Is Original Medicare more beneficial?

[4176jp]

I am 74 and was informed by  a few  doctors that transferring back to original Medicare would be more beneficial as I will not need referrals to doctors outside my network anywhere in the United States. I would however have to get additional supplemental coverage for the 80% of what Medicare does not cover, 

My reason?  I no longer wish to put my life in the hands of my healthplan surgeons especially after 3 failed surgeries one causing the other resulting in huge pain, suffering and expense for me, the loss my ability to work and not to ignore the tremendous cost and burden to my family since 2014!

My first rotator cuff surgery failed causing the loss of the use of my dominant right arm, whcih I later found  was because they ran out of anesthesia during the surgery. Both the surgeon,anaesthetist, the health plan are all covering for each other and of course the medical board after '2 years of so called investigation' will not admit any wrong doing!  I tried to sign up an Attorney to file a case but was told that my case was not 'big' enough to warrant the filing.  The ibuprofen and medications through the 3 years of pain, caused a hole in my esophagus which required a fundoplication surgery to push back my stomach which had entered upward into the hole. Unable to eat, this surgery also failed as the rubber band slipped- but not before causing a massive 2.5 inch saddle embolism leaving me unable to breathe and 15 minutes away from a body bag!  An IVC filter was placed during this time to prevent further blood clots and this again and not surprisingly, got embedded in my tissue and the hospital 'specialists' were unable to extricate it!  I will no longer undergo surgeries now or in the future through my current health plans and prefer instead to choose surgeons at University Medical Centers where they conduct extensive research and I can rely on less invasive next generation regenerative and AI technology. Here there is more oversight with other attending specialists and med students who participate both in the surgery room as well as remotely and nothing will be hidden or covered up!  I have until Dec .9th to decide and as time is of the essence, can someone with knowledge please explain the true differences in costs along with the pros and cons of original medicare vs a third party health plan?

[GailL1]

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@4176jp wrote:

I am 74 and was informed by  a few  doctors that transferring back to original Medicare would be more beneficial as I will not need referrals to doctors outside my network anywhere in the United States. I would however have to get additional supplemental coverage for the 80% of what Medicare does not cover, 

I have until Dec .9th to decide and as time is of the essence, can someone with knowledge please explain the true differences in costs along with the pros and cons of original medicare vs a third party health plan?

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As somarco said . . . . you can go back to traditional Medicare BUT you will have to get a free-standing Medicare Prescription Drug plan AND YOU MIGHT NOT BE ABLE TO GET A MEDIGAP PLAN OR IF YOU CAN, IT MAY BE TREMENDOUSLY EXPENSIVE.

There is no (regular)  annual open enrollment dates for a Medigap plan - state law determines if it gives any specific timing to change a plan.  So you can start now checking whether or not this is even a reality.  If you cannot get or afford a Medigap plan - will that be the deciding factor in going back to original Medicare?

Since we are now in the annual open enrollment period for Medicare Advantage plans and/or Medicare Prescription drug plans, why don't you check with those providers that you like and see what, if any, Medicare Advantage plan they may take for 2020 - also make sure that your meds are covered under any other MA plan you may consider, if they include prescription drug coverage within the plan.

Easiest way to do this is to contact an independent Medicare insurance agent in your area - many of them can help you determine if you can get a reasonable, if at all,  Medigap plan, pick up a free-standing Prescription Drug plan OR a better MA plan for you that covers the docs you want to see and your meds, if inclusive of both.

[somarco]

@4176jp enrolling in a stand alone Part D plan by 12/7 (not 12/9 as you indicated) will automatically disenroll you from your MA plan. This will create a transition to original Medicare as of 1/1.

But you do not appear to have a guaranteed right to a Medicare supplement plan. If you live in a state where underwriting is not permitted (CT, MA, ME and NY) you should be able to pick up a plan for the 20% balance.

Medicare pays 80% of approved Part B expenses after satisfaction of the B deductible.

There are also situations where you may qualify for a Medigap plan due to involuntary loss of coverage.

https://www.medicare.gov/supplements-other-insurance/when-can-i-buy-medigap/guaranteed-issue-rights

Otherwise you are stuck with an MA plan.

[4176jp]

I live in California. What does a supplement cost? What are the pitfalls, negatives and limitations?

I am on a limited income and have incurred phenomenal debt paying for outside surgeons using credit cards to repair the damage caused by my plan surgeons and my PC Physician still refuses to refer me out to outside specialists of my choosing. 

Thanks for your input.This is so confusing and calling these various Plan advertisers on TV is so frustrating as each pitches their own plans and benefits to the detriment of others.

[GailL1]

@4176jp wrote:

I live in California. What does a supplement cost? What are the pitfalls, negatives and limitations?

I am on a limited income and have incurred phenomenal debt paying for outside surgeons using credit cards to repair the damage caused by my plan surgeons and my PC Physician still refuses to refer me out to outside specialists of my choosing. 

Thanks for your input.This is so confusing and calling these various Plan advertisers on TV is so frustrating as each pitches their own plans and benefits to the detriment of others.

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You are very confused and need help understanding your options.  Stop watching TV and seek some direct help. Do a little reading so that you will understand how the different faces of Medicare work.

If you want a more national plan, yes, Original Medicare is better than a Medicare Advantage plan.

But to save money - you do have to use Medicare providers that take assignment.

Medicare (Original) - Physician Compare 

But would you consider Original Medicare if you have to pay the other 20% of cost out of pocket cause I do not know if you could even get a Medigap plan or if you can, the monthly cost for a Medigap plan.

Just for your understanding, the differences in Original Medicare Medigap coverage and a Medicare Advantage Plan:

https://www.medicare.gov/supplements-other-insurance/whats-medicare-supplement-insurance-medigap/med... 

Original Medicare covers approved and necessary medical needs for seniors that have worked and paid into the Medicare system during their working career.  SOME physicians take what is deemed "assignment" meaning that they will accept what Medicare pays as 80% coverage of the Medicare amount.  The remaining 20% of the cost is up to you -

• out of your pocket,
• with a Medigap plan or
• if your income is low enough, Medicaid (Medi-Cal in California). 

There are many different Medigap plans and insurers.  They are LOCALLY designated by zip code usually but some are groups like the AARP branded UHC Medigap plans (called supplemental plans).

Like somarco said, it is doubful that you would be able to get a Medigap plan because of your age, health condition, at least one at a decent monthly premium.  The window to purchase a Medigap plan that works as GAP insurance with Original Medicare is only optimal during strictly defined times of guaranteed enrollment - mostly when you turn 65 years old and 1st go on Medicare. 

However, for you to talk to hopefully someone that can help you better, here is the number for the California Dept of Aging - maybe they can give you better direction.

Medicare Questions - California Dept of Aging (HICAP)

Call 1-800-434-0222

Health Insurance Counseling and Advocacy Program (HICAP) serves current Medicare beneficiaries and those planning for future health and long-term care needs. HICAP counseling is confidential and free of charge. Calls are automatically routed to the appropriate HICAP.

California Medicare Counseling via HICAP 

It seems you picked a Medicare Advantage plan rather than original Medicare.  A Medicare Advantage plan may still work well for you - but I am not too sure that you have the best one for your needs - You have until December 7 to find out and make a switch to another Medicare Advantage plan.  You can also talk to the California Dept. of Aging (HICAP) about finding a better plan, if possible.

You might be able to ask them if you qualify for Medicaid in the state of California too.

You should have the following info ready for them when you call -

• your name and address
• Your current MA name and Insurer - policy number if there is one.  Have your card - MA card and your Medicare card.
• Your separate or included (with MA plan) Medicare Prescription Drug (Medicare Part D) insurer and plan #
• your current medications and dosage
• the doctor(s) name that you want to continue to use or any others you want access to -
• Your income and assets

Hopefully the HICAP representative can key in your zip code, your meds and your docs to see if there is a better MA plan for you so that you have the option of signing up for a better plan before December 7 (open enrollment ends for MA and Part D plans).

The representative should also be able to tell you if you might be able to get a Medigap plan at a somewhat decent monthly rate (they usually increase yearly).  But they might just refer you to some Medigap Insurers in your area.    The HICAP representative might be able to help you pick a Medigap plan.  Here are the ones that were available in California in 2019. 

http://www.insurance.ca.gov/01-consumers/105-type/95-guides/05-health/03-medsup/upload/MSRG2019BPoli... 

Here is another way of locating one via Medicare.gov

https://www.medicare.gov/medigap-supplemental-insurance-plans/ 

Here is a description of the plans themselves

https://www.medicare.gov/supplements-other-insurance/how-to-compare-medigap-policies 

In fact read ALL of this from Medicare on Medigap plans and coverage (note:  more info is on the left side of the page)

https://www.medicare.gov/index.php/supplements-other-insurance/whats-medicare-supplement-insurance-m...

The booklet that Medicare sends to you each year entitled "Medicare and You" is also a good thing to read.  Download it if you do not have it in paper form:

https://www.medicare.gov/medicare-and-you 

You need more direct help than I can give you - I am no place close to California; Thank Goodness for me.  Good Luck in your quest - work fast - December 7 is next week.