Health Insurance

[Jim Simmers]

Oh man I can’t believe I’m doing this! I said I would not so I am a dink.

Jim give it up! You are not doing your self any favors! Advantage plans are not the end all.

Why does a g or n plan or other gap plan not need a max out of pocket? Because the coverage for that 20% you refer to is covered 100%. Yes a n plan has a co pay for office visits. Might cost you a couple hundred bucks at most for most people much less. The big thing for me is the pharmacy. I am in a BCBS group plan with my former employer. I am a diabetic and have had congestive heart failure. I am on 3 diabetes drugs and 3 heart drugs. Now I.could go into drug tiers. I know them all too well. There is a major difference between tiers with gap plans and advantage plans.Will tell you my pharmaceutical coverage with my group gold plan with drug plan and monthly premium is less per year than any advantage plan. And no hassle. No denials no referrals. And more.

I will tell you from experience that max out of pocket is not the only thing to consider and what I pay for drugs and med coverage is less than most max out of pocket c plans.

What does suck is that dental is not covered. Now talk to any dentist or do the math yourself. If you need a cavity filled every few years and cleanings twice a year dental insurance does not pencil out. If you have dental issues it will make sense. I get vision screens and a discount on glasses and contacts. Not vision coverage.

I was in the hospital two times in in 2023. And with my pharmacy needs I can guarantee I’m on the right plan. Wife had cancer, will be on cancer drugs for several years. By her doctor recommendation/ approval. Not Humana. She is not at Medicare age and we are not sure if my employer plan is right for her or if we should consider an advantage plan? I am worried about approvals referrals with advantage plans? I’ve been there! Her drug costs other than the cancer drug is minimal. So advantage plan could be right for her.

Jim again you are not doing your self any favors! You are a salesman for Medicare coverage. And that’s ok! But you are biased! You can not be. This is not if gap is a better option or advantage plans are a better option! This is do your homework see what’s best for your situation! But to make claims that advantage plans are best for 99.5% of seniors is snake oil.

Just drop it. You will be doing your self a favor.

Obviously you dont understand and wont listen with an open mind. Advantage plans no not require referrals. You can see any doctor that accepts Medicare, most plans are PPOs and there is a network but even out of network, if you can find an out of network doctor for Medicare benefits, good luck. There is a chance but it is small. You cant compare your drug plan through your employer to one through a Medicare plan. Its different and that's awesome for you. Not everyone here is as lucky as you are. As far as dental, vision and hearing, they are included at no extra cost. I offer Medicare supplements, Medicare cost plans and Medicare Advantage. So, where am I biased? To be biased I would have to offer one over another. I offer them all. I see and understand how they all work. I get recertified every year.
Medicare doesn't have an out of pocket max, that's why some choose to get a supplement. And don't worry about me doing myself any favors, I do this for a living and can talk about this all night long. So here is an example for you. Medicare part B is $164.50 per month. A Humana plan N for a 75 year old male non tobacco is $155.69 per month. If you need a drug plan that's an average of $34.00 and foreign travel $250. Now because we need to keep it apples to apples, a Dental plan averages about $50 and vision coverage is $15.00 you also pay the part B deductible of $226 and a few doctor visits @ $20=$60, that's a whopping total of $5566.28 per year total Medicare costs for a calendar year. Now lets look at an Advantage plan. Part B premium of $164.50. premium, $0, deductible, $0, Drugs plan, dental, vision, hearing aid coverage, gym membership, otc and a meal program all for nothing more. so with a $0 premium Medicare Advantage plan with Part D, $164.50 per month Part B or $1974 per year. that's a total savings of $3592.28 yearly savings. So in 10 years thats $35922.80 in total savings. So worse care scenario you hit a Max out of pocket 1 time and spent $4000 one year, that's one year out of 10 and it only cost you $407.72 more than your current plan. That's assuming your plan N never took a rate increase. Numbers do not lie. I see this every day! It is real, they do work and thats why they will continue to be popular and will grow.
So you do the math, if there are 65 million seniors on Medicare, and 52% are on an advantage plan, and if I feel that 99ish % are better off on an Advantage plan, that's still a sizable number that might be better off on a lettered supplement.
Now I also understand you want me to do myself a favor by dropping it. I think that's because you know you are far from correct. You might be for you and that's great. But your needs are not the same as anyone else's. So like I said a couple days ago; You do you! No snake oil here! Happy Holidays buddy.

 

[Jim Simmers]

Called blue cross about the rate increase from $517 to $580/month.
They have advantage plan and our premium with that would be $140 versus the $580 per month. Big savings of $440/month.
But it would go from zero copay to as high as $3,750 each on an annual cost. Still probably a savings.
And there is question about what doctor and what hospital i would get with advantage. Nice to know one can go to Mayo if needed.
So, in end depends on how much you use to reach your max copay.

So, she said i can sign you up for advantage but when all is considered i recommend you stay with what you have.
There is no way i am able to make a decision as i do not know the whole story so will stay as is. Pay the increase cost no deductible as i go with the premium.
She did say for me with VA health care and drop my part of what i have to save $330/month is maybe something to consider but i know there are issues there also. My upcoming dentist bill would not be cover by advantage. db

That $3750 is the max out of pocket if you had the worse yr one might have and not be pushing up daiseys. With BC, you would have a premium of $69.00, that does not count towards your out of pocket max, or moop. but a hospital stay might cost you $350 per admittance. maybe a few specialist visits for $30 or so you would not come close to that $3750 MOOP. but that is the worse that plan would ever cost you.

 

[eyexer]

I am sorry, I just saw you are in Williston. I can get you a cost plan with a zero premium. pretty close to an advantage plan. Like benefits, works the same, it is just paid differently than an advantage plan.

Nothings free. So he’s paying the premium

 

[Jim Simmers]

Nothings free. So he’s paying the premium

Never ever have I ever said free. No matter what, you pay your part B premium. But you can have an Advantage plan or a cost plan with a $0 monthly plan premium. Plus get all the extra benefits.

 

[Jiffy]

Just go to the VA, they'll kill you when you're young so you don't have to worry about it.

 

[Lapper]

I work with providers on a a daily basis, and yes, very few of them actually understand insurance. But every single one of them refer to these as dis-advantage plans. I know the small print says that they must cover everything that Medicare does but many of them find ways around this by Requiring prior authorization that can take many weeks to get an answer. The providers I work with across the entire state all say the same thing, it is harder to get the care they want to provide if you are on an advantage plan.

 

[shorthairsrus]

Work in healthcare. See the patients get denied time after time on advantage plans vs traditional Medicare. Co-pays are exponentially more costly on advantage plans as compared to traditional Medicare for the same service rendered (CTs, etc).

And, you are wrong. If you take an advantage plan you MAY not be accepted into standard Medicare should you change your mind. You actually have to apply for what would have rightfully been yours and may be denied. I see it often.

Again, you are obviously in sales. You know the lingo and are probably reporting directly off of a pamphlet provided to you by an advantage plan; but have zero clue about the real downstream effects of these shit plans on our elderly. If you are healthy and eligible for Medicare it may be a viable option until you become ill (which most in their 60s+ either are or become). Stop selling snake oil.

Last time I shopped for insurance health (annually) or otherwise ---- its free country the more you pay generally the more coverage you have. Period. Nothing wrong with shopping provided you know the outcome.


Every day i drive by the taj mahal were all reminded of our health insurance costs.

 

[Coldfront]

I am not of Medicare age. I have been an insurance agent for 23 years. I have been primarily an advantage plan agent for almost 18 years. Providers are dropping them at an alarming rate? Where at? Not in ND. Program has never been bigger and growing fast as we are close to the middle of the baby boomer generation. These plans grow by 2-3% every year at close to 52% of the Medicare population choosing an advantage plan. I am trained to be an expert in the field. Basically it’s all I do. The main reason why some Medicare providers might not like dealing with these plans is because they require pre authorization before a major procedure can be done. Doctors have to do that for the plan member. Providers have been over billing original for decades helping to break the Medicare program financially. 70% of all insurance fraud is from the doctors office in double billing or billing for services not rendered. Previously those claims would sit at CMS in pending status and it would be 6 months before the federal government would pay that claim without checking to see that the service was actually provided. The feds put a cap on how much profit a carrier can make. Most of all monies paid to part c carriers must be used to pay claims and provide benefits. Fact is, this year there are more plans to choose from than ever before. Plans don’t pop up if providers are dropping. Not sure where you are getting your information but you’re terribly wrong. They are here to stay.

I have a friend here in minot that took out an Atvantage plan last year. He made an appointment to see his doctor in minot and after the appointment he got a bill because the doctor was out of network. He the insurance and they explained what happened. He asked what doctor was in network and told him that the doctor was in bottineau 80 miles away. He then went to his dentist and again was told the same thing. Again he made a call to find out what dentist that he was supposed to go to and was told the only dentist in network was in bismarck. Needless to say he is switching back to real insurance.

 

[BrokenBackJack]

No longer? They never did. They do not accept Medicare. Out of the 4 Mayo clinics, only Rochester accepts Medicare and most carriers are in-network.

In the past, I know Mayo in Phoenix and Scottsdale didn't accept Medicare but that changed some years ago. My bride has been going to both of them for the past 3 years or so for her Lung cancer and we have Medicare with Blue Cross as a secondary.
When you look around at people while in Mayo, it is 90% of us old geezers getting treatments there.

 

[Pheasant 54]

Yeah from what I have found Medicare is accepted in all Mayo clinics .

 

[Jim Simmers]

In the past, I know Mayo in Phoenix and Scottsdale didn't accept Medicare but that changed some years ago. My bride has been going to both of them for the past 3 years or so for her Lung cancer and we have Medicare with Blue Cross as a secondary.
When you look around at people while in Mayo, it is 90% of us old geezers getting treatments there.

I was referred to the Mayo in AZ last year and they said if I had Medicare I would have to self pay. I am 55 and not on Medicare. But even Medicare is not accepted at all places and different doctors can decide that they are only taking so many Medicare and so many Medicaid. I guess in a free system everyone can choose who they want to do business with and who they want to get paid from.

 

[eyexer]

Never ever have I ever said free. No matter what, you pay your part B premium. But you can have an Advantage plan or a cost plan with a $0 monthly plan premium. Plus get all the extra benefits.

You seem to be avoiding the question. Who pays for someone’s zero monthly plan premium? Obviously there’s qualifications because you said not everybody gets zero premium plans.

 

[Jim Simmers]

I have a friend here in minot that took out an Atvantage plan last year. He made an appointment to see his doctor in minot and after the appointment he got a bill because the doctor was out of network. He the insurance and they explained what happened. He asked what doctor was in network and told him that the doctor was in bottineau 80 miles away. He then went to his dentist and again was told the same thing. Again he made a call to find out what dentist that he was supposed to go to and was told the only dentist in network was in bismarck. Needless to say he is switching back to real insurance.

Dentists are not a Medicare benefit so the network status doesn't really count but in any event, you can get a out of network reimbursement form and get all or most of things reimbursed When it comes to plans available up there, UHC, Medica and BC/BS I think are the only ones considered part C plans, they all only offer reimbursement. Your friend should contact their agent and get forms, can always file a grievance. Or have them call or text me, I will look into it.

 

[Jim Simmers]

You seem to be avoiding the question. Who pays for someone’s zero monthly plan premium? Obviously there’s qualifications because you said not everybody gets zero premium plans.

I did address this. The part C plan always gets paid per their contract with CMS. Its just that you will not have an extra premium.

 

[Jim Simmers]

Just go to the VA, they'll kill you when you're young so you don't have to worry about it.

sadly that's true, they like to hand out prescriptions like a big Pez dispenser.

 

[eyexer]

I did address this. The part C plan always gets paid per their contract with CMS. Its just that you will not have an extra premium.

Who’s is CMS?

 

[Jim Simmers]

Nothings free. So he’s paying the premium

Part B, just like every one else. I have also stated that many times. traditional Medicare is A&B for $164.50 + supplemental +part D then need to purchase dental, vision if you want it. advantage plans, A&B for $164.50 many plans $0 + part D, dental, vision and hearing included for same $0.
In order to qualify for an Advantage plan, you must have Medicare A&B due to age or disability and live in the plans service area at least 6 months out of the year. Advantage plans typically have plans that range from an extra $0-$196 per month, depending on which plan you choose and what's available in your area. No health questions. If you look in your Medicare and you handbook, it the front it talks about your Medicare options and how they work. So you don't have to take my word for it, its all right there.

 

[Jim Simmers]

Who’s is CMS?

The Centers for Medicare and Medicaid Services or Medicare.

 

[Jim Simmers]

Dentists are not a Medicare benefit so the network status doesn't really count but in any event, you can get a out of network reimbursement form and get all or most of things reimbursed When it comes to plans available up there, UHC, Medica and BC/BS I think are the only ones considered part C plans, they all only offer reimbursement. Your friend should contact their agent and get forms, can always file a grievance. Or have them call or text me, I will look into it.

I hate the "My friend" cause you never really know if your friend is telling the whole story as it really happened or just giving parts. I looked up what plans are all available in ward county with a 58701 zip code, Blue Cross has three plans and United Healthcare has 3-4 plans. Those are the only Advantage plans and they are PPO, So i would need to know who the doctor is to know for sure if they are in net work but when I put in Mercy hospital to see if they accept the Advantage plan, they are in network. The other plans through part C is Medica and Health Partners, Those are cost plans and those do not have a network. As I stated in another post that Advantage and Cost are all in the part C to Medicare plan and act the same where on is a PPO with a network and the other has no network.

 

[BrokenBackJack]

I was referred to the Mayo in AZ last year and they said if I had Medicare I would have to self pay. I am 55 and not on Medicare. But even Medicare is not accepted at all places and different doctors can decide that they are only taking so many Medicare and so many Medicaid. I guess in a free system everyone can choose who they want to do business with and who they want to get paid from.

I don't know who you would have talked with that told you Mayo at Phoenix wasn't taking Medicare. They take it everyday and have for at least the last 3 years. Unless it was Medicare Advantage or something like that.
Everybody that we talked with at Mayo that is retired of course, had Medicare.
You find out you talk about just about anything, while your partner is undergoing treatment. Helps to pass the time.