- You can go to any doctor anywhere in the United States who will take original Medicare. So, if you decide to spend a year traveling across the country and you need ordinary medical attention you don't have to worry about networks or whether a doctor will accept your "zip code" based insurance. Even though you buy a supplemental medigap plan based on your zip code, in most states medigap plans work the same way as original Medicare. That is, they cover deductibles and copayments irrespective of where you are being treated. I say most states because Wisconsin, Massachusetts and Minnesota have some unique state medigap rules.
- Although you may not need to see a doctor in another state when you are traveling - you might want to go to an expert or a clinic in another state should you have a serious disease. If the doctor or the clinic will take original Medicare - book an appointment and go! There is no permission to seek from the plan, no primary physician referrals and no mystery on what you will pay. The payment structure is the same no matter what state you are in or what procedure needs treatment.
- The payment structure is always the same. There are no surprise costs to you or surprise payments to your provider. Part B copayment is always a 20 - 35% depending on whether the provider takes assignment aka the official Medicare fee payment. The only way to truly know the cost structure for a Medicare Advantage plan is to ask the plan for a payment schedule for EVERYTHING. The MA plan tell you copays for routine stuff. But, unusual services such as an ambulance typically have a 50% copay. They will never tell you what they pay providers - they do not always pay the provider 80% of the fee. That is more often true for out of network providers.
- Doctors rarely "drop out" of original Medicare. They might stop accepting new Medicare patients but if they "drop out" of Medicare it means they have NO Medicare patients. That is a radical decision for a provider if they have a number of Medicare patients. They'll likely phase out of Medicare but are unlikely to abruptly stop treating you. However, doctors often do drop out of MA plans abruptly and it is usually because of how those plans pay them. The MA plans not only might pay providers less than original Medicare but may be slow to pay providers. When providers leave HMO plans you can no longer go to the doctor and have to find a new doctor in the HMO. For other types of MA plans a doctor can stop accepting the MA plan at any time. So, you might have an MA PPO plan and are being treated for a complex condition by a doctor you trust. That doctor can decide to not accept your plan any time during your treatment.
- I believe Medicare Advantage plans deny claims at a higher rate than original Medicare. I can only verify this anecdotally. I volunteer at the Medicare Rights Center and a large number of the calls I handle revolve around issues with Medicare Advantage plans even though MA plans are used by only 25% of Medicare eligible recipients. There are some insurance providers that are particularly egregious so be sure to look at the star ratings for an MA if you chose this type of plan. There is one company that makes it almost impossible to talk to a "human" to resolve a claim issue. The MA plans also rely on people being befuddled by the appeals process and will give up fighting a denial as it is not easy to appeal a denial of coverage even though people win appeals over 50% of the time.
- I want the option of being able to select the best, lowest cost prescription drug plan and the ability to switch drug plans from year to year. If you select a Medicare Advantage plan that includes prescription drug coverage you are limited to that plan's formulary and it becomes harder to switch MA plans because you then may have to switch doctors. In fact, if you decide to switch from one MA plan to another or to go onto original Medicare for any reason you may face needing to find a new set of doctors.
- Original Medicare does not restrict the types of prosthetic devices, experimental procedures or durable medical equipment a recipient can use. For example, some MA plans will only allow one type of hip replacement device to be used even though original Medicare covers all of them. The MA plan is only required to provide "hip replacement". They are not required to cover all devices available in the marketplace.
Sunday, September 22, 2013
IBM Extend Health - Why I like Original Medicare
In an earlier post I described the history behind Medicare's current structure. In 1997 after private insurance companies began offering plans that provide an alternative to the federal government insurance pool the government insurance pool that was created in 1965 was called "original Medicare". I am a big fan of original Medicare and would never use a private plan alternative aka a Medicare Advantage plan for a number of reasons.