Does Anyone Just Have Medicare A and B Only - NO Advantage or Medigap?

[SharRog]

I've been researching a lot and found a video from David Belk about how we shouldn't get a Medigap plan and just use Medicare A and B.  I have been on a Medigap Plan N for a year and the premiums are getting high and also what they pay just doesn't seem worth it. 

So, I thought not to get ANY Medigap or Advantage plan.

I've also read from people on the Advantage plans they had serious issues with the various incurance companies.

Of course my concern is a catastrophic event and that I'd have to owe a lot of money though...this video states that Medicare sets prices and if I did have a catastrophic event my expenses wouldn't be out of a range that I could probably afford.

Just wondering if anyone has thoughts on this. 

Thanks

[mpuop02]

I just recently went on medicaire , I was lucky enough to be able to keep my insurance from my job at the PO ( I pay for it )  but with my health problems it's well worth it , I see a few specialists , my Drs don't have to be " in network " & only 2 of my meds need preapproval , I have MS , I see the best Drs in Boston & have never been turned down for any meds , infusions , MRIs etc . I have BCBSHD Federal PPO. , it's a bit expensive but we'll worth it .

[rkbansal1]

Thank you all for this interesting discussion. I have the same question as the topic of this discussion. I am 70 and I and my wife have Medigap Plan G for last 4 years. As usual premiums keep jumping up every year. We had started at about $260 for both of us 4 years ago and now we are close to $400 per month, that is 4800 dollars per year for Plan G for 2 of us. In my rough calculations, we have to incur roughly 25000 dollars medical expense per year to even out current expense on Medigap Plan G. Suppose we dump Medigap Plan G and incur less than $25K per year on medical expenses, we save money,.else we lose. 

Considering our health situation today, it does not look like we will spend anywhere close to 25K per year. But of course we can never tell what will happen tomorrow. Assuming we stay reasonably healthy for the next 5 years, the chances are that we will save 2 to 3K per year. But we may lose out in the longer run. 

I am not really sure about switching to an Advantage Plan, however good it may sound. I have heared a lot of horror stories about payment denial by insurance companies on suspecious grounds. One common problems I have heard is about bills from out-of-network doctors working at in-network hospitals. Patients go to in-network assuming that all services there are provided by in-network doctors and nurses only to discover later that they are stuck (more like struck) by surprise bills. In my view any Advantage Plan is worse than regular Medicare A and B without Medigap. 

I wonder if anyone would care to add more about negatives of Advantage Plans.

Regards to all.

[GailL1]

@rkbansal1 

Ok, just some thoughts about your predicament.

$ 25,000 is small change if you have a major health occurance even with traditional Medicare.  Remember as a traditional Medicare beneficiary either you or a Medigap plan has to pay what Medicare does not pay.  Things like you part of the hsopital cost, your part of a SNF cost, your cost of chemotherapy or some other costly treatment condition. 

What I would do is to check with a local independent Medicare insurance agent on switching to another Medigap plan - if it is one of lesser coverage, even with possible underwriting, it might save on the premium cost.

This will show you the coverage under all the plans and you can compare it to the one you have now.  Medicare.gov - How to compare Medigap plans 

BTW, there is nothing wrong with you and your spouse having different plans - the needs maybe different.

Now if that does not work out for you - You should consider a Medicare Advantage plan - in most areas there are many to choose from. The same local independent Medicare insurance agent may be able to help you here too.  Speak up about your concerns on coverage.

Medicare Advantage plans cover the same things that traditional or original Medicare covers, just in a different way.  Under a MA plan, you know your copays, deductibles, etc, your total OOP - original Medicare has NO top limit for OOP cost - not annually and not by lifetime.  A MA plan may offer other things that orignal Medicare doesn't offer like some coverage for dental, vision and hearing and sometimes other things too.  Many time a MA plan has its formulary built into the plan and you also determine the best plan by using that just like in a free standing Med D plan. 

MA plan premiums are low to zero.

Even in traditional or original Medicare, you have to make sure any providers you see accept assignment to get the best price.  But if a provider does not accept assignment - even with a Medigap plan, they may bill you - a little or a lot.  In traditional Medicare, there are providers that

• accept assignment
• are considered "non-participating"
• are considered contract providers

Medicare.go - Lower Cost With Assignment 

Don't think that even traditional Medicare is without its own little surprise billing especially under some conditions.  And remember that if Medicare does not pay, your Medigap plan will not pay either.

PBS 04/03/2019 - How this Medicare loophole can lead to surprise medical bills 

Federal rules generally prevent people on Medicare from being hit with such surprise charges. However, Americans need to be aware of a major hole in Medicare’s safety net. It concerns people who need skilled nursing care after being hospitalized for a health issue.

Such care is covered by Medicare, but only if the person has been formally admitted to the hospital as inpatients for at least three days. Hospitals also are free to admit people as outpatients for what is technically called observational care. Outpatients, it turns out, are not covered by Medicare for subsequent nursing needs And in recent years, more people have been classified by hospitals as outpatients. 

read more about this at the PBS link above

According to this article in Forbes, it seems MA insurers have a hook against surprised billings in MEDICARE hospitals.

https://www.forbes.com/sites/theapothecary/2019/03/12/how-to-end-the-scourge-of-surprise-medical-bil... 

Medicare forbids out-of-network providers from charging more than what traditional Medicare would pay for a given service. This has given insurers critical leverage against hospital monopolies, because the worst-case scenario is paying an out-of-network provider at Medicare rates. That means insurers have the ability to negotiate even lower rates with in-network providers.

Personally, there are a lot of "gotchas" out there; yes, even within Medicare but I would rather have as much coverage as possible because that is where most risk lies. 

See a local independent Medicare insurance agent and see whether or not you can switch to another Medigap plan that is more economical for you in premiums but will give you some coverage that you can financially handle.  And review the MA plans available to you in your areas with the agent and see if one may fit your needs - financially and healthwise.  Like I said, there is no reason that you and your spouse have to have the same plan because each of your will have your own individual health needs.

Do you happen to know how your Medigap Plan G is rated?

Medigap policies can be priced or "rated" in 3 ways:

Community-rated (also called “no age-rated”) Issue-age-rated (also called “entry age-rated”) Attained-age-rated

Sorry for the long post - when you get into this stuff - one thing just runs into another.

I hope  I have given you some points to ponder to make a good decision.

[GailL1]

@SharRog 

Yes, there are many seniors who have traditional Medicare and do not buy a Medigap plan.

But they usually fall into one (1) of (2) categories -

1.  They are wealthy enough to have no problem paying their part of the traditional Medicare cost.

2.  They are poor enough to become a dual eligible beneficiary where Medicaid picks up their part of the traditional Medicare cost or they can qualify for some Extra Help.

Medicare.gov - Getting Help Paying Cost 

This leaves those seniors that are in-between, income-wise, a decision to make about their choice of Medicare plans -

• traditional Medicare without a Medigap plan OR 
• a Medicare Advantage plan of their choice available to them in the area where they live.

You still need a Prescription Drug plan - some Medicare Advantage Plans have these built-in.

I would say, usually, in the everyday course of  health care, most in this middle income classification would be able to pick up that 20% (Part B) of their traditional Medicare cost with little problem BUT there could be some higher cost if a more severe health condition arises because of the cost of some treatments and/or recuperation period.

Remember that the traditional Medicare program has NO limit on out of pocket expenses - not by year; not by lifetime limits.  Some of the things that could "break the bank", so to speak, would be cancer treatments - chemotherapy / radiology.  Another would be a Medicare beneficiary's part of the cost of a Skilled Nursing Facility during a recuperation period. 

(Part A)
Hospital Stay
In 2019, you pay
■ $1,364 deductible per benefit period
■ $0 for the first 60 days of each benefit period
■ $341 per day for days 61–90 of each benefit period
■ $682 per “lifetime reserve day” after day 90 of each benefit period (up to a maximum of 60 days over your lifetime)

Skilled Nursing Facility Stay
In 2019, you pay
■ $0 for the first 20 days of each benefit period
■ $170.50 per day for days 21–100 of each benefit period
■ All costs for each day after day 100 of the benefit period

For Chemotherapy under traditional Medicare

https://www.medicare.gov/coverage/chemotherapy 

• Medicare Part A (Hospital Insurance) covers chemotherapy if you have cancer, and you're a hospital inpatient.
• Medicare Part B (Medical Insurance) covers chemotherapy if you’re a hospital outpatient or a patient in a doctor’s office or freestanding clinic.
• Your costs in Original Medicare - You pay a Copayment for chemotherapy covered under Part B in a hospital outpatient setting. For chemotherapy given in a doctor's office or freestanding clinic, you pay 20% of the Medicare-approved amount, and the Part B Deductible applies.

Note - Your doctor or other health care provider may recommend you get services more often than Medicare covers. Or, they may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all of the costs. Ask questions so you understand why your doctor is recommending certain services and whether Medicare will pay for them.

Having traditional Medicare WITHOUT having gap insurance is definitely a risk - but it just depends on your situation (and pocketbook) if you can handle such risk.

IF you are healthy, see if another Medigap plan would work better for you price-wise.  If there is any underwriting necessary because of your health, this could eat up any savings but you can check.

Here are the standardized plans with coverage shown side-by-side -

Medicare.gov - Medigap Plans 

If I were you, I wouldn't discount a Medicare Advantage plan either -  there are many pluses for them - they have a set deductible, they have low to no premiums, they may have a built-in Prescription Drug Plan, you can change every year during open enrollment  if you need / want to, some have extra coverage benefits like vision, dental, hearing and some even others.

For both of these options - See an Independent Medicare Insurance Agent in your area - they should be knowledgeable about the coverage and calibre of any Medicare Plan - Gap or Medicare Advantage.

I encourange you to read the Medicare.gov site on Medicare Plans - Gap and Advantage.  Then you can ask questions and get the knowledge to make the best decision for you.

[mpuop02]

I am far from wealthy , but not poor enough for any help , I was fortunate enough to be able to keep my medical & dental insurance from my job when I retired 2 yrs ago. I have BCBSHD Federal PPO , ( I worked for the PO for over 28 yrs . , it's not cheap , but I can see any Dr I need to , they don't have to be " in network " , I've never been denied payment on any meds ( I have MS )  or new treatments , MRIs , infusions, etc. . So I don't fall into either of thise categories . 

[sktn77a]

If you are not wealthy enough to "self insure" the medicare gap, and not poor enough for Medicaid, and can't afford a Medigap supplement, you might consider a Medicare Advantage option.  They are cheaper than Medicare + Medigap but are more restrictive on services.

[SharRog]

Thank you so much for your indepth response.