’t consider if the surgery is modern or lower risk. Other than this issue, you gave a good and balanced talk that is important for people to know.
Thank you Alan! We released an updated Advantage vs Supplement video that, in a way, addresses your points a bit better. Doesn't give specifics like you have, but does address the Managed Care a bit better.
You need to add this to your video: "Trial Right Exception An exception: There is a trial period for people who try Medicare Advantage for the first time. If you decide to dis-enroll from the plan and go back to Original Medicare within the first 12 months of Medicare Advantage coverage, then you can return to your Medigap plan with no underwriting. After the 12 months is up, then you are subject to underwriting."
A few questions/comments: 1) Other than the few that will qualify for Part B premium reduction, do the folks that choose a “no cost or low cost” advantage plan still need to pay the $170/mo for Part B? Just for clarity of budgeting monthly premium costs for advantage plans, it would seem this should have been noted in this video. Some folks that hear about free or no or low cost advantage premiums may not properly understand that they will still need to budget this $170 monthly part B premium. It would seem that this should at least be added as a footnote in any advantage plan pro/con comparison. 2) It was noted that the hoops to jump through on managed care for an advantage plan are the same as we have had with our employer provided health coverage. True. However, it is likely that most of us may be healthier in our working years while employed and maybe did not mind jumping through such hoops while in generally better health. As we age, our health will likely deteriorate compared to our health while we were employed. As an example, a formerly relatively healthy retiree that is now older with deteriorating health that needs pre-authorization for a hip replacement or other procedure may encounter a more difficult experience with a Medicare advantage plan in which the insurance company is making final decisions on patient care, what the patient is approved for or not compared to our doctor making those decisions. It is understood that this would be part of the risk tolerance noted in this video. However, in a real life scenario as an elderly person in their latter years, it cannot be over emphasized how much of a problem this could be for someone having delays or denial of coverage due to their advantage plan that they thought would be so convenient compared to the less convenient a la carte option of original Medicare + supplemental + part D. If I was advising my mother, my wife, and other elderly family members that I love, these potential downsides of the advantage plan would have to be clearly emphasized in a strong way to make sure that they are aware of the potentially disastrous downsides. To be fair, the presenter of this video did mention similar information as relating to risk tolerance, but I believe “currently” healthier people signing up for Medicare might not be emphasizing enough as relating to these major risks of the advantage plan. Also, with the high potential of deteriorating health as we age, those on an advantage plan that want to change their mind and go back to a supplemental plan may not be approved by underwriting and therefore would be stuck with an advantage plan for the rest of their lives. I believe this painful potential end of life scenario should be painted in the minds of those approaching Medicare enrollment and are going to choose whether to go with original Medicare (+ medigap/supplemental plan + part D) or an advantage plan. This way, their eyes can be wide open to such risks involved with choosing the Medicare replacement (advantage plan) option in which it likely would be impossible to later switch back to a non-advantage plan (if after advantage trial period expires and can’t qualify with underwriting to get medigap/supplemental plan). 3) For someone on advantage plan In which their doctor recommends a new hip, surgery, or other procedure that may be denied during advantage insurance company’s preauthorization review, what are the rules governing appeals? Is there a guarantee that the appeals process will be successful? If not successful, and if the patient proceeds to do what the doctor recommends, wouldn’t the out-of-pocket expense be 100% rather than an affordable advantage copay? I understand some comments to what I am noting here may state that these are worst case scenarios that relate to risk tolerance. True. I would then ask if any of these worst case scenarios occurred, and our loved one on Medicare advantage would not be allowed to switch back to a supplement plan with original Medicare, how would that affect the quality of life and finances of our loved one at their advanced age? Wouldn’t this be catastrophic to their quality of life? This should be a major decision for anybody that is choosing between original Medicare and Medicare advantage when they are turning 65 years old or are otherwise signing up for Medicare for the first time. Maybe one of the most important decisions in one’s life. Human nature is to make decisions based on our current circumstances (currently relatively healthy as an example). For such a decision that likely would be hard to reverse later (or impossible to reverse depending on decision of supplemental plan underwriting), it would seem choosing between the advantage option and the non advantage option and the potential finality of such a decision that likely would affect the rest of a person’s life, that the likely potential “future deterioration of health” should be a major consideration when considering Medicare options. Although the non advantage plan option (orig Medicare + supplemental plan + pard D) would include higher premiums (with likely lower out of pocket costs for coinsurance/copays), the noted risks are the very risks that original Medicare with a supplemental plan would help alleviate. Just my 2 cents. Thx.
Hi @jvel7, first off, thank you for watching and taking the time to comment, especially a comment as thought out as this one. You're a strong advocate for Supplement plans, which is fantastic. Like most things in life, this decision isn't a one-size fits all, and there are so many variables in a person's life that go into this that make it impossible for us to recommend supplement plans 100% of the time. Hopefully we can still be friends :) I'll try to address the questions you have within your thoughts. 1) Yes, everyone on Medicare still has the Part B premium they will be responsible for with the exception of low income individuals on Medicaid. Part B premiums are part of Original Medicare. An individual cannot get an Advantage plan nor a Supplement plan without having Original Medicare. Whether someone chooses an Advantage plan or a Supplement plan, that individual will still have Part B premiums, which is why, if you remove what will be standard with both plans (Part B premiums), Advantage plans still own the pro over Supplement plans when it comes to premiums. We address this in several other videos as well, including a total financial risk estimate if one were to go with an Advantage vs a Supplement plan. Also, if we're being fair in a comparison between Advantage vs Supplement (which is a different video), Supplement plans come with at least one (and often 2) premium increases each year, so by the time you are in your 80s, you could be looking at several hundred dollars a month for the Supplement plan premiums alone, not to mention Part D premiums and if they have dental/vision. Add in the fact that in many parts of the country, that person is under the same rules of being unable to switch to a different supplement plan carrier without medical underwriting and this can cause a lot of pain. This shifts an individual's total risk with supplements much higher than with certain Advantage plans in certain areas of the country, but definitely not all areas of the country. So, can a person afford high fixed costs in the form of premiums? Or, is it better for that person to save money in the good years to cover their out of pocket max in the bad years? That's the decision people need to consider. 2) I couldn't find a question in your second bullet, but you're not wrong in your reasoning. Most of your points were covered with Cons 2, 3, and 5 in the video. Are there Advantage plans that are tremendously difficult to work with? Yes. Are there Advantage plans that have poor customer service and can make life miserable for the patient? Absolutely. Are ALL Advantage plan carriers this way? Absolutely not. This is why working with an agent who represents both supplement plans and advantage plans is important. This is also why working with and agent who represents several different carriers that offer supplement and/or advantage plans is important. If an agent is only offering 1 option through 1 carrier, that's a red flag. When we talk about what we would recommend for a spouse or parent, that's a tough one to make a universal decision unless you live in an area that does not have any Advantage plans available or does not have reputable, decent plans available. Supplement plans are not the best option for everyone. Advantage plans are not the best option for everyone. One of my parents is on a supplement plan and loves it. The other is on an advantage plan and loves it. 3) A lot of this is summed up above. Unfortunately, we place ill-will on all insurance companies. They exist to make a profit, absolutely, but not all carriers are evil and refusing to cover procedures. Again, another reason to work with a good agent who knows which plans offer a better experience. Back to the 1 or 2 supplement plan premium increases per year, we've seen individuals with $600-$700 per month in premium costs who can't switch to another Supplement carrier because of medical underwriting. So it's difficult for us to tell them to have $7,200 in premium costs a year when they could have an advantage plan at $0 in premium and a max out of pocket of $1,500 and Part D coverage, dental, vision, hearing, etc. I couldn't advise a parent living on a fixed income to do that. In fairness, this is a worst case scenario, but isn't that what we're both addressing at this point? Sincerely, thank you for your thoughts and insights. I hope I'm able to convey in this video and the others that we do how both Supplement plans and Advantage plans offer very strong coverages, just in radically different ways.
@@Theretirementnerds Your points are well taken. My main point was not that the supplement plans are the best for 'everyone'. Rather it is to emphasize the need for a wide eyed picture of the downsides to both options and to consider future potential or likely deterioration of health into the decision rather than just current health at age 65 when making such an important "rest of life" decision. For many, well after the decision is made (age 65 for most people), after deterioration of health is apparent in later years, and considering the generally confusing topic of Medicare and various options to consider when the decision is made, that many will wish they made a different decision. I agree it is important to have a well informed agent or broker that offers all types of plans (both original + medigap and also advantage plans). Someone that can take into consideration each person's individual situation, finances, priorities, and clearly explain the importance of their Medicare choice/decision as changing to a different plan later may be difficult or possibly impossible due to underwriting. Also, the agent should clearly emphasize the risks of both options (including potential worst case scenarios) to decrease the chance that the elderly person at the end of their life is wishing they would have known more about the potential pitfalls of their selected Medicare plan. Due to monthly premiums being higher for original Medicare + medigap compared to Medicare Advantage plans, and people generally making decisions based on short term/current finances and health status rather than a longer view, it seems the risks of original Medicare + medigap (cost/premiums) are more thoroughly covered than the risks (and sometimes catastrophic risks) of the lower monthly premium Medicare Advantage plans. This comment is meant to convey information that is readily available to a soon to be enrolled Medicare recipient when doing a Google/UA-cam search. Also, my concerns/comments would apply more to people that would be able to afford original Medicare + medigap + part D donut hole, etc. For people that do not have the financial wherewithal for such, and Medicare Advantage is their only option, then it is understood that they should get a good knowledgeable agent/broker that can help guide them into a higher rated Medicare Advantage plan for their local area and pray their insurance company is not too motivated to increase profits via denial of Dr recommend medical services.
@@jvel7 100% agree on all fronts. It is a huge decision for anyone approaching Medicare. One that should look at both short term and long term risks. Our hope and advice to everyone is to work with an agent you trust. Don't make your final decision based off a Google search or a UA-cam video, including ours. Get informed. Find an agent you trust. Work with him or her on a plan. You know your stuff! Appreciate you!
One additional point related to "risk". Risks related to costs, especially monthly premium, seem to be generally covered pretty well in the public information space. Would you agree with the following as relating to various types of risk related to Medicare plans? 1) Monthly Premiums. This would affect healthy or unhealthy individuals. Monthly premiums would be higher for those with regular Medicare + medigap and much lower for Medicare Advantage plans. 2) Premium increases. Premiums for all Medicare plans will likely go up in future, but risk of higher monthly increases may be higher for regular Medicare + medigap recipients and lower for Medicare Advantage. 3) Out of pocket costs. This would seem to affect mostly those on regular Medicare (without medigap), part D (donut hole), and also those on advantage plans. The healthier the individual, the lower the risk. However, for regular Medicare + medigap recipients, especially for Plan F or G medigap, out of pocket costs should remain low compared to Medicare Advantage. 4) Denial or delayed insurance approval of service/procedure. This would affect primarily Medicare Advantage plans. Higher rated plans may decrease risk, but not remove such risk. 5) Risks of insurance having final say in whether physician recommended medical services/procedures are approved via pre-authorization requirement. This is related to #4 above. This would affect only Medicare Advantage plans. 6) Desire to change plans which would require underwriting review/approval. Although could affect desire to change from medigap to different medigap plan, risks would be higher for Medicare Advantage recipients later desiring to change to regular Medicare + medigap plan.
Yes, in general, you're absolutely correct on how the various types of risk can play out with each of the options. Each of those numbers 1-6 carry different weight to them for each individual, so that individual has to decide what they are more comfortable taking on, both now and in the future. Very well summed up.
One clear disadvantage of medigap is the rapidly and continuously escalating annual premiums due to the massive costs from all the unhealthy people is crowd into the plans immediately at age 65. The "guaranteed insurability" feature is of no value if you have to drop the policy as you age because you can no longer afford the premiums. You are then "stuck" the same way a MA customer would be who may not qualify to switch from MA to a "medigap " program. The alternative "community" based programs also usually start out with higher premiums to begin with. Moral: There is no free lunch, just a reduced size "senior meal".
Thomas Vest, your statement makes a lot of sense. Unfortunately, many people with chronic health issues and unhealthy people, have signed up for supplemental plans, and they are submitting many claims because of this, therefore premiums every year are going up astronomically on these plans. That is why I'm keeping my Medicare Advantage Plan.
This is excellent! Another great resource for those who do not completely understand all the benefits and/or restrictions of a Medicare Advantage plan. Thanks.
Let’s assume that I have been on Medicare for several years - What happens if I have a supplement plan tied to original Medicare and during the annual re-enrollment period I want to switch to a different carrier? Will health underwriting be required or is it still guaranteed issue? Same question except - assume the carrier no longer want to continue to write business in future periods. Can I switch to another carrier on a guaranteed issue basis? Last question - the same scenario as the fist 2 questions - since most supplement policies in Florida do not adjust or “age up” over time, would I get grandfathered in on that provision with the other carriers carrier?
Hi Ron, In MOST states... no. If you try switching, you'll likely go through underwriting. There are 13 states with different rules around this. In MOST of these 13 states, you have windows to switch to an equal or lesser supplement plan, not up. So the HD G to regular G isn't guaranteed. In 2 states (NY & CT), there is year-round open enrollment for any supplement plan. VT, too, for 2 insurance companies, not all. Now, an insurance company in any of these states can make an exception to this. We most commonly see a carrier say we'll take an equal or lesser plan switch, but this is an exception, not a rule. For the second question, if a carrier goes bankrupt or withdraws and you are left without a plan at no fault of your own, you have guaranteed issue rights and can get a supplement plan without underwriting. For community rated plans, you'll go in at that year's rate, not a previous year's rate.
@@Theretirementnerds Excellent additional info. - thank you! So I guess this is why it makes sense to thoroughly scrutinize whichever company you select for the supplemental policy.
@ron8566 agents or agencies who have been around a while can help. They will be able to know trends of these plans which can mitigate some risk, however, a traditionally stable plan could have a bad year or two that could change things. Impossible to know the future, but we can try to hedge our bets.
Thank you for your great videos. Always excellent cotent! Have you done any analysis if federal retirees with an FEHB plan, let say an HMO, should pay Part B Premiums at age 65? Some folks out there conmenting/writing about this do insist federal retirees don't need Part B. Thank you, in advance, if you already have specific content about this.
Thank you for watching! We are writing that video to release hopefully soon. A member of our team is one of the best FEHB people around so working with her on that video. Appreciate you!
My employer offers medical insurance to retirees. None of my doctors were in the network thru the advantage plan offered by my employer. Most of the doctors in my county are not in the plan. So supplement plan is what I went with.
I have a question on deductibles for Original Medicare Part A. I understand that the deductible for Part A is $1556 in 2022, and has to be payed on each occurrence, maybe two or three times in that year. My question is, would I also have to pay these Part A deductibles with a Medicare Advantage Plan HMO, or are they covered in this Plan?
Great question. Advantage plans replace original Medicare, so that Part A deductible isn't applicable with an Advantage plan. What typically happens is that the Advantage plan has its own daily copays for days 1-5 as an example and then after day 5, the Advantage plan takes care of the rest. Those copays would go towards the Advantage plan Out of Pocket Maximum.
When on supplement and go to a advantage plan you have 12 months to decide to stay on the advantage plan or go back to supplement plan.only the fist year. I am one who is thinking on going on advantage plan and have been on supplement g plan.
Yes, if you went on Medicare at 65 and chose Advantage, you have 1 year to decide to switch to Supplement if you want. If you initially chose Supplement, you can switch to Advantage anytime during AEP each year. Switching back to supplement is usually not as easy.
Excellent video but I'd like to correct you on one thing I'm in New York state and to switch to a Supplement Plan I don't need underwriting anyone in New York can switch something I think you should mention in your video thank you
Hi Pat, I appreciate you watching and adding your insights. You are correct. There are 12 states with some form of rule on this with varying levels of flexibility around it. We went with what we said because of the majority of states not having those same rules. We will make another video touching on what you said though because it is important for people in those states to know.
@@Theretirementnerds How can we get more states to agree to do away with the underwriting? That seems to be the biggest obstacle to making your choice.Who knows what will happen in the future?
@@KM-vw6zx great question. There are a lot of risks to it from a dollars perspective, which is why those states have some of the highest supplement plan premiums in the country (double or triple rates in other states) so there are tradeoffs for sure.
Another great video. Thank you. I've commented on some of your other videos. My former employer (big aerospace) is eliminating our post retiree Medicare supplemental plan to a Advantage PPO plan with extended service area (all of US) and low max out of pocket ($800) and the ability of using out of network. All sounds great. My question is this: my doctors I use are out of their network. They say thats ok as long as they accept Medicare AND are willing to bill the advantage plan directly. Should I be concerned that they my doctor may charging a bit more that what the new advantage plan would allow and I could get hit with this out of pocket? Even though I may have hit my out of pocket max? Thank you so much for your videos. Very helpful!
When you say, "They say you can" is that your company insurance plan saying that, or your doctor? Those employer plans aren't as standard as regular Medicare plans, so your company plan administrator would know more specific details around those networks. What state are you in? Or, you can send me an email to erik@90daysfromretirement.com if you don't want that in a UA-cam comment.
We'd recommend working with an agent so will depend where you live. You can also work directly with the insurance company you want that has the supplement plan. A few variables go into that decision in most cases.
This was very good. I have no major health problems. Take no medications. But I cannot stand the idea of managed care. Hate it. So I will be getting a supplement plan. Just can't stand insurance companies making decisions about my health.
I've had a UHC advantage plan for 9 years and have saved thousands of dollars. The PPO allows me to go anywhere in the United States or outside the country. They have an extremely large network. A supplement plan cost you up front while an advantage plan you pay as you need it. My max out of pocket $3,900. Do the math and you can choose what you think is best. Risk tolerance is the key.
I have access to that plan as well, and I was pretty sure we were going to enroll in it next year. Then I think about when my mom was in and out of the hospital her final years (after a lifetime of near perfect health) , and realize how much harder it would have been on the family if we had to deal with specialty networks and the delays and hassle of prior authorizations. It's not worth even saving the 10s of thousands of dollars. Thank you, mom and dad.
@@marciabutler987 It's everybody's call and it's always based on your risk tolerance. I have discovered watching many of these UA-cam agents ONLY point out the most negative scenarios. I find that extremely biased. It's an unfair picture of managed health care. Most working people had such insurance while employed. These agents are primarily interested in obtaining new business. Millions of people have a Medicare Advantage plan. However, these agents never get any testimonials from individuals who will speak positively. I was an all lines agent years ago. I NEVER showed any bias towards any form of insurance. I only presented the choices and the options available. I allowed them to decide what served them best. Not me. Sure there are hundreds of "what ifs" but that's life. Odds are you'll never experience the worst. Those are the real facts. Insurance of any kind is really quite simple. Good luck.
Very informative but there is one question I did not see an answer to. I am looking at AARP United Healthcare Medicare Advantage Choice Plan 1 (PPO) for 2023 being offered in my area. Being a PPO, this plan has both in-network and out-of-network benefits but the plan requires even the out-of-network providers to accept Medicare. For in-network specialist, there is a $45 copay and 40% coinsurance for out-of-network specialist, with no referrals needed for both cases. The question I have is how the 40% coinsurance for out-of-network is calculated. Is it based on the total amount charged by the doctor or is it based on what UHC decides is the "approved" amount? Whatever the case may be, it is not likely that UHC will pay the 60% of the full amount charged by the doctor without making the "normal and customary charge" adjustment. If so, the out-of-network doctor will look to me to make up the amount unpaid by the insurance, so I end up paying 40% of the amount charged by the doctor plus the amount unpaid by the insurance which makes out-of-network specialist benefit to be 40% coinsurance listed in the brochure PLUS the amount unpaid by the insurance. OR, since even the out-of-network doctor is required to accept the Medicare as required by the plan, does UHC invoke "Medicare approved amount" and UHC pays 60% and I pay 40% of the Medicare approved amount? I have asked this question to UHC and a number of insurance agents and received different answers.
This will be outlined in Plan details and warrants a longer answer than I can currently type on my phone 🙂 When I can get in front of a computer, I can give you a more detailed answer.
@@jonathankim8157 We are back :) Got pretty crazy catching up from the weekend. This is a complicated question, which is why you are probably getting a few answers. First off, we always recommend finding a plan that has the doctor you want to see as in network. Going out of network on a PPO plan is tough, even with the higher coverage. Also, if you go to an out-of-network provider because of an emergency, this is still covered as in-network. Now, if you do decide to go out of network, that 40% will depend on that provider, specifically, does that provider participate with Medicare. This is participating with Medicare as a whole, not necessarily the insurance company. If yes, the provider participates with Medicare, just not that insurance company's network, then USUALLY, your 40% will be based on the Medicare allowed amount. If that doctor does not participate with Medicare, you could be balanced billed and your insurance carrier would likely take steps to try and convince the provider to agree to Medicare-allowed amounts. This is a common problem though. Some hospitals and providers will notice an out of network patient and try to take the opportunity to charge astronomical amounts. I am not sure if it fully answers your question or not, but as you can see, it gets complicated with some variables in the provider/facility.
@@Theretirementnerds Thanks and I agree this is complicated. The UHC plan requires I select out of network providers that accept Medicare and the Evidence of Coverage document states that UHC will pay the out of network provider using the Original Medicare rules. According to your answer, the provider will usually accept this Medicare allowed amount determined by UHC as payment in full because he accepts Medicare even though he is out of network and does not have a contract with UHC. I guess the safe thing is for me to verify with the provider that there will not be "balance billing" but, when you say "USUALLY", what exceptions are you referring to? Can the Medicare accepting but out of network provider charge a much higher amount than Medicare approved amount and insist on balance billing? Is there something in the contract the provider signed with Medicare that stipulates that he has to accept out of network Medicare Advantage PPO plan payment and my 40% coinsurance as payment in full?
@@jonathankim8157 precisely. 1. Provider or facility accepts the Medicare fee schedule as full payment (97%ish of providers), but is not in-network, can charge the Medicare fee schedule and the beneficiary (you) usually has a coinsurance, which would be higher than in-network. 2. The provider/facility are non-participating providers (2%ish of providers). They CAN accept Medicare fees as full payment if they want, but generally don't. They are allowed to charge 115% of the Medicare fees schedule. Certain states have this further restricted. 3. Opt out providers (1% of providers. 42% of this list are psychiatrists). They do not accept Medicare under any circumstances and their payment agreements are directly with the patient. When you schedule an appointment with the provider, they should tell you they have opted out and will not accept payments and you would cover all of this. As mentioned earlier, if it is emergency care, your plan will pick up out of network costs so you experience them as in-network. Clear as mud?
Medical doctors prefer supplemental plans over Advantage plans. Nobody really talks about this.....A md recommended a procedure for me then immediately asked "What kind of Medicare are you on?" ...I answered "I have Supplement G"....She said "Great- we can schedule this right now. I don't have to preauthorize anything.".......Advantage plans are more work for the office staff & give md's more headaches. Copays have to be taken care of. Procedures need to be preauthorized. Everything takes longet....If Medicare thinks you are too old or too sick for a procedure or feel you won't have a good outcome, they can deny a procedure & over ride your doctor's recommendation.
Thank you for watching and your insight. We cover it more here: ua-cam.com/video/yxXuGQYJ-ug/v-deo.html While your comment is mostly true, there are entire hospital systems in different parts of the country that won't take Original Medicare and only take their Advantage plans. Those are probably the only exception we can think of. Other than that, yes, most facilities and providers prefer working with Original Medicare and Supplements.
Is it ever the case that an Advantage Plan coming from inside a pension group such as Texas Retirement System for Texas teachers is better (when you have a health crisis) than other Advantage Plans? Or are they pretty much the same across the board?
Great question. Yes, there are times where it is stronger. It'll depend on the Advantage plans available in your area. We've seen instances where the plan offered by the group is stronger as well as times where a plan outside the group is stronger. I know it's not a definitive answer, but Medicare plans are so highly variable by even zip code.
Tricare is amazing and a lot of those with Tricare get a no-cost advantage plan for the perks they come with. Most carriers in our area have plans designed for Vererans.
Very helpful and informative video. Thank you for producing it. My wife is looking at potentially transitioning from her current employer insurance and getting onto Medicare for the first time. How far in advance do you need to apply to Medicare in order to avoid a gap in coverage from the transition from employer coverage to Medicare? For example, if she knew she was going to leave the job at the end of February, how far in advance should she be applying for the Medicare coverage that we decide to go with? Also, I had heard previously somewhere that once you chose to go on to a Medicare advantage plan, that you did not have the option to come back to traditional Plan B in combination with a supplemental plan. However, in listening to you, it seemed like that is not a hard rule, but rather a risk you take if you attempt it to come back to Medicare B after being on a Medicare advantage plan. The risk being that you must go through underwriting to make that transition and could potentially be denied. Am I getting that right?
All great questions. We always recommend getting g started 90 Days before you need Medicare. You can start closer than that, but starting 90 days before gives you plenty of lead time as you wait on the government. We recently released a video on switching from Advantage to Supplement that I think will answer that question better than typing on UA-cam: ua-cam.com/video/djuGeI829M4/v-deo.html
@@Theretirementnerds Good info. Just watched the video you referred me to. Also very helpful. Sometimes I cannot help but wonder 🤔 if the government sits around and tries to come up with convoluted systems to make things as difficult to understand as possible. I am not the sharpest knife in the drawer, but neither am I a butter knife. 😂 I can't imagine how many people must muddle their way through this stuff with no confidence or assurance that they are making an well-informed decision based upon a clear understanding of the options that they have. I appreciate your videos. Thank you.
@@rongoodman2844 it is very convoluted. We've wanted to do a satire video on how they came up with supplement plan nomenclature because it makes no sense.
We who are lower income have no choice but to use the advantage plan because simply cannot a ford 200 to300 $ a month for anything else. Not complicated.
Thank you so much for the detailed information about Medicare Advantage plan HMO and PPO and Medicare Supplemental plan. I was enlightened and understand more about it. Medicare is really confusing.
I loved this video so much I watched it twice before commenting. I had no clue my Doctor could just quit the plan mid year. About 10 years ago he had these posts all over in the waiting room and offices that if you were using medicare payment had to be made up front and the patient would need to send in their insurance claim to their provider. I didn't like that, but since I was only 53 I didn't worry about it. My last wellness visit in 2021 I noticed all the posts were gone so not sure what is up with that. I remember in my younger days talking about retiring, traveling and having a nice garden. Now I have no desire to travel. My daughter lives in Lafayette, La, about a 100 miles away and that road trip is not fun. As far as a garden I will just go to the farmers market on Saturday's and buy local supporting them. It seems if one can afford it that the supplement plan is the way to go from the beginning since it is no questions asked at that point. I find it odd that in my area which we have a lot of commercials about medicare plans they never ever advertise the supplement plan. It is always an Advantage plan. Not sure why it is like that, but it did get me thinking about it. Great Video!!!!! "Both times I watched it" lol
There are a lot of intricacies around it all, that's for sure. And your self-awareness around travel plans is unique :) There is more money in Advantage plans for insurance companies and agents than there is in Supplement plans, which is why you will see more advertisements around the Advantage side of things. The knee-jerk reaction when people hear there is more money in one thing or another is that it means something bad. In this case, it is not bad, it is just different. Unless an agent is pushing an Advantage plan to someone who would be better off with a Supplement plan to chase commissions... then that would be bad. We are working on a similar video for Supplement plans so stay tuned! Always appreciate your comments.
If you have a straight Medicare plan with a supplement you can go to any doctor that takes Medicare. There may be small co-pays but nothing close to $5000. The out of pocket cost if you get cancer could be great and could easily go on to the next year. If you get sick in November, you may not be better by January and the out of pocket costs start over. So you don't have the cost of a supplement or maybe $35 extra for vision and dental. Just don't get sick.
True. This conversation gets pretty complicated, but yes... in general Supplement plan out of pocket costs will be less if there is a bad year (or several). However, there are areas of the country where the Out of Pocket Max on an Advantage plan is $1,000 with $0 premiums, plus dental, vision, part d and others. So it all depends on where you live and the devil is in the details.
@@Theretirementnerds When you mention costs in “our area”, what area are you currently in please? Also, when you talk about areas of the country that have $1000 maximum out of pocket for an advantage plan and zero dollar premiums again what areas are you referring to?
@Patrick Manley we are in the Intermountain West. The cost averages we use are looking at Arizona, Colorado, Idaho, Nevada, and Utah. Certain areas in Nevada have some $1,000 - $1,500 MOOPs. Certain areas in California do as well.
It can be. We try to cover as many variables and situations as we can in this video. It gets much more manageable knowing individual circumstances and preferences.
I’m a new agent & I want to know EVERYTHING about ALL of these plans before I even attempt to sell & service any plans. You are one of my favorite Medicare agents thank you so much for being honest & explaining these plans so well!
Thank you for watching! There is a lot to unpack for sure!
Yes. New agent here too. I initially struggled with why MA is better than supplement or vice versa. There are a handful of content creators that really frown upon MA plans. but at least in our area (St Louis) the MA market is very competitive with MOOPs
@@craigabt1808 thank you for watching! There are pockets of the country that are REALLY hard to ignore some Advantage plans. We love Supplement plans, but the fact is that many people cannot afford them and another group of people do not want them. Every situation is different. Thank you for watching!
The main con, which allows all of the "pros" is the hurdle of prior authorization. These advantage plans receive funding by the govt and they turn a profit by denying you care via this authorization process, not by being more efficient at delivering care. In fact they make a ton of money off these plans which is why they push them so hard. As a physician I can tell you multiple times per week I receive denials from advantage plans. Sometimes I'm successful in changing that decision but a fair amount of the time I'm not. This never occurs with traditional medicare. Additionally, if you do need a test/procedure/imaging study/etc this can be done the next day. With the advantage plans the authorization process can take weeks delaying care and prolonging suffering. If you can afford a medicare supplement it is almost always a better decision. The only time an advantage plan is likely better is if the financial burden of a supplement plan is too large and you assume you will never be significantly sick. The sad reality of anyone pushing these advantage plans is that they are paid everytime they convince someone to sign up for one. This is probably true of the gentleman in this video as well. So I caution everyone, buyer beware.
Appreciate you watching and adding your perspective. Would caution about making judgements like that. Our group does not push Advantage plans and we have several videos that outline how they really work.
There are several cases against physicians committing fraud against Medicare because they know Original Medicare will pay. Extra, unnecessary tests and procedures are added to get more dollars. Would it be fair to say that you, as a physician, probably do this and people shouldn't trust physicians even though we know nothing about you except that you are a physician? Doesn't seem like a decent way to treat people.
We would rather hope that you are ethical like the VAST majority of physicians we know trying to do right for your patients and not one of the bad apples that cheat the system for profit.
We welcome all opinions. We agree with your assessment of how some Advantage plans have the prior authorization hurdles, can be difficult to work with, and deny care. Just careful with character judgements.
No character judgements were made. I didn't question your ethics or morals. Your comments did that for me. I was simply highlighting for the viewers the important fact that many people promoting these plans do so for profit. In contrast, you did make a character attack against me and imply I defraud Medicare. Based on what, I have no idea. Also, you seemed to make an argument in favor of Advantage plans as a way to prevent fraud. I assume then, you are not aware of the dozens of lawsuits against these plans by whistleblowers, the govt, etc. for improper coding regarding the level of health issues of their subscribers? So these plans, which were sold as being more efficient, are instead costing tax payers untold billions. Given you have never had the "pleasure" of arguing for weeks with one of these plans about a necessary treatment for your patient, only to be denied because of their own unique company policy, I would assume you would show some humility. Even worse yet, is having to be the person to explain to the patient why their treatment was denied and bearing the brunt of their anger, frustration, sadness and despair. This is an ever growing cause of physician burnout and something insurance agents never have to deal with. Instead, you choose to cast aspersions and change the focus of the debate, which is the fact that these plans have many drawbacks and are universally worst for most.
A lot of copy pastes happening, but it is important.
In a different way, we do address the prior authorizations and denials with our clients who, in turn, are patients of providers like yourself. Our conversations, while difficult, do not compare in difficulty to yours as the physician counseling your patient in the high-stress environment of healthcare. The unfortunate part of this comment string is that I think we both agree on the crux of the issues. We both agree that prior authorizations and the managed care aspect of Advantage plans are a drawback to these plans and a matter to look at and make sure it improves, which from what we see and experience, is happening. Is it where it should be? No, but we, along with agents in this community are advocating for the same thing you are.
Our whole point in the caution against character judgements was the implication made that we are pushing our clients into Advantage plans - at their detriment - for a higher 1st-year commission that comes with Advantage plans, which we disclose in this video and others. Our business model, just like your practice, would not be sustainable if we were pushing people into inappropriate plans.
We do not accuse you of Medicare fraud. It is the exact opposite. It would be foolish of us to accuse you or any other provider of fraud solely based on the fact that you are a physician because we heard that there are physicians out there who do those practices. The way we phrased it, which is the downside of comments made through a keyboard, was meant to show how unfair it would be to make such a blanket statement with no information about how you run your practice or treat your patients. Same thing here. To assert that we are pushing people into Advantage plans, having never sat down and seen the at-times-hours long conversations we have with our clients about their health, finances, risk tolerance, and plans available to them prior to their decision, seems equally unfair.
There are agencies out there who put people on a plan and hope to never speak to them again. We aren't that agency. And to your excellent point in your most recent comment, the additional hours of conversations and phone calls that we have with our clients and the insurance carriers to help and push where we can with those prior authorizations and denials - happens every day.
When we see that you are a physician, our first thought and assumption is that you are amazing at what you do and are a help to your patients, NOT the fringe, worst-case scenario.
Genuinely hope we can work together on these issues, not separate.
This is a great video. If you are looking for a Medicare Advantage Plan, which I am, this is the best most simple explanation on what these plans cover, and who would benefit from them. I for one, have found my answers to several questions that I had about them. Many of these videos are pushing more towards supplemental plans which pays higher commissions. I went ahead and subscribed to this channel. Thanks for the great info.
Thank you for watching and subscribing!
I think you have it backwards. Advantage Plans pay much higher commissions to brokers than Supplement Plans. That's been talked about on many UA-cam videos by brokers themselves.
Thank you for the information on Medicare advantage plan has really worked for me thank you and if you take it with medicad it becomes even better
Thank you for sharing your experience!
The big thing y0u didn’t emphasize is that you need approvals for many treatments under Medicare advantage that you don’t have for supplements. I had prostate cancer and a supplement. I was able to get robotic prostatectomy whereas a friend who 6 months later came down with prostate cancer was told under his “advantage” plan that robotic surgery was experimental and not covered. He had many problems. Similarly, the local Medicare advantage plan in our area didn’t cover modern cataract surgery (phacoemulsification) until some 20 years after it came into existence. The “advantage” plan interprets the rule to cover what Medicare covers as prostate surgery is prostate surgery or cataract surgery is cataract surgery and they don’t consider if the surgery is modern or lower risk.
Other than this issue, you gave a good and balanced talk that is important for people to know.
Thank you Alan! We released an updated Advantage vs Supplement video that, in a way, addresses your points a bit better. Doesn't give specifics like you have, but does address the Managed Care a bit better.
You need to add this to your video: "Trial Right Exception
An exception: There is a trial period for people who try Medicare Advantage for the first time. If you decide to dis-enroll from the plan and go back to Original Medicare within the first 12 months of Medicare Advantage coverage, then you can return to your Medigap plan with no underwriting. After the 12 months is up, then you are subject to underwriting."
Excellent point!
A few questions/comments:
1) Other than the few that will qualify for Part B premium reduction, do the folks that choose a “no cost or low cost” advantage plan still need to pay the $170/mo for Part B? Just for clarity of budgeting monthly premium costs for advantage plans, it would seem this should have been noted in this video. Some folks that hear about free or no or low cost advantage premiums may not properly understand that they will still need to budget this $170 monthly part B premium. It would seem that this should at least be added as a footnote in any advantage plan pro/con comparison.
2) It was noted that the hoops to jump through on managed care for an advantage plan are the same as we have had with our employer provided health coverage. True. However, it is likely that most of us may be healthier in our working years while employed and maybe did not mind jumping through such hoops while in generally better health. As we age, our health will likely deteriorate compared to our health while we were employed. As an example, a formerly relatively healthy retiree that is now older with deteriorating health that needs pre-authorization for a hip replacement or other procedure may encounter a more difficult experience with a Medicare advantage plan in which the insurance company is making final decisions on patient care, what the patient is approved for or not compared to our doctor making those decisions. It is understood that this would be part of the risk tolerance noted in this video. However, in a real life scenario as an elderly person in their latter years, it cannot be over emphasized how much of a problem this could be for someone having delays or denial of coverage due to their advantage plan that they thought would be so convenient compared to the less convenient a la carte option of original Medicare + supplemental + part D. If I was advising my mother, my wife, and other elderly family members that I love, these potential downsides of the advantage plan would have to be clearly emphasized in a strong way to make sure that they are aware of the potentially disastrous downsides. To be fair, the presenter of this video did mention similar information as relating to risk tolerance, but I believe “currently” healthier people signing up for Medicare might not be emphasizing enough as relating to these major risks of the advantage plan.
Also, with the high potential of deteriorating health as we age, those on an advantage plan that want to change their mind and go back to a supplemental plan may not be approved by underwriting and therefore would be stuck with an advantage plan for the rest of their lives. I believe this painful potential end of life scenario should be painted in the minds of those approaching Medicare enrollment and are going to choose whether to go with original Medicare (+ medigap/supplemental plan + part D) or an advantage plan. This way, their eyes can be wide open to such risks involved with choosing the Medicare replacement (advantage plan) option in which it likely would be impossible to later switch back to a non-advantage plan (if after advantage trial period expires and can’t qualify with underwriting to get medigap/supplemental plan).
3) For someone on advantage plan In which their doctor recommends a new hip, surgery, or other procedure that may be denied during advantage insurance company’s preauthorization review, what are the rules governing appeals? Is there a guarantee that the appeals process will be successful? If not successful, and if the patient proceeds to do what the doctor recommends, wouldn’t the out-of-pocket expense be 100% rather than an affordable advantage copay?
I understand some comments to what I am noting here may state that these are worst case scenarios that relate to risk tolerance. True. I would then ask if any of these worst case scenarios occurred, and our loved one on Medicare advantage would not be allowed to switch back to a supplement plan with original Medicare, how would that affect the quality of life and finances of our loved one at their advanced age? Wouldn’t this be catastrophic to their quality of life? This should be a major decision for anybody that is choosing between original Medicare and Medicare advantage when they are turning 65 years old or are otherwise signing up for Medicare for the first time. Maybe one of the most important decisions in one’s life.
Human nature is to make decisions based on our current circumstances (currently relatively healthy as an example). For such a decision that likely would be hard to reverse later (or impossible to reverse depending on decision of supplemental plan underwriting), it would seem choosing between the advantage option and the non advantage option and the potential finality of such a decision that likely would affect the rest of a person’s life, that the likely potential “future deterioration of health” should be a major consideration when considering Medicare options.
Although the non advantage plan option (orig Medicare + supplemental plan + pard D) would include higher premiums (with likely lower out of pocket costs for coinsurance/copays), the noted risks are the very risks that original Medicare with a supplemental plan would help alleviate.
Just my 2 cents.
Thx.
Hi @jvel7, first off, thank you for watching and taking the time to comment, especially a comment as thought out as this one. You're a strong advocate for Supplement plans, which is fantastic. Like most things in life, this decision isn't a one-size fits all, and there are so many variables in a person's life that go into this that make it impossible for us to recommend supplement plans 100% of the time. Hopefully we can still be friends :)
I'll try to address the questions you have within your thoughts.
1) Yes, everyone on Medicare still has the Part B premium they will be responsible for with the exception of low income individuals on Medicaid. Part B premiums are part of Original Medicare. An individual cannot get an Advantage plan nor a Supplement plan without having Original Medicare. Whether someone chooses an Advantage plan or a Supplement plan, that individual will still have Part B premiums, which is why, if you remove what will be standard with both plans (Part B premiums), Advantage plans still own the pro over Supplement plans when it comes to premiums. We address this in several other videos as well, including a total financial risk estimate if one were to go with an Advantage vs a Supplement plan.
Also, if we're being fair in a comparison between Advantage vs Supplement (which is a different video), Supplement plans come with at least one (and often 2) premium increases each year, so by the time you are in your 80s, you could be looking at several hundred dollars a month for the Supplement plan premiums alone, not to mention Part D premiums and if they have dental/vision. Add in the fact that in many parts of the country, that person is under the same rules of being unable to switch to a different supplement plan carrier without medical underwriting and this can cause a lot of pain. This shifts an individual's total risk with supplements much higher than with certain Advantage plans in certain areas of the country, but definitely not all areas of the country.
So, can a person afford high fixed costs in the form of premiums? Or, is it better for that person to save money in the good years to cover their out of pocket max in the bad years? That's the decision people need to consider.
2) I couldn't find a question in your second bullet, but you're not wrong in your reasoning. Most of your points were covered with Cons 2, 3, and 5 in the video. Are there Advantage plans that are tremendously difficult to work with? Yes. Are there Advantage plans that have poor customer service and can make life miserable for the patient? Absolutely. Are ALL Advantage plan carriers this way? Absolutely not.
This is why working with an agent who represents both supplement plans and advantage plans is important. This is also why working with and agent who represents several different carriers that offer supplement and/or advantage plans is important. If an agent is only offering 1 option through 1 carrier, that's a red flag.
When we talk about what we would recommend for a spouse or parent, that's a tough one to make a universal decision unless you live in an area that does not have any Advantage plans available or does not have reputable, decent plans available. Supplement plans are not the best option for everyone. Advantage plans are not the best option for everyone. One of my parents is on a supplement plan and loves it. The other is on an advantage plan and loves it.
3) A lot of this is summed up above. Unfortunately, we place ill-will on all insurance companies. They exist to make a profit, absolutely, but not all carriers are evil and refusing to cover procedures. Again, another reason to work with a good agent who knows which plans offer a better experience.
Back to the 1 or 2 supplement plan premium increases per year, we've seen individuals with $600-$700 per month in premium costs who can't switch to another Supplement carrier because of medical underwriting. So it's difficult for us to tell them to have $7,200 in premium costs a year when they could have an advantage plan at $0 in premium and a max out of pocket of $1,500 and Part D coverage, dental, vision, hearing, etc. I couldn't advise a parent living on a fixed income to do that.
In fairness, this is a worst case scenario, but isn't that what we're both addressing at this point?
Sincerely, thank you for your thoughts and insights. I hope I'm able to convey in this video and the others that we do how both Supplement plans and Advantage plans offer very strong coverages, just in radically different ways.
@@Theretirementnerds Your points are well taken.
My main point was not that the supplement plans are the best for 'everyone'. Rather it is to emphasize the need for a wide eyed picture of the downsides to both options and to consider future potential or likely deterioration of health into the decision rather than just current health at age 65 when making such an important "rest of life" decision.
For many, well after the decision is made (age 65 for most people), after deterioration of health is apparent in later years, and considering the generally confusing topic of Medicare and various options to consider when the decision is made, that many will wish they made a different decision.
I agree it is important to have a well informed agent or broker that offers all types of plans (both original + medigap and also advantage plans). Someone that can take into consideration each person's individual situation, finances, priorities, and clearly explain the importance of their Medicare choice/decision as changing to a different plan later may be difficult or possibly impossible due to underwriting.
Also, the agent should clearly emphasize the risks of both options (including potential worst case scenarios) to decrease the chance that the elderly person at the end of their life is wishing they would have known more about the potential pitfalls of their selected Medicare plan.
Due to monthly premiums being higher for original Medicare + medigap compared to Medicare Advantage plans, and people generally making decisions based on short term/current finances and health status rather than a longer view, it seems the risks of original Medicare + medigap (cost/premiums) are more thoroughly covered than the risks (and sometimes catastrophic risks) of the lower monthly premium Medicare Advantage plans. This comment is meant to convey information that is readily available to a soon to be enrolled Medicare recipient when doing a Google/UA-cam search.
Also, my concerns/comments would apply more to people that would be able to afford original Medicare + medigap + part D donut hole, etc. For people that do not have the financial wherewithal for such, and Medicare Advantage is their only option, then it is understood that they should get a good knowledgeable agent/broker that can help guide them into a higher rated Medicare Advantage plan for their local area and pray their insurance company is not too motivated to increase profits via denial of Dr recommend medical services.
@@jvel7 100% agree on all fronts. It is a huge decision for anyone approaching Medicare. One that should look at both short term and long term risks.
Our hope and advice to everyone is to work with an agent you trust. Don't make your final decision based off a Google search or a UA-cam video, including ours. Get informed. Find an agent you trust. Work with him or her on a plan.
You know your stuff! Appreciate you!
One additional point related to "risk".
Risks related to costs, especially monthly premium, seem to be generally covered pretty well in the public information space.
Would you agree with the following as relating to various types of risk related to Medicare plans?
1) Monthly Premiums. This would affect healthy or unhealthy individuals. Monthly premiums would be higher for those with regular Medicare + medigap and much lower for Medicare Advantage plans.
2) Premium increases. Premiums for all Medicare plans will likely go up in future, but risk of higher monthly increases may be higher for regular Medicare + medigap recipients and lower for Medicare Advantage.
3) Out of pocket costs. This would seem to affect mostly those on regular Medicare (without medigap), part D (donut hole), and also those on advantage plans. The healthier the individual, the lower the risk. However, for regular Medicare + medigap recipients, especially for Plan F or G medigap, out of pocket costs should remain low compared to Medicare Advantage.
4) Denial or delayed insurance approval of service/procedure. This would affect primarily Medicare Advantage plans. Higher rated plans may decrease risk, but not remove such risk.
5) Risks of insurance having final say in whether physician recommended medical services/procedures are approved via pre-authorization requirement. This is related to #4 above. This would affect only Medicare Advantage plans.
6) Desire to change plans which would require underwriting review/approval. Although could affect desire to change from medigap to different medigap plan, risks would be higher for Medicare Advantage recipients later desiring to change to regular Medicare + medigap plan.
Yes, in general, you're absolutely correct on how the various types of risk can play out with each of the options. Each of those numbers 1-6 carry different weight to them for each individual, so that individual has to decide what they are more comfortable taking on, both now and in the future.
Very well summed up.
One clear disadvantage of medigap is the rapidly and continuously escalating annual premiums due to the massive costs from all the unhealthy people is crowd into the plans immediately at age 65. The "guaranteed insurability" feature is of no value if you have to drop the policy as you age because you can no longer afford the premiums. You are then "stuck" the same way a MA customer would be who may not qualify to switch from MA to a "medigap " program. The alternative "community" based programs also usually start out with higher premiums to begin with. Moral: There is no free lunch, just a reduced size "senior meal".
Your comment is sad, but true. We are releasing a video that goes over this exact thing tomorrow.
Thomas Vest, your statement makes a lot of sense. Unfortunately, many people with chronic health issues and unhealthy people, have signed up for supplemental plans, and they are submitting many claims because of this, therefore premiums every year are going up astronomically on these plans. That is why I'm keeping my Medicare Advantage Plan.
Thank you. Great video
Thank you!
Participation is not just up to the doctors; Insurance companies can also drop providers mid year.
100%
Thank you for Explain reply clear .
Thank you so much for watching!
Excellent video!
Thank you Kathy!
Thank you for this video, it was very helpful as Medicare is very confusing!!!
Thank you Tina!
This is excellent! Another great resource for those who do not completely understand all the benefits and/or restrictions of a Medicare Advantage plan. Thanks.
Thank you Sherry!
Let’s assume that I have been on Medicare for several years - What happens if I have a supplement plan tied to original Medicare and during the annual re-enrollment period I want to switch to a different carrier? Will health underwriting be required or is it still guaranteed issue? Same question except - assume the carrier no longer want to continue to write business in future periods. Can I switch to another carrier on a guaranteed issue basis? Last question - the same scenario as the fist 2 questions - since most supplement policies in Florida do not adjust or “age up” over time, would I get grandfathered in on that provision with the other carriers carrier?
Hi Ron,
In MOST states... no. If you try switching, you'll likely go through underwriting.
There are 13 states with different rules around this. In MOST of these 13 states, you have windows to switch to an equal or lesser supplement plan, not up. So the HD G to regular G isn't guaranteed.
In 2 states (NY & CT), there is year-round open enrollment for any supplement plan. VT, too, for 2 insurance companies, not all.
Now, an insurance company in any of these states can make an exception to this. We most commonly see a carrier say we'll take an equal or lesser plan switch, but this is an exception, not a rule.
For the second question, if a carrier goes bankrupt or withdraws and you are left without a plan at no fault of your own, you have guaranteed issue rights and can get a supplement plan without underwriting.
For community rated plans, you'll go in at that year's rate, not a previous year's rate.
@@Theretirementnerds Excellent additional info. - thank you! So I guess this is why it makes sense to thoroughly scrutinize whichever company you select for the supplemental policy.
@ron8566 agents or agencies who have been around a while can help. They will be able to know trends of these plans which can mitigate some risk, however, a traditionally stable plan could have a bad year or two that could change things. Impossible to know the future, but we can try to hedge our bets.
Great, thorough video. Thanks! I wish you discussed IRMA a bit.
Thank you for watching! You may like this on on IRMAA
ua-cam.com/video/7Ttzbrl3lIU/v-deo.html
Thank you for your great videos. Always excellent cotent! Have you done any analysis if federal retirees with an FEHB plan, let say an HMO, should pay Part B Premiums at age 65? Some folks out there conmenting/writing about this do insist federal retirees don't need Part B. Thank you, in advance, if you already have specific content about this.
Thank you for watching! We are writing that video to release hopefully soon. A member of our team is one of the best FEHB people around so working with her on that video. Appreciate you!
Outstanding presentation.
Thank you John! We appreciate you watching and taking the time to leave such a nice comment.
My employer offers medical insurance to retirees. None of my doctors were in the network thru the advantage plan offered by my employer. Most of the doctors in my county are not in the plan. So supplement plan is what I went with.
Sounds like you made an excellent decision. Provider availability is very important. Thank you for sharing your experience.
I have a question on deductibles for Original Medicare Part A. I understand that the deductible for Part A is $1556 in 2022, and has to be payed on each occurrence, maybe two or three times in that year. My question is, would I also have to pay these Part A deductibles with a Medicare Advantage Plan HMO, or are they covered in this Plan?
Great question. Advantage plans replace original Medicare, so that Part A deductible isn't applicable with an Advantage plan. What typically happens is that the Advantage plan has its own daily copays for days 1-5 as an example and then after day 5, the Advantage plan takes care of the rest. Those copays would go towards the Advantage plan Out of Pocket Maximum.
@@Theretirementnerds This gets better in making my decision. Thanks again.
@@EightyDeuce-x1d of course!
When on supplement and go to a advantage plan you have 12 months to decide to stay on the advantage plan or go back to supplement plan.only the fist year. I am one who is thinking on going on advantage plan and have been on supplement g plan.
Yes, if you went on Medicare at 65 and chose Advantage, you have 1 year to decide to switch to Supplement if you want.
If you initially chose Supplement, you can switch to Advantage anytime during AEP each year. Switching back to supplement is usually not as easy.
Awesome information! Very detailed and explained in a simple way. Thank you!!!!!!!!!
Thank you for watching Jodie!
Excellent video but I'd like to correct you on one thing I'm in New York state and to switch to a Supplement Plan I don't need underwriting anyone in New York can switch something I think you should mention in your video thank you
Hi Pat, I appreciate you watching and adding your insights.
You are correct. There are 12 states with some form of rule on this with varying levels of flexibility around it. We went with what we said because of the majority of states not having those same rules. We will make another video touching on what you said though because it is important for people in those states to know.
@@Theretirementnerds How can we get more states to agree to do away with the underwriting? That seems to be the biggest obstacle to making your choice.Who knows what will happen in the future?
@@KM-vw6zx great question. There are a lot of risks to it from a dollars perspective, which is why those states have some of the highest supplement plan premiums in the country (double or triple rates in other states) so there are tradeoffs for sure.
Took a while, but finally got this video out for you Pat. Thank you for your insight!
ua-cam.com/video/djuGeI829M4/v-deo.html
Another great video. Thank you. I've commented on some of your other videos. My former employer (big aerospace) is eliminating our post retiree Medicare supplemental plan to a Advantage PPO plan with extended service area (all of US) and low max out of pocket ($800) and the ability of using out of network. All sounds great. My question is this: my doctors I use are out of their network. They say thats ok as long as they accept Medicare AND are willing to bill the advantage plan directly. Should I be concerned that they my doctor may charging a bit more that what the new advantage plan would allow and I could get hit with this out of pocket? Even though I may have hit my out of pocket max? Thank you so much for your videos. Very helpful!
When you say, "They say you can" is that your company insurance plan saying that, or your doctor? Those employer plans aren't as standard as regular Medicare plans, so your company plan administrator would know more specific details around those networks. What state are you in? Or, you can send me an email to erik@90daysfromretirement.com if you don't want that in a UA-cam comment.
@@TheretirementnerdsI’ll email uou
Who do I call to change from Adv. To Supplement?
We'd recommend working with an agent so will depend where you live. You can also work directly with the insurance company you want that has the supplement plan. A few variables go into that decision in most cases.
This was very good. I have no major health problems. Take no medications. But I cannot stand the idea of managed care. Hate it. So I will be getting a supplement plan. Just can't stand insurance companies making decisions about my health.
100% valid reason to go supplement. Thank you for watching!
I've had a UHC advantage plan for 9 years and have saved thousands of dollars. The PPO allows me to go anywhere in the United States or outside the country. They have an extremely large network. A supplement plan cost you up front while an advantage plan you pay as you need it. My max out of pocket $3,900. Do the math and you can choose what you think is best. Risk tolerance is the key.
Very well put David. It's all about risk tolerance.
I have access to that plan as well, and I was pretty sure we were going to enroll in it next year. Then I think about when my mom was in and out of the hospital her final years (after a lifetime of near perfect health) , and realize how much harder it would have been on the family if we had to deal with specialty networks and the delays and hassle of prior authorizations. It's not worth even saving the 10s of thousands of dollars. Thank you, mom and dad.
@@marciabutler987 It's everybody's call and it's always based on your risk tolerance. I have discovered watching many of these UA-cam agents ONLY point out the most negative scenarios. I find that extremely biased. It's an unfair picture of managed health care. Most working people had such insurance while employed. These agents are primarily interested in obtaining new business. Millions of people have a Medicare Advantage plan. However, these agents never get any testimonials from individuals who will speak positively. I was an all lines agent years ago. I NEVER showed any bias towards any form of insurance. I only presented the choices and the options available. I allowed them to decide what served them best. Not me. Sure there are hundreds of "what ifs" but that's life. Odds are you'll never experience the worst. Those are the real facts. Insurance of any kind is really quite simple. Good luck.
Very informative but there is one question I did not see an answer to. I am looking at AARP United Healthcare Medicare Advantage Choice Plan 1 (PPO) for 2023 being offered in my area. Being a PPO, this plan has both in-network and out-of-network benefits but the plan requires even the out-of-network providers to accept Medicare. For in-network specialist, there is a $45 copay and 40% coinsurance for out-of-network specialist, with no referrals needed for both cases. The question I have is how the 40% coinsurance for out-of-network is calculated. Is it based on the total amount charged by the doctor or is it based on what UHC decides is the "approved" amount? Whatever the case may be, it is not likely that UHC will pay the 60% of the full amount charged by the doctor without making the "normal and customary charge" adjustment. If so, the out-of-network doctor will look to me to make up the amount unpaid by the insurance, so I end up paying 40% of the amount charged by the doctor plus the amount unpaid by the insurance which makes out-of-network specialist benefit to be 40% coinsurance listed in the brochure PLUS the amount unpaid by the insurance. OR, since even the out-of-network doctor is required to accept the Medicare as required by the plan, does UHC invoke "Medicare approved amount" and UHC pays 60% and I pay 40% of the Medicare approved amount? I have asked this question to UHC and a number of insurance agents and received different answers.
This will be outlined in Plan details and warrants a longer answer than I can currently type on my phone 🙂 When I can get in front of a computer, I can give you a more detailed answer.
@@Theretirementnerds OK, thanks. I hope you can get in front of your computer pretty soon. 🙂
@@jonathankim8157 We are back :) Got pretty crazy catching up from the weekend.
This is a complicated question, which is why you are probably getting a few answers.
First off, we always recommend finding a plan that has the doctor you want to see as in network. Going out of network on a PPO plan is tough, even with the higher coverage.
Also, if you go to an out-of-network provider because of an emergency, this is still covered as in-network.
Now, if you do decide to go out of network, that 40% will depend on that provider, specifically, does that provider participate with Medicare. This is participating with Medicare as a whole, not necessarily the insurance company.
If yes, the provider participates with Medicare, just not that insurance company's network, then USUALLY, your 40% will be based on the Medicare allowed amount. If that doctor does not participate with Medicare, you could be balanced billed and your insurance carrier would likely take steps to try and convince the provider to agree to Medicare-allowed amounts.
This is a common problem though. Some hospitals and providers will notice an out of network patient and try to take the opportunity to charge astronomical amounts.
I am not sure if it fully answers your question or not, but as you can see, it gets complicated with some variables in the provider/facility.
@@Theretirementnerds Thanks and I agree this is complicated. The UHC plan requires I select out of network providers that accept Medicare and the Evidence of Coverage document states that UHC will pay the out of network provider using the Original Medicare rules. According to your answer, the provider will usually accept this Medicare allowed amount determined by UHC as payment in full because he accepts Medicare even though he is out of network and does not have a contract with UHC. I guess the safe thing is for me to verify with the provider that there will not be "balance billing" but, when you say "USUALLY", what exceptions are you referring to? Can the Medicare accepting but out of network provider charge a much higher amount than Medicare approved amount and insist on balance billing? Is there something in the contract the provider signed with Medicare that stipulates that he has to accept out of network Medicare Advantage PPO plan payment and my 40% coinsurance as payment in full?
@@jonathankim8157 precisely.
1. Provider or facility accepts the Medicare fee schedule as full payment (97%ish of providers), but is not in-network, can charge the Medicare fee schedule and the beneficiary (you) usually has a coinsurance, which would be higher than in-network.
2. The provider/facility are non-participating providers (2%ish of providers). They CAN accept Medicare fees as full payment if they want, but generally don't. They are allowed to charge 115% of the Medicare fees schedule. Certain states have this further restricted.
3. Opt out providers (1% of providers. 42% of this list are psychiatrists). They do not accept Medicare under any circumstances and their payment agreements are directly with the patient. When you schedule an appointment with the provider, they should tell you they have opted out and will not accept payments and you would cover all of this.
As mentioned earlier, if it is emergency care, your plan will pick up out of network costs so you experience them as in-network.
Clear as mud?
Nice vids
Thank you!
@@Theretirementnerds The dedication to reply to everyone is impressive. Good luck to ya 👍🏻
@@GotoyourhomeBall We don't quite reply to everyone, but we try. With a name like GotoyourhomeBall, we couldn't ignore that one :)
Very informative! Thank you for sharing your knowledge.
Thank you Heidi!
This is fantastically helpful! Thank you!
Thank you for watching Marielle and a huge thank you for commenting with such kind words!
Medical doctors prefer supplemental plans over Advantage plans. Nobody really talks about this.....A md recommended a procedure for me then immediately asked "What kind of Medicare are you on?" ...I answered "I have Supplement G"....She said "Great- we can schedule this right now. I don't have to preauthorize anything.".......Advantage plans are more work for the office staff & give md's more headaches. Copays have to be taken care of. Procedures need to be preauthorized. Everything takes longet....If Medicare thinks you are too old or too sick for a procedure or feel you won't have a good outcome, they can deny a procedure & over ride your doctor's recommendation.
Thank you for watching and your insight. We cover it more here: ua-cam.com/video/yxXuGQYJ-ug/v-deo.html
While your comment is mostly true, there are entire hospital systems in different parts of the country that won't take Original Medicare and only take their Advantage plans. Those are probably the only exception we can think of. Other than that, yes, most facilities and providers prefer working with Original Medicare and Supplements.
You’re talking about Kaiser Permanente?
Is it ever the case that an Advantage Plan coming from inside a pension group such as Texas Retirement System for Texas teachers is better (when you have a health crisis) than other Advantage Plans? Or are they pretty much the same across the board?
Great question. Yes, there are times where it is stronger.
It'll depend on the Advantage plans available in your area. We've seen instances where the plan offered by the group is stronger as well as times where a plan outside the group is stronger.
I know it's not a definitive answer, but Medicare plans are so highly variable by even zip code.
What about Tri Care / Medicare or Advantage Plan?
Tricare is amazing and a lot of those with Tricare get a no-cost advantage plan for the perks they come with. Most carriers in our area have plans designed for Vererans.
Very helpful and informative video. Thank you for producing it. My wife is looking at potentially transitioning from her current employer insurance and getting onto Medicare for the first time. How far in advance do you need to apply to Medicare in order to avoid a gap in coverage from the transition from employer coverage to Medicare? For example, if she knew she was going to leave the job at the end of February, how far in advance should she be applying for the Medicare coverage that we decide to go with? Also, I had heard previously somewhere that once you chose to go on to a Medicare advantage plan, that you did not have the option to come back to traditional Plan B in combination with a supplemental plan. However, in listening to you, it seemed like that is not a hard rule, but rather a risk you take if you attempt it to come back to Medicare B after being on a Medicare advantage plan. The risk being that you must go through underwriting to make that transition and could potentially be denied. Am I getting that right?
All great questions. We always recommend getting g started 90 Days before you need Medicare. You can start closer than that, but starting 90 days before gives you plenty of lead time as you wait on the government.
We recently released a video on switching from Advantage to Supplement that I think will answer that question better than typing on UA-cam:
ua-cam.com/video/djuGeI829M4/v-deo.html
@@Theretirementnerds Good info. Just watched the video you referred me to. Also very helpful. Sometimes I cannot help but wonder 🤔 if the government sits around and tries to come up with convoluted systems to make things as difficult to understand as possible. I am not the sharpest knife in the drawer, but neither am I a butter knife. 😂 I can't imagine how many people must muddle their way through this stuff with no confidence or assurance that they are making an well-informed decision based upon a clear understanding of the options that they have. I appreciate your videos. Thank you.
@@rongoodman2844 it is very convoluted. We've wanted to do a satire video on how they came up with supplement plan nomenclature because it makes no sense.
@@Theretirementnerds Indeed, a very fertile field for satirical humor.
This is so helpful. You explained it really clear!
Thank you Sidney!
The word free is one of the ten most persuasive in the English language.
It is a very persuasive word for sure!
@@Theretirementnerds And money makes the top ten list as well .😃
We who are lower income have no choice but to use the advantage plan because simply cannot a ford 200 to300 $ a month for anything else. Not complicated.
Thank you so much for the detailed information about Medicare Advantage plan HMO and PPO and Medicare Supplemental plan. I was enlightened and understand more about it. Medicare is really confusing.
Glad we could help! It is confusing! We are working on a similar video only around Supplemental plans so stay tuned!
I loved this video so much I watched it twice before commenting. I had no clue my Doctor could just quit the plan mid year. About 10 years ago he had these posts all over in the waiting room and offices that if you were using medicare payment had to be made up front and the patient would need to send in their insurance claim to their provider. I didn't like that, but since I was only 53 I didn't worry about it. My last wellness visit in 2021 I noticed all the posts were gone so not sure what is up with that. I remember in my younger days talking about retiring, traveling and having a nice garden. Now I have no desire to travel. My daughter lives in Lafayette, La, about a 100 miles away and that road trip is not fun. As far as a garden I will just go to the farmers market on Saturday's and buy local supporting them. It seems if one can afford it that the supplement plan is the way to go from the beginning since it is no questions asked at that point. I find it odd that in my area which we have a lot of commercials about medicare plans they never ever advertise the supplement plan. It is always an Advantage plan. Not sure why it is like that, but it did get me thinking about it. Great Video!!!!! "Both times I watched it" lol
There are a lot of intricacies around it all, that's for sure. And your self-awareness around travel plans is unique :)
There is more money in Advantage plans for insurance companies and agents than there is in Supplement plans, which is why you will see more advertisements around the Advantage side of things.
The knee-jerk reaction when people hear there is more money in one thing or another is that it means something bad. In this case, it is not bad, it is just different. Unless an agent is pushing an Advantage plan to someone who would be better off with a Supplement plan to chase commissions... then that would be bad.
We are working on a similar video for Supplement plans so stay tuned!
Always appreciate your comments.
3:15
If you have a straight Medicare plan with a supplement you can go to any doctor that takes Medicare. There may be small co-pays but nothing close to $5000. The out of pocket cost if you get cancer could be great and could easily go on to the next year. If you get sick in November, you may not be better by January and the out of pocket costs start over. So you don't have the cost of a supplement or maybe $35 extra for vision and dental. Just don't get sick.
True. This conversation gets pretty complicated, but yes... in general Supplement plan out of pocket costs will be less if there is a bad year (or several).
However, there are areas of the country where the Out of Pocket Max on an Advantage plan is $1,000 with $0 premiums, plus dental, vision, part d and others. So it all depends on where you live and the devil is in the details.
@@Theretirementnerds
When you mention costs in “our area”, what area are you currently in please? Also, when you talk about areas of the country that have $1000 maximum out of pocket for an advantage plan and zero dollar premiums again what areas are you referring to?
@Patrick Manley we are in the Intermountain West. The cost averages we use are looking at Arizona, Colorado, Idaho, Nevada, and Utah.
Certain areas in Nevada have some $1,000 - $1,500 MOOPs. Certain areas in California do as well.
That’s why you need to find the plan with lowest co pay.
Very overwhelming
It can be. We try to cover as many variables and situations as we can in this video. It gets much more manageable knowing individual circumstances and preferences.
Yup. That’s why everyone should use an agent to guide you thru the process to make an efficient choice.