Retirement, Medicare and Supplemental Insurance

[TripleThreat]

I work for a Medicare advantage plan believe it or not. Can you emphasize what you're interested in? Are you interested in Regular Medicare, or Medicare Advantage plans? Regular Medicare a lot of people enjoy and a lot of people find MA plans (Medicare Advantage Plans) to be just as good if not better due to the Part C services they provide

A few pointers I can provide:

Choosing between Medicare & Medicare Advantage.

Medicare - You are provided Part A & Part B services, no Part C and you need to sign up with a Part D Medicare Drug plan in order to avoid building a lifetime LEP (late enrollment penalty) after 63 days of not having a valid Part D plan under Medicare (this pertains to MA plans as wel.) Part A & B services are typically what you would get with your normal insurance, a doctor, referrals, treatments, surgerys, hospital stay, SNF's, you name it.

Medicare Advantage Plans - Provide Medicare Part A & Part B services but also include Part C & Part D. Part C is "bonus services" which is why they are called advantage plans which can include chiropractic service that can be better than the standard medicare chiropractic services, Vision benefits, Over the counter allowances that you can use at participating retailors such as CVS/Walmart ETC, some have grocery allowances, you have transportation benefits, GYM benefits, you see where this is going. These are all Part C services that typically aren't covered under original Medicare.

Moving on to choosing plans under Medicare and Medicare Advantage plans
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I'm not 100% familiar with how original Medicare plans work I've only worked for Medicare Advantage plans so the process of how original Medicare may work may differ a bit so the below is how MA plans work but Original Medicare may be different, for example any MA plan I've work with does not provide Plan's F or G.

Your choosing of a PBP (Plan benefit Package)

HMO - You must stay within your own network of doctors. Typically you sign up with a MA plan but you are assigned to what is called an IPA/Medical Group that 9 times out of 10 are processing your referrals/authorizations to see various specialists or have procedures done. What that means is when Jimmy wants you to see Billy to have your foot amputated, your IPA will review Jimmy's request for you to see Billy and they will either approve or deny your request. If Denied you have the option to appeal said denials with your MA plan. If your MA plan denies your request, your denial goes back to Medicare where Medicares review team reviews the denial to ensure that you are not getting screwed over by your MA plan or IPA. In short it keeps everyone responsible and accountable.

PPO - You can go to any specialist/doctor but you pay a bit more if OON (Out of network) and from what I've learned specialists and doctors can refuse you service and there's nothing your insurance company can do it about it because there is no contract in place so it can be tempting but also not as promising as intended. In 2022, I wouldn't enroll into a PPO under Medicare plans or at least MA plans because I've seen so many specialist and doctors say "we don't take PPO plans.."

Do you qualify for Medical? If so, I'd look into enrolling or at least attempting to enroll into MediCal because it really does help so much. They cover all of your %coinsurances payments (NOT COPAYMENTS) and to add while your financial status plays a big role, I have seen diabetics be approved while taking home 100k a year so again, it doesn't hurt to attempt to see what options you have with obtaining Medical assistance. Here's an example below on how MediCal works in paying your claims that your share of cost would be under an MA plan:

Lets pretend you need a wheelchair and your plan benefits for DME (Durable Medical Equipment) are as follows:

0% Coinsurance if less than or equal to $350.00, 30% if greater than $350.01 With a PA required. What that means is that first you will need a referral from your PCP (Primary Care Provider/Physician) to a DME company and have it be approved, secondly if your wheelchair costs say $12,000.00 you are on the hook to pay 30% of that without having the financial assistance provided by MediCal.


AVOID signing up for plans that are NEW in an area or not established. The reasoning for this is because their provider network in your area may be limited and therefore you may find yourself driving 20-30 Miles to see a provider because the one closer to you that's 15 miles away is booking 2 months out and if you ask your MA plan to see your favorite oncologist down the street they are going to ask you to have your doctor submit a referral to the plan/IPA to be reviewed and if denied they will say you can file an appeal as explained prior. This is a complete waste of time because you will be denied with your appeal 9.9 times out of 10 because you will have been provided and supplied a doctor that can provide the same services and your feelings wont matter and Medicare will agree with the decision and Medicare won't even see the denial for 2-3 months anyways so by that time you could have already had your procedure done rather than being stubborn and trying to go the appeals route.

GET AN EOC (Evidence of Coverage) from any plan that you "MIGHT WANT" to sign up for or if your more computer savvy get it online so you cant cntrl F the things your interested about. If your needing drug information, ask for a drug formulary. Not all PBP's and Plans cover the same drugs. Also something that annoys the shit out of me, Part B drugs are Medicare regulated and theres nothing the MA plan can do or say about your cost or what they do or don't cover. Medicare Part B drugs are always 20% coinsurance, and without MediCal you wil be stuck paying for that coinsurance HOWEVER, your plan will have a Maximum OOP limit you have to reach before your plan will completely pay for everything you have done NOT INCLUDING Part D drugs. The general plan's I see for MOOP( Maximum Out of Pocket) are around $3,000-$4,000 but I've seen one recently which was only $1,100.00 but again, read your benefits.

Also don't expect when you jump from company to company that your same diabetic monitor that was covered under "blank" is going to be covered under "blank" unless its a Medicare covered item, the plans will have completely different providers from one another and their benefits will/may be different so be prepared that your favorite monitor or item you have been using for 5 years may not be covered under this new fancy plan a sales agent sold you on.


I could go on and on so you can just quote and reply with any questions you have and I can try my best to explain them. I've had some conversations with some people that never even knew that when they sign up for a MA plan that they had an IPA that was paying for half their shit and processing their requests..

MY OPINION - Go with Original Medicare for now, and do some research. There are things called SEP (Special enrollment Periods) and you can also change plans throughout the year if you qualify for an SEP... Open enrollment period I believe though begins on OCT 15 each year and ends Dec 31... Then you have from Jan - March 31 to still openly change plans with other plans but with your internal MA plan, you can only change once during this time period. Between March 31 - Oct 15 the only way you can call your plan and change your PBP is by qualifying for an SEP these are like moving out of the area, leaving prison etc. The most common is moving but there are others.. If you want to sleep easy IMO Go with Kaiser and their MA plans... From what I've heard the referral process is non existent since you can only go to Kaiser doctors anyways and their establishments are always good however if you're like some and your PCP isn't a Kaiser doctor, then you're most likely going to find yourself following your PCP to whatever IPA they are contracted with and then whatever plan that IPA is contracted with. A lot of folks prefer to follow their doctors from place to place.

Anywho there's my wall of text and if you have questions feel free to reply to me and I'll answer best I can.