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G26ster

TomsTXCHL wrote: I know that by discussing Medicare I have taken this subject away from the topic, but it's been so valuable to my Medicare questions that I've taken to reading the whole thread and this caught my eye. It is (truly) interesting that when you buy an Advantage program, you essentially opt-out of Medicare! You have instead a private insurance plan, subsidized and regulated by the US govt, but it's not Medicare any more!

Correct, and the gov't makes it even more confusing by calling Medicare Advantage Medicare Part C. I think that is why Medicare is referred to as "Original" Medicare.

G26ster

TomsTXCHL wrote: Tell me specifically please what decision I must make correctly now that if I don't I am "out of luck for life"?

It's pretty simple. Should you choose to drop your Advantage plan after you are diagnosed with a major condition, and switch back to Original Medicare to avail yourself of top hospitals and specialists, you will not be able to get a supplement plan with your major pre-existing condition as you are no longer in a "Guaranteed Right" position. That Guaranteed Right window closes 6 months after you "Originally" sign up for Medicare Part B. It, except for a few rare events, never opens again. Of course, as rotor says, if you can guarantee that you will die quietly in your sleep, go Advantage plan.

TomsTXCHL wrote:Well MD Anderson is one I suppose but WHO KNOWS: what kind of specialized care I might need down the road, and whether any plan I sign-up for today will cover X-Y-Z tomorrow.

That's the whole point. Since you can't guess "what kind of specialized care I might need down the road, and whether any plan I sign-up for today will cover X-Y-Z tomorrow" selecting Original Medicare opens up using just about ANY major medical center and top specialists in the country for just about any condition you can think of.. Advantage severely limits the specialists and facilities you can use.

G26ster

TomsTXCHL wrote:
G26ster wrote:Thanks Rotor. makes sense. Yes, although my Advantage HMO has been really great since 2008 even with some pretty heavy duty bills and procedures, when it comes to a catastrophic illness, and you want the best possible doctors available in the country, they fall short, as you are restricted in doctor and hospital choice to those in your network. My advice to anyone soon to retire (65 and over) is to avoid a Medicare Advantage Plan, and take advantage of the 6 month "guaranteed right" window after signing up for Medicare Part B, where you cannot be turned down for pre-existing conditions of any kind with a Medigap supplement plan. If you miss this 6 month window, you are basically out of luck for life, with a few rare exceptions, in getting a supplement should you become a victim of a catastrophic illness.
I guess your comment that I bolded above is directed at folks with a nasty preexisting condition? Sorry don't understand you.

I am about to turn 65, am already on SS thus I've been automatically signed-up for Parts A and B, and am being absolutely hounded by insurance agents representing the various Advantage plans. And in surfing the medicare web site itself, I find that I can sign-up for most/any of these plans directly thru the medicare.gov site without apparently dealing with ANY of these "exchange" companies (e.g. extendhealth/oneexchange from Tower Watson).

I don't know WHAT the heck to do, but I've got a couple months still to think and study on it. As healthy as I am (knocks on wood) I still have a GP and a Urologist and a Dermatologist and a Gastroenterologist and <who else> so am thinking still that I want an Advantage plan and co-pays of $15-50 bucks and some minimal prescription help.

I'll make it easy. Ask anyone trying to sell you an Advantage plan one hypothetical question. "If I develop cancer down the road, is MD Anderdson Cancer Center (or really and nationally recognized cancer hospital) in my network?" If the answer is no, you may want to consider Original Medicare w/Medigap supplement, and a Part D drug plan.

So yes, Original Medicare + Medigap supplement + Drug plan costs a lot more than an advantage plan. The downside of Advantage is that you will be restricted to the doctors, hospitals, and specialists in your Advantage plan's "network." Do your homework and decide. It's a personal decision we all have to make at our age, and as I said, I was very happy with my Advantage plan until this cancer popped up. I educated myself too late.

G26ster

rotor wrote:I agree. I have regular medicare and a supplement from USAA. I think that is the best way to go.

I agree of course. I have been a member of USAA for over 47 years, and even they cannot not sell me a supplement plan, with my condition, as it cannot be underwritten. I think the whole "guaranteed right" situation, which requires one to see into the future, is basically wrong. Today, a person under 65, with no insurance at all, can wait for a disastrous condition to befall them, and sign up for insurance after the fact and cannot be denied. With Medicare supplements, the gov't only allows you to do the same within a certain "one time only" period, and if you didn't know about that in advance, you are screwed for life. I think it is unfair and discriminatory for seniors to deny them the same rights as the rest of the country under 65.

G26ster

rotor wrote:
G26ster wrote:If there's someone here that is knowledgeable in State health law, I have one for you. I am in a Medicare Advantage HMO. This means I must deal with the PCPs and specialists in my network. I wanted to get a second opinion from a noted specialist at UT Southwestern in Dallas (UT Southwestern does not accept my insurance). I told them I would pay cash. I was informed that Texas state law prohibits them from accepting cash from a patient who has health insurance, even if they do not accept that insurance. Any one ever heard of this?
It is Federal law. A doctor that accepts medicare can not accept such a cash payment from a medicare beneficiary outside of the medicare system for a covered service. Now if the service is not covered by medicare, like some plastic cosmetic surgery, the doctor makes you sign an ABN (I believe that's what it is called) which tells you that the service is not covered by medicare. A second opinion though is a covered service and therefore the doctor if he agrees to see you must accept payment from medicare and since you are an advantage hmo patient and the doctor is outside your network you just won't get seen. You give up a lot when you become an advantage patient. Having insurance does not mean having a card. You must know the network of doctors and hospitals provided. In an hmo the doctor gets paid for not growing corn, as you probably now know.
Options for you, don't tell the consulting doctor you have medicare- I guess you would have to give a false name and ss#. Very hard to do as almost every clinic will require photo id. On the other hand, you can complain like mad, write a letter to the editor, your hmo may make an exemption. Best of luck.

Thanks Rotor. makes sense. Yes, although my Advantage HMO has been really great since 2008 even with some pretty heavy duty bills and procedures, when it comes to a catastrophic illness, and you want the best possible doctors available in the country, they fall short, as you are restricted in doctor and hospital choice to those in your network. My advice to anyone soon to retire (65 and over) is to avoid a Medicare Advantage Plan, and take advantage of the 6 month "guaranteed right" window after signing up for Medicare Part B, where you cannot be turned down for pre-existing conditions of any kind with a Medigap supplement plan. If you miss this 6 month window, you are basically out of luck for life, with a few rare exceptions, in getting a supplement should you become a victim of a catastrophic illness.

G26ster

Beiruty wrote:UT SW should accept medicare patients.

They accept Original Medicare, not my Medicare Advantage HMO. There's a big difference between Original Medicare and a Medicare Advantage HMO.

The difference is that Original Medicare is accepted at most hospitals/doctors but you are responsible for the 20% of Part B costs unless you also have a Medicare (Medigap) supplement plan. Under a Medicare Advantage HMO, you;'re not responsible for that 20% BUT you are restricted to doctors and hospitals in that HMO. The two should never be confused.

G26ster

If there's someone here that is knowledgeable in State health law, I have one for you. I am in a Medicare Advantage HMO. This means I must deal with the PCPs and specialists in my network. I wanted to get a second opinion from a noted specialist at UT Southwestern in Dallas (UT Southwestern does not accept my insurance). I told them I would pay cash. I was informed that Texas state law prohibits them from accepting cash from a patient who has health insurance, even if they do not accept that insurance. Any one ever heard of this?

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