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Medicare Supplement - Medicare Advantage

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Which is better? Medicare supplement or Medicare Advantage? 

 

This is not a case of one-size-fits-all. One is not inherently better than the other. Like belly buttons, everyone has one and each one thinks there is nothing wrong with theirs.

 

Medicare supplement, AKA Medigap, pairs with original Medicare. Most states follow CMS guidelines and use standardized plans assigned a letter. 

 

A few states have their own designs approved by CMS.

 

Advantage plans are managed care plans offered by insurance carriers. Members receive their Medicare benefits from an insurance carrier, not Medicare.

 

Supplement plans pay AFTER the claim has been adjudicated and approved by Medicare.

 

Any provider that accepts original Medicare will also take your Medigap plan, no questions asked.

 

Common Misunderstanding

 

 

Medicare is Medicare. All payments from Medicare are the same to doctors.

 

Not true.

 

Medicare has it's own scale based on claim coding. Adjustments to the formula are made based on different cost areas. Dr. Welby and Dr. Kildare live in the same area and will be paid the same for the same procedure.

 

Medicare Advantage plans have fee schedules that vary by carrier, plan design and the physician rating. Dr. Welby could be paid more or less than Dr. Kildare, depending on the type of Advantage plan and carrier.

 

 I can control that by who I see and how often.

 

One of the most absurd statements I see. It ranks up there with those who say they are not planning on getting sick.

 

Who does?

 

As far as doctors not taking Advantage plans, they can't tell the difference. Having to stay within a network of doctors varies by plan and those plans are usually privately backed by local healthcare systems in one area trying to monopolize business

 

If doctors can't tell the difference why do some accept Advantage patients while others do not? Why do some docs take patients with carrier ABC but not XYZ?

 

There are situations where a hospital or clinics in a geographic area will receive monthly payments, over and above treatment fees, in exchange for signing an exclusive agreement with a carrier. But those are rare.

 

No conspiracy theories. No tin hats.

 

But hospitals don't care. If they take any Medicare, they have to take ALL Medicare.

 

Again, misses the mark.

 

Call around or go online and see which hospitals accept original Medicare (almost every one of them) and which participate in Advantage plans.

 

Pay particular attention to specialty hospitals like Mayo, Sloan-Kettering, MD Anderson, Cleveland Clinic. Every one of them accept original Medicare but may only accept specific PPO Advantage plans. Don't plan on going there if you have an HMO.

 

Advantage plans don't dictate any part of your healthcare to you. You can go to any physician you want to. They are the same as any supplement plan

 

I see and hear this quite a bit. You are free to use any doctor or hospital, anywhere in the country.

 

What you are not told is this. You CAN use any provider but your Advantage plan may choose to deny the claim, in which case YOU pay the full cost.

 

Or they will pay the claim but only up to our regular fee schedule.

 

Advantage plans will sometimes agree to pay non-par providers but ONLY IF the provider agrees to their fee schedule.

 

Pre-authorization

 

About 80% of Advantage plans require pre-authorization for some tests or procedures. Claims may be denied if you failed to obtain pre-authorization. You can always appeal, but who wants to go through that hassle?

 

Original Medicare does not require pre-authorization except for some DME.

 

MOOP

 

Advantage plans have a maximum out of pocket (MOOP) for health care claims.

 

This limit applies to IN NETWORK APPROVED claims. Some PPO plans assign a higher MOOP for out of network claims.

 

Claims that are denied do not count toward your MOOP.

 

Year End Surprise

 

Advantage plans not only have MOOP in the thousands of dollars, but also have networks.

 

If you hit your MOOP during the calendar year approved health care claims are normally paid at 100% for the balance of the calendar year. If you need care the following year your MOOP starts all over again.

 

Ongoing treatment is common resulting in hundreds or thousands OOP in back to back years.

 

And don't overlook the networks.

 

Dr. Welby may be in network this year but not next. If you want to continue seeing Dr. Welby you may have to pay the full amount.

 

If saving money is your driving consideration then switch providers and go with the one that costs you the least.

 


Bark less. Wag more.
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