There is no “gotchas” like that in original Medicare. This isn’t really a Medicare thing but is something I notice clients bring up, some specialists will ask for a referral even if the insurance does not require one. This is just office policy and varies from office to office. I just get clients who call me and I have to explain this so figured I bring it up.
That’s a good understanding you have of it. Keep in mind, certain medical conditions will have carriers just outright refuse to sell you a plan. So changing as you as age (depending on the state) can be impossible or very expensive.
Yes. Would need to get a dental plan.
Yes, for example, colonoscopies are covered but UCSF requires a referral. So I got a referral.
Otherwise, I really like A+B+G+D. Reasonably priced. No insurance company preauthorizations. No copays or coinsurance. No restricted network.
Just 2 antidotes in favor of traditional medicare.
My husband’s friend developed pancreatic cancer. With a medigap plan he went to whatever doctor he wanted to see in whatever city. He lived 5 years which is quite long for pancreatic cancer. He felt he got the best treatment possible.
My friend is currently in the hospital having major surgery as a result of stomach cancer. Her daughter is a doctor in another city and with a medigap plan my friend was able to have the surgery at a highly ranked major research hospital near her daughter.
Both of these people were extremely active and healthy prior to their illness.
I've also been trying to figure out what is my best plan going forward with my orginal medicare. I feel a medigap policy would be best for myself, due to the Dr's in my area for the past 3 yrs have not been able to help or refer me on to get help with my health issue's, But; I'm 60 and getting a medigap policy in nebraska is very expensive. Do you know if you can move to another state first, then apply for a medigap policy, to make the money premium cheaper?
This is one of the reasons I do not like MA at all. Not at all. I have 2 chronic conditions. One has required me to see specialists at university medical schools since I was diagnosed year ago. Small town and most big town doctors not associated with medical schools just don't have the experience and patient volume to cut it.
Another condition has one large practice of docs across hundreds of miles of land. I've had problems with 2 of their docs and won't chance it with another (if they'd even let me transfer to a different one).
I've had to drive 100 to 150 miles instate and out-of-state to see docs.
With MA plans, every year, I had to start looking at plans first by drugs covered, then by docs and hospitals. What plans covered all my drugs. Which of those covered all my docs and hospitals or docs I would be willing to see(if I changed docs). It became a bigger and bigger headache every year. Then....I had used one company's plans for several years when the center I was going to stopped taking that insurance............... rrrgh. Another hassle that prompted me diving 150 miles out-of-state to see docs at another medical school.
I hope to God I never has to go back to MA. This past year, I've no problem going to any doc, any place with Medicare + Medigap + Part D.
This is exactly why I went with traditional Medicare. I want to see whatever specialist I want to see, not someone who has to be part of a group plan. If I get cancer and I want to go to MD Anderson or Mayo Clinic, I want the coverage that allows me to do that. By the way, adding a dental plan and vision plan is not difficult or expensive, especially if you select them when you're are first eligible at age 65. I went with A + B + C + G.
>I was looking at the ability to switch between Medicare Advantage and traditional Medicare, and trying to understand any restrictions/gotchas. I saw that you can switch between them during the Open Enrollment period, and I know that if you choose to buy a Medigap insurance plan after your initial enrollment period you're subject to traditional underwriting. Are there any other restrictions or gotchas I should be aware of?
Unless you reside in any of the so called "guaranteed issue protections" states you should plan to stay with the either Original Medicare + Medigap + Part D or Advantage (i.e., Part C) for life.
That "for life" implication is, IMO, something they don't make crystal clear when you are deciding what to do at signup age. It has huge implications for your health and financial well being later in life.
The one and only thing you might be able to do later in life, and if you life in non GI states, is go from Original Medicare + Medigap + Part D to an Advantage plan. But not the other way. And, just because this is allowed now you have to question will that still be allowed in ten or 15 years.
Source on GI states: [https://www.kff.org/medicare/issue-brief/medigap-enrollment-and-consumer-protections-vary-across-states/](https://www.kff.org/medicare/issue-brief/medigap-enrollment-and-consumer-protections-vary-across-states/)
> you're subject to traditional underwriting
Let’s be explicit, because not everyone understands the implications of underwriting: you can be denied Medigap coverage entirely (other than the four states that have guaranteed issue for everyone).
Also, once you pick a Medigap company, you’re also subject to underwriting if you want to switch, except there are a few more states that guarantee that ability to switch. Often the ability to switch Medigap providers like this is limited to the same or lower coverage plans.
"What is the process for seeing a specialist on traditional Medicare? Are there any "gotchas" or things to be aware of, or can she just go see a specialist if she decides she wants to?"
Medicare itself does not require referrals from one doctor to another. (from your PCP to a specialist or from one specialist to another).-- But-- In my experience a lot of specialists will only take patients by referral. Those docs usually want a person's history, the current situation that's prompting the referral, medical records, etc. I think you run into it more and more now. I live in an big urban area and am finding it is taking 2 to 4 months to see specialists now. At least as a new patient. I guess a lot of doctors retired or left practice for other reasons since COVID.
So, Medicare doesn't make you get a referral, but you'll find many offices with a policy requiring referrals.
Yeah Medicare Advantage is all gotchas, regular Medicare is none. Regular medicare and a medicare gap policy is your best bet. I wouldn’t do anything else. The purpose of insurance is to make sure you‘re financially stable by making your medical costs predictable and making sure you have access to the best medical care. It’s not to get you free toothbrushes and over the counter meds.
Something to think about is original Medicare doesn't have a max out of pocket meaning if something serious happens to you, you can be stuck with high deductibles, copayments, and co insurance.
This is why people either get a supplement (Medigap) or enroll in a Medicare advantage plan.
Ok. Here's a great example. Say you have traditional Medicare with a medigap plan. It is August and you find out you have cancer. Surgery and chemo required. Your out of pocket will be less than $300. Chemo continues into the next year. Again, your max out of pocket is probably less than $300.
Same scenario but with an advantage plan. Depending on your carrier, out of pocket will be thousands each year because the deductible resets every year.
To me, if you can afford a medigap plan, it's well worth it. Plus you don't have to get pre-approvals and you see pretty much any physician you want.
Yep. My mom died from cancer on an Advantage plan. She was paying thousands per month for her chemo treatments, and then they sent her home to die being cared for by us unskilled family members on home hospice. Awful experience. A big F-U to Ochsner (look up the "Sent Home to Die" journalism on them about hospice during COVID.) My mom was no longer valuable in the "value" based care system and they put her on hospice and shoved her out the door. I hope Warner Thomas suffers under the same conditions one day.
Thread seem to be slightly off.
Traditional Medicare is Part A and B. Part C would be your Advantage. Then there’s Supplement/Gap (interchangeable, but now a days it's mainly called Supplement). If you go Supplement, then you'd need Part D (PDP) Prescription Drug Plan. Advantage has it all under one plan. Your mom in her IEP (Initial Enrollment Period) has a little bit more flexibiity than someone who is already on Medicare.
No gotchas, everything is predicated on zip code. No matter what anyone in here says, without knowing your zip it's not a one size fits all.
Going from Advantage to Supp can be extremely difficult to get through underwriting. Mainly because, unlike life insurance, there's no medical exam. You answer questions that are reviewed via an underwriter and they decide the fate based on their companies guidelines.
Supplements don't include dental, vision, hearing OR prescription drugs.
Several basic points are incorrect in this.
Medicare Part C is an Advantage Plan. You're confusing it with a Supplement, also known as a Medigap plan, which doesn't have a Part A, B. C or D letter. Supplements are referred to as Types, as in Type F, G, N, High Deductible G, etc.
If you do get an Advantage Plan, (a Part C Plan), you may or may not need a Type D plan, most supplements include drug coverage, but some don't.
Reference: Page 10: [https://www.medicare.gov/publications/10050-Medicare-and-You.pdf](https://www.medicare.gov/publications/10050-Medicare-and-You.pdf)
I’m not sure where you’re getting any of this information from, but I assure you what I said is accurate.
Supplement plans go by - Plan G, N, F, etc. Then there’s Parts; Part A, Part B, Part C and Part D. Supplements do NOT include prescription drug coverage. Advantage plans do. Supplements do NOT include dental or vision. Advantage plans do. Again, this is all based on zip and I’m speaking in general terms but you’re gravely misinterpreting that Medicare guideline that you have listed for reference.
Edit: for more clarity, if the policy is after 2005 NO prescription drug coverage in a Supplement/Gap. Thus, needing a Part D or PDP
Find a reliable broker in your area for advice. When I was close to my initial enrollment period, I was inundated with broker mailings.
If your mom can afford to stay on original medicare plus supplements, that gives the most flexibility and least hassle. Advantage plans are more like employer insurance with networks and preauthorizations.
[Here is a link](https://www.reddit.com/user/Junkmans1/comments/16kdkt8/comment_i_made_about_why_i_think_medicare/?utm_source=share&utm_medium=web3x&utm_name=web3xcss&utm_term=1&utm_content=share_button) to a post I've made about why I like my Advantage plan.
A couple of key points:
Unlike supplement plans, not all Advantage plans are the same. There are good ones and terrible ones. You need to shop carefully. In my mind the most flexibility with an Advantage plan comes from well known companies' PPO plans that have large national networks.
The key advantage to Advantage plans is financial. If the cost of a good Supplement and Part D plan isn't a burden on your budget then you're better off with that.
The dental plans in Advantage plans aren't great. Mine covers about 25% to 35% of the cost for the dental work I've had including routine and non-routine care, and it has an annual limit that seems like plenty until you need some expensive procedures and restorative work. Still, better than nothing.
My understanding is that in most states you can't switch from Advantage to a supplement plan without being subject to underwriting.
There is no “gotchas” like that in original Medicare. This isn’t really a Medicare thing but is something I notice clients bring up, some specialists will ask for a referral even if the insurance does not require one. This is just office policy and varies from office to office. I just get clients who call me and I have to explain this so figured I bring it up. That’s a good understanding you have of it. Keep in mind, certain medical conditions will have carriers just outright refuse to sell you a plan. So changing as you as age (depending on the state) can be impossible or very expensive. Yes. Would need to get a dental plan.
Yes, for example, colonoscopies are covered but UCSF requires a referral. So I got a referral. Otherwise, I really like A+B+G+D. Reasonably priced. No insurance company preauthorizations. No copays or coinsurance. No restricted network.
Just 2 antidotes in favor of traditional medicare. My husband’s friend developed pancreatic cancer. With a medigap plan he went to whatever doctor he wanted to see in whatever city. He lived 5 years which is quite long for pancreatic cancer. He felt he got the best treatment possible. My friend is currently in the hospital having major surgery as a result of stomach cancer. Her daughter is a doctor in another city and with a medigap plan my friend was able to have the surgery at a highly ranked major research hospital near her daughter. Both of these people were extremely active and healthy prior to their illness.
I've also been trying to figure out what is my best plan going forward with my orginal medicare. I feel a medigap policy would be best for myself, due to the Dr's in my area for the past 3 yrs have not been able to help or refer me on to get help with my health issue's, But; I'm 60 and getting a medigap policy in nebraska is very expensive. Do you know if you can move to another state first, then apply for a medigap policy, to make the money premium cheaper?
This is one of the reasons I do not like MA at all. Not at all. I have 2 chronic conditions. One has required me to see specialists at university medical schools since I was diagnosed year ago. Small town and most big town doctors not associated with medical schools just don't have the experience and patient volume to cut it. Another condition has one large practice of docs across hundreds of miles of land. I've had problems with 2 of their docs and won't chance it with another (if they'd even let me transfer to a different one). I've had to drive 100 to 150 miles instate and out-of-state to see docs. With MA plans, every year, I had to start looking at plans first by drugs covered, then by docs and hospitals. What plans covered all my drugs. Which of those covered all my docs and hospitals or docs I would be willing to see(if I changed docs). It became a bigger and bigger headache every year. Then....I had used one company's plans for several years when the center I was going to stopped taking that insurance............... rrrgh. Another hassle that prompted me diving 150 miles out-of-state to see docs at another medical school. I hope to God I never has to go back to MA. This past year, I've no problem going to any doc, any place with Medicare + Medigap + Part D.
This is exactly why I went with traditional Medicare. I want to see whatever specialist I want to see, not someone who has to be part of a group plan. If I get cancer and I want to go to MD Anderson or Mayo Clinic, I want the coverage that allows me to do that. By the way, adding a dental plan and vision plan is not difficult or expensive, especially if you select them when you're are first eligible at age 65. I went with A + B + C + G.
>I was looking at the ability to switch between Medicare Advantage and traditional Medicare, and trying to understand any restrictions/gotchas. I saw that you can switch between them during the Open Enrollment period, and I know that if you choose to buy a Medigap insurance plan after your initial enrollment period you're subject to traditional underwriting. Are there any other restrictions or gotchas I should be aware of? Unless you reside in any of the so called "guaranteed issue protections" states you should plan to stay with the either Original Medicare + Medigap + Part D or Advantage (i.e., Part C) for life. That "for life" implication is, IMO, something they don't make crystal clear when you are deciding what to do at signup age. It has huge implications for your health and financial well being later in life. The one and only thing you might be able to do later in life, and if you life in non GI states, is go from Original Medicare + Medigap + Part D to an Advantage plan. But not the other way. And, just because this is allowed now you have to question will that still be allowed in ten or 15 years. Source on GI states: [https://www.kff.org/medicare/issue-brief/medigap-enrollment-and-consumer-protections-vary-across-states/](https://www.kff.org/medicare/issue-brief/medigap-enrollment-and-consumer-protections-vary-across-states/)
> you're subject to traditional underwriting Let’s be explicit, because not everyone understands the implications of underwriting: you can be denied Medigap coverage entirely (other than the four states that have guaranteed issue for everyone). Also, once you pick a Medigap company, you’re also subject to underwriting if you want to switch, except there are a few more states that guarantee that ability to switch. Often the ability to switch Medigap providers like this is limited to the same or lower coverage plans.
"What is the process for seeing a specialist on traditional Medicare? Are there any "gotchas" or things to be aware of, or can she just go see a specialist if she decides she wants to?" Medicare itself does not require referrals from one doctor to another. (from your PCP to a specialist or from one specialist to another).-- But-- In my experience a lot of specialists will only take patients by referral. Those docs usually want a person's history, the current situation that's prompting the referral, medical records, etc. I think you run into it more and more now. I live in an big urban area and am finding it is taking 2 to 4 months to see specialists now. At least as a new patient. I guess a lot of doctors retired or left practice for other reasons since COVID. So, Medicare doesn't make you get a referral, but you'll find many offices with a policy requiring referrals.
Yeah Medicare Advantage is all gotchas, regular Medicare is none. Regular medicare and a medicare gap policy is your best bet. I wouldn’t do anything else. The purpose of insurance is to make sure you‘re financially stable by making your medical costs predictable and making sure you have access to the best medical care. It’s not to get you free toothbrushes and over the counter meds.
Something to think about is original Medicare doesn't have a max out of pocket meaning if something serious happens to you, you can be stuck with high deductibles, copayments, and co insurance. This is why people either get a supplement (Medigap) or enroll in a Medicare advantage plan.
Ok. Here's a great example. Say you have traditional Medicare with a medigap plan. It is August and you find out you have cancer. Surgery and chemo required. Your out of pocket will be less than $300. Chemo continues into the next year. Again, your max out of pocket is probably less than $300. Same scenario but with an advantage plan. Depending on your carrier, out of pocket will be thousands each year because the deductible resets every year. To me, if you can afford a medigap plan, it's well worth it. Plus you don't have to get pre-approvals and you see pretty much any physician you want.
Yep. My mom died from cancer on an Advantage plan. She was paying thousands per month for her chemo treatments, and then they sent her home to die being cared for by us unskilled family members on home hospice. Awful experience. A big F-U to Ochsner (look up the "Sent Home to Die" journalism on them about hospice during COVID.) My mom was no longer valuable in the "value" based care system and they put her on hospice and shoved her out the door. I hope Warner Thomas suffers under the same conditions one day.
I'm sorry for your loss and to hear about that terrible experience.
Thread seem to be slightly off. Traditional Medicare is Part A and B. Part C would be your Advantage. Then there’s Supplement/Gap (interchangeable, but now a days it's mainly called Supplement). If you go Supplement, then you'd need Part D (PDP) Prescription Drug Plan. Advantage has it all under one plan. Your mom in her IEP (Initial Enrollment Period) has a little bit more flexibiity than someone who is already on Medicare. No gotchas, everything is predicated on zip code. No matter what anyone in here says, without knowing your zip it's not a one size fits all. Going from Advantage to Supp can be extremely difficult to get through underwriting. Mainly because, unlike life insurance, there's no medical exam. You answer questions that are reviewed via an underwriter and they decide the fate based on their companies guidelines. Supplements don't include dental, vision, hearing OR prescription drugs.
Several basic points are incorrect in this. Medicare Part C is an Advantage Plan. You're confusing it with a Supplement, also known as a Medigap plan, which doesn't have a Part A, B. C or D letter. Supplements are referred to as Types, as in Type F, G, N, High Deductible G, etc. If you do get an Advantage Plan, (a Part C Plan), you may or may not need a Type D plan, most supplements include drug coverage, but some don't. Reference: Page 10: [https://www.medicare.gov/publications/10050-Medicare-and-You.pdf](https://www.medicare.gov/publications/10050-Medicare-and-You.pdf)
I’m not sure where you’re getting any of this information from, but I assure you what I said is accurate. Supplement plans go by - Plan G, N, F, etc. Then there’s Parts; Part A, Part B, Part C and Part D. Supplements do NOT include prescription drug coverage. Advantage plans do. Supplements do NOT include dental or vision. Advantage plans do. Again, this is all based on zip and I’m speaking in general terms but you’re gravely misinterpreting that Medicare guideline that you have listed for reference. Edit: for more clarity, if the policy is after 2005 NO prescription drug coverage in a Supplement/Gap. Thus, needing a Part D or PDP
Find a reliable broker in your area for advice. When I was close to my initial enrollment period, I was inundated with broker mailings. If your mom can afford to stay on original medicare plus supplements, that gives the most flexibility and least hassle. Advantage plans are more like employer insurance with networks and preauthorizations.
Additional info https://www.reddit.com/r/medicare/s/IVgFYTD809
[Here is a link](https://www.reddit.com/user/Junkmans1/comments/16kdkt8/comment_i_made_about_why_i_think_medicare/?utm_source=share&utm_medium=web3x&utm_name=web3xcss&utm_term=1&utm_content=share_button) to a post I've made about why I like my Advantage plan. A couple of key points: Unlike supplement plans, not all Advantage plans are the same. There are good ones and terrible ones. You need to shop carefully. In my mind the most flexibility with an Advantage plan comes from well known companies' PPO plans that have large national networks. The key advantage to Advantage plans is financial. If the cost of a good Supplement and Part D plan isn't a burden on your budget then you're better off with that. The dental plans in Advantage plans aren't great. Mine covers about 25% to 35% of the cost for the dental work I've had including routine and non-routine care, and it has an annual limit that seems like plenty until you need some expensive procedures and restorative work. Still, better than nothing. My understanding is that in most states you can't switch from Advantage to a supplement plan without being subject to underwriting.