I have been in Medigap Plan F since I enrolled in original Medicare. My current monthly premium is $359. I appreciate the fact that under this plan I have never received a medical bill in my mail box. Apparently, everything is covered.
If I were to switch to a Medigap Plan G, I would now have to pay out of pocket my current annual Medicare Part B Deductible of $240. However, my monthly premium would be reduced to $308, for an annual saving of $372.
If the above is correct, and there are no other hidden charges under Medigap Plan G, I would be curious if there are any other posters who are still enrolled in Medigap Plan F, and why they haven't switched to Plan G?
As I said, in my case, it's the comforting feeling of never having to worry about paying any medical bills, especially as I get older and becoming at some point a semi-senile "alter Kacker". Hence, peace of mind with one less thing to worry about might be worth the extra $372 a year.
If there are any other good reasons to stay in Plan F, I would appreciate hearing about it.
Comments
Right now, Plan G saves you $372 dollars, less whatever extra expenses you would have with it. Those include $240 (part B deductible)
and part A deductible ($1,632 per hospitalization).Each person evaluates odds differently, even before considering peace of mind. Personally, I would count on having to pay the part B deductible ($240). Good health or not, seeing a doctor for something other than preventive care over 12 months is likely.
Major edit Plan G covers Part A deductibles. With that in mind, since Plan G, including the cost of the Part B deductible (making it equivalent to Plan F) is already cheaper than Plan F, and that advantage should only increase in the future, Plan G seems like the obvious choice.
https://www.medicare.gov/health-drug-plans/medigap/basics/compare-plan-benefits
So in my mind, I'd be thinking about a $132 savings and comparing it with the likelihood of being hospitalized ($1,632 per incident). Those are 1:12 odds - you "win" $1 for every $12 you put at risk. While becoming hospitalized is not likely for someone in good health, those are still awfully long odds. I'd still stick with peace of mind (Plan F) for now. But that's just me.Each year the price gap between plans should increase, so each year you'll need to do the same evaluation. And each year you'll be another year older.
An argument for switching sooner than later is that in most states, Medigap is medically underwritten - you have to be in good enough health to qualify for it. Renewal is guaranteed, but changing plans may not be.
https://boomerbenefits.com/medigap-underwriting/
At 65 I had none of the conditions listed under "Sample Underwriting Questions" on the link msf posted. Now I have 1.5.
(Thanks for the useful link, @msf !)
Every year, the price for "F" goes up a bit. BC/BS plays word games, calling it an annual reduction of the initial discount. Bushwah. Anyhow, since I'm paying so much, I'm deliberately getting a bunch of surgical work done. Along the way, some serious junk was discovered and a few laser treatments have killed the bad stuff. I'm making use of every bit of that policy. Luckily, we can afford the payments. And no bills. Period. That's the biggest benefit. Until this country grows a brain and institutes universal coverage.
Medicare does have a network; it's just very large and includes about 99% of non-pediatric physicians as of June 2023. Unlike Medicare Advantage plans, the Medicare network is opt-out, not opt-in. Physicians have to explicitly opt out of taking Medicare.
Mass. does have special rules and exemptions granted by CMS. Among those are the ability to offer Regional PPO (RPPO) Medicare Advantage plans with skinny networks and its own set of Medigap plans (not the usual A, B, ...). These days, they're called Core (analogous to Plan A), Supplement 1 (analogous to Plan F), and Supplement 1A (analogous to Plan G).
https://www.medicare.gov/medigap-supplemental-insurance-plans/#/m/plans?fips=25025&zip=02108&year=2025
Mass. is a community rated state, meaning that a plan must be sold at the same rate to all customers, regardless of age or other conditions, within a "community" (generally a county). But it allows the equivalent of gas station "cash discounts". If you're younger an insurer is allowed to offer you a larger discount off the "rack rate". (NY is different; it is also community rated but without age discounts.)
Even without declining discounts, Medigap premiums increase yearly. "Rates generally do go up over time, and that’s because of inflation and other factors."
Getting no bills is definitely an advantage of having a policy that covers everything (Medicare + Medigap). Whether that is the least expensive alternative in worst case scenarios is another matter. I'll use NY as an example since I'm more familiar with plans there.
HealthFirst, a nonprofit insurer, "has the largest Medicare Advantage membership in the NY metropolitan area". Good insurer, I've used their ACA plan. Their PPO (allowing you to go to any doctor in the Medicare "network") has $0 premium and caps out-of-pocket costs at $5K (in network), $8K total. Very large regional network (including Sloan Kettering), so it's very easy to get in-network coverage for virtually any care needed.
Compare that $5K cap (2025) with Plan F Medigap. The cheapest Plan F anywhere in NYC is $359/mo or $4308/yr. That $700 gap closes when one adds in the $1500 that Healthfirst will pay to any dentist ($0 deductible; $0 copay in network, small co-pay OON) for dental services. Not to mention superior drug coverage vs. standalone Part D plans that are available.
Universal coverage does not mean single payer, it does not mean government run. The Bismarck model (Germany, France, Japan, etc.) works with tight government regulation, non-profit insurers (like HealthFirst and some others), and of course mandatory coverage.
https://www.pnhp.org/single_payer_resources/health_care_systems_four_basic_models.php
However, at this point of my life, it's still the comfortable feeling of not having to worry about paying any medical bills that persuades me to stay in Medigap Plan F. Hence, peace of mind, with one less thing to worry about as I get older, is still worth the extra $372 a year.
But, I will definitely check the viability of my current position as annual premium increases come down the pike, assuming, of course, that my mental faculties remain intact, more or less.
By the way, I luckily live in a state where you have Medigap Open Enrollment year-round with no medical underwriting.
Medicare Advantage Plans are definitely not my cup of tea. All of my doctors will only accept Original Medicare, the word "Advantage" is a poison pill for them, it stops the conversation right there.
Secondly, Medicare Advantage Plans often require prior authorization for certain services, which means that approval is needed before a service or benefit will be covered. Also definitely not my cup of tea, and probably the reason why most good doctors shy away from Advantage plans. Just too much bureaucracy for them to deal with.
Regarding absence of bills with Plan F, that's the theory. And at worst, you may get a couple of bills that you're not responsible for paying. But you still have to deal with them. Crash gave an example. The result of our crazy quilt insurance system.
With a PPO, it doesn't matter (much) whether the doctor accepts the plan or not. Typically the plan will have a higher copay for out of network doctors. The doctors themselves are required to charge no more than they could charge under Original Medicare. If they won't submit a bill to an insurer, then you pay upfront and submit the bill to the PPO for reimbursement. (I know, less peace of mind, more paperwork.) The point is simply that doctors accepting only OM does not stop the conversation (for some people).
Prior authorization: it's a myth that OM never requires prior authorization. It does, albeit for just a limited number of services and for certain durable medical equipment.
https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/prior-authorization-and-pre-claim-review-initiatives
And despite horror stories (there's peace of mind, again), things usually go smoothly.
"Of the 46.2 million prior authorization determinations [in MA plans] in 2022, more than 90% (42.7 million) were fully favorable, meaning the requested item or service was approved in full."
https://www.kff.org/medicare/issue-brief/use-of-prior-authorization-in-medicare-advantage-exceeded-46-million-requests-in-2022/
OM prior authorization approval rates were generally lower (below 80% for outpatient services, below 70% for durable medical equipment in FYs 2021 and 2022). But that's not a fair comparison, because CMS selected for review a limited number of services that are more likely to be abused. Hence the denial rate is expected to be higher.
https://www.cms.gov/files/document/prior-authorization-and-pre-claim-review-program-statistics.pdf
"require prior authorization ... probably the reason why most good doctors shy away from Advantage plans". We can test that theory. Do most good doctors shy away from all commercial insurance - employer sponsored, ACA, etc.? The vast majority of these policies also require prior authorizations.
I know of providers that have dropped various insurers because of slow payments or other difficulties receiving payment. But it is individual insurance companies and not commercial insurance in general that they are dropping.
I do know of one doctor (4.8* on HealthGrades) who stopped taking all insurance other than OM this year. He's near retirement and fed up with dealing with insurance companies, period. As he's phasing out his practice, he doesn't mind losing some patients because of this change. I suggest that he is the exception, that most doctors take commercial insurance despite their prior authorization baggage.
Well, despite Crash's example, all I can say is that I have been on Plan F for over a decade and have never received a medical bill in my mailbox.
Regarding prior authorization, I recently came across an article in a local paper (City&State) regarding the so far unsuccessful efforts by the City of NY to force its retired employees from Original Medicare into an Aetna Medicare Advantage Plan. Here is an excerpt: "Opponents of Medicare Advantage say that the privately-managed plan will make it more difficult for retirees to receive care, citing investigative reports in The New York Times and Kaiser Health News that documented how private plans were ripping off the federal government while restricting retirees’ access to critical medical care through pre-authorizations.
The Times investigation, published in October, ran under the headline: “‘The Cash Monster Was Insatiable’: How Health Insurers Exploited Medicare for Billions – By next year half of Medicare beneficiaries will have a private Medicare Advantage plan. Most large insurers have been accused in court of fraud.”
According to the Times, “eight of the 10 biggest Medicare Advantage insurers – representing more than two-thirds of the market – have submitted inflated bills, according to the federal audits. And four of the five largest players – UnitedHealth, Humana, Elevance and Kaiser – have faced federal lawsuits alleging that efforts to over diagnose their customers crossed the line into fraud. … The additional diagnoses led to $12 billion in overpayments in 2020, according to an estimate from the group that advises Medicare on payment policies – enough to cover hearing and vision care for every American over 65.”
Most of your post (2+ of 3 paragraphs) talks about how unethical, money hungry the health care insurers are. No argument there. If your position is one of principle, how does that comport with buying Supplemental Medicare insurance from one of these private insurers?
"four of the five largest players – UnitedHealth, Humana, Elevance [formerly Anthem] and Kaiser – have faced federal lawsuits". Can we infer that the fifth in that group of largest players has not faced federal lawsuits? That would be CVS (Aetna), the insurer that NYC planned to use.
https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2024-enrollment-update-and-key-trends
"NYC retirees age 65+ and their eligible dependents have ... choices in how they receive their retiree health insurance benefits, with the vast majority of retirees in either HIP VIP HMO, or GHI Senior Care."
https://bplc.cssny.org/blog/nyc-retiree-health-benefits-update
HIP and GHI are insurance brands of EmblemHealth, a large regional health insurance provider. Senior Care is a "supplemental coverage plan that works with Original Medicare. HIP VIP HMO is exactly what it sounds like - an HMO. Since it is an Emblem plan, it is regional and retirees must be living in the NYC area to use it. Retirees (especially ones out of town) can also choose among other HMOs and PPOs.
https://www.nyc.gov/site/olr/health/retiree/health-retiree-choosing-a-health-plan.page
This chart (link below) compares the existing (VIP HMO and Senior Care) plans with the proposed Aetna plan. On features and value, Aetna comes out even or slightly ahead.
https://www.nyc.gov/assets/olr/downloads/pdf/health/aetna-ma-docs/plan-comparison-chart-seniorcare-hip-aetna.pdf
The union members raised many objections, such as: "concerns that retirees will be stuck with a smaller network of providers and larger out-of-pocket costs." The above cited chart says otherwise.
OTOH, the added preauthorization requirement for some procedures would be a real, change, and the only substantial objection that I found credible. The KFF study reports that over 90% of preauthorization requests are granted in full for MA insurers generally.
In court, Aetna submitted figures for its own plans. "According to Aetna, out of more than 82 million claims under its Medicare Advantage plans last year, only 3.4% were subject to prior approval, and 0.49% were denied."
https://gothamist.com/news/aetna-reveals-health-care-denial-rates-in-medicare-advantage-court-case-for-nyc-retirees
That 0.49% may not give you peace of mind, but then again, Original Medicare also denies some procedures.
P.S. When people quote from articles (or even paraphrase) it would be nice if they would cite the articles. The NYTimes article is here:
https://www.nytimes.com/2022/10/08/upshot/medicare-advantage-fraud-allegations.html
Regarding Aetna, it says: "The fifth company, CVS Health, which owns Aetna, told investors its practices were being investigated by the Department of Justice." That was two years ago. Any updates?
The political and legal shenanigans which took place by the current city administration over the past 2+ years have been repelled in court in multiple cases. This is not “old news.” The Adams administration has continued to appeal the court decisions.
The majority of NYC retirees do not want to lose our choice of health care plans which were part of the hiring package and promise to us, and that access to traditional medicare would always be available to us.
For a review of the history of our struggle to maintain our choice of health services you can visit one of the union sites here: https://psc-cuny.org/whats-happening-retiree-healthcare/
My apologies for going off topic, but the tangential topic of the NYC retirees, issue with health care, required some background info. The reasons for our push-back are already embedded in earlier posts.
It would be interesting to watch what happens in NY (or, is it only NYC?).
We continue to have a "choice" (Medicare Supplemental vs Medicare Advantage) but the premium difference between the two attracted a lot of retirees to sign up for our MA option.
Both are offered by United Healthcare.
Curiously, that premium difference was a factor of 10X for 2024, with UHMA being 10X cheaper. Now that a large number of retirees have this UHMA plan, UHMA tripled their premium for 2025. The United Healthcare Medicare Supplemental plan premium actually decreased about 3% for 2025.
Seems like a pure bait and switch with the UHMA choice.
Quite. Slimebags, all.
Glad that retirees fighting the Adams Admin. in NYC have been winning in court. ... So far. ... Recent revelations show that the price of his integrity was pretty cheap.
This is old news because basically nothing has changed since August 2023, when the injunction barring NYC from implementing its retiree health plan switch was made permanent. Nothing new aside from the injunction being sustained on appeal.
Since you brought up PSC CUNY, it is worth mentioning that its retirees have their own drug plan which they would not lose in a move to Aetna.
Looking at the appellate ruling, it is predicated on "Many City retirees [having] stated that their chosen providers and hospitals, like many healthcare providers, do not accept the MAPs [Medicare Advantage Plans]."
However, when using a PPO, it doesn't really matter whether a chosen provider accepts the PPO. If you go to an out-of-network provider who accepts Original Medicare, you're covered.
There are three possibilities:
1. The provider, though out-of-network, bills the PPO. I have an out-of-network provider that does this. The amount of the bill is set by law (see below) so long as it is a Medicare provider and you are enrolled in Medicare (any form, original or MA).
Your PPO pays the provider (even though out of network), less your cost-sharing portion. The provider may not take Aetna, but it will not turn down a check from Aetna. The provider then bills you the remaining balance, i.e. your cost-sharing amount.
2. You are presented a bill that you can pass along to your PPO. From there, things proceed as above.
3. The provider insists on immediate payment. I have another out-of-network provider that does this. You pay the bill and then send it along with a receipt to the PPO for reimbursement. You get reimbursed for all but your cost-sharing amount.
No matter what the procedure, at the end of the day you wind up paying just the cost-sharing amount stated in the Evidence of Coverage for the out-of-network service.
The three possibilities above are just expositions of Aetna's Evidence of Coverage: https://www.nyc.gov/assets/olr/downloads/pdf/rfp/ma-hearing/cony-ma-eoc-soc-02102023.pdf
------------------
There is a federal law, §1852(k)(1) of the Social Security Act, that says that a Medicare provider cannot charge anyone enrolled in Medicare Advantage (originally called Medicare+Choice) more than it would charge a person enrolled in Original Medicare.
https://www-origin.ssa.gov/OP_Home/ssact/title18/1852.htm
This is what makes Medicare PPOs work. If you're covered by a PPO other than Medicare Advantage (e.g. an employer plan), then a provider can charge whatever. The PPO insurer will pay only a UCR (usual, customary and reasonable) amount that it itself determines. This nearly always leaves you owing more than the policy cost sharing amount.
For example, suppose a doctor bills $100 and your stated copay is $10. If the insurer decides that the doctor should get only $50, then it will pay the doctor $40 ($50 minus your $10 copay). You'll get stuck paying the $60 difference. That shouldn't happen under Medicare since a billed amount is not subject to a provider's whim.
First, let me say that I enjoy your investment contributions on this site. You take a focused and analytical approach to data, which is well thought-out and clearly outlined. I appreciate it. You have carried that forward in your response to me about MA plans and what they are *required* and *should* provide. For me, there is a trust issue at stake, especially as my wife and I age, requiring more anxiety provoking health services.
My wife and I have been with Traditional Medicare and a medicare supplemental plan over 7 years and have never had to communicate an appeal, request authorization, denied coverage, or received a bill during that time. I can see any doctor who accepts Medicare anywhere in the country. All of these items are advertised as policy for MA Plan.
But what I keep in mind is that all MA Plans are private companies whose overarching principle is to generate profits. That in itself is not a bad thing. I invest my money with companies to generate an income. But I think health care is a different entity completely, and I do not trust that drive for profit in this case.
So I do not dispute what you’ve posted (with one exception - the last court decision was 5/2024; Adams continues to press on). I choose the peace of mind that I’ve experienced with Traditional Medicare and Supplemental plan even though it costs me more in the short term; and even though the supplemental plan increases each year, I know there will be no surprises with accessing the health care, I or my wife needs.
Simply put, it comes down to - “who do you trust?”
With respect to insurance of any kind, the correct answer is "no one".
Thanks for the well stated post. I agree that much of this comes down to trust, which is a variant of what @fred495 originally expressed as peace of mind.
Your supplemental plan, whether it is NYC's Senior Care or a standard Medigap plan (A-N), is provided by the same "dishonest" insurance companies that provide MA plans. So some trust in these companies is still needed. Though perhaps because less can go wrong with supplemental plans they are easier to trust. Or perhaps seven years of good experience has made your provider more trustworthy.
Not all MA providers are out for profit. Some, like HealthFirst, like the "Blues" that haven't yet gone over to the dark side (switching from not-for-profit to for-profit), aren't driven by making money. Maybe that makes a difference. I don't know. Though I agree that there is something off putting about profiting from, effectively, someone's misery.
For me, I've had more hassles with insurers because of incompetence than because of what motivates them.
Quick example: my SO and I had the same policy, went to the same PCP on the same day, had the same blood test. One of us was charged a $20 copay, the other was charged $0. I recognized this as a coding problem. One had been coded as a lab procedure ($0 copay), the other as a diagnostic test ($20 copay).
The insurer refused to acknowledge that this inconsistency proved that something was wrong. I had to go to the state attorney general's office (they have a special department to handle this stuff) to get the insurer to fix things. On principle.
I did mention last court decision, but dismissed it as nothing substantial: "Nothing new aside from the injunction being sustained on appeal."
With any luck, Adams won't be the one pressing on much longer. Can I say that, or is it too political?
@msf knows the rules more than most here. So good that this coding mistake was fixed.
But that difference may be valid in many cases. The 1st test may be covered at 100% (lab procedure), but any quick repeat or follow up test (a diagnostic test) may be covered at less than 100% or require copay.
We have gotten burned on this more than once. My wife had some radiology work done, but the images didn't come out clear enough and they should have just redone it to fix their error. But they had my wife sign a paper that made it a follow up with her consent. When I questioned the insurer later, it won't budge because the policy on 1st test vs follow up (diagnostic) tests is clearly spelled out. The amount wasn't worth wasting more time, but my wife now wont sign some forms on the spot.
The point about insurers is also good - after all, the same insurers that we rely on while working are also the same ones who run Medigap insurance, but suddenly become totally untrustworthy for MA. I am in a large urban area with a large MA-PPO plan and haven't encountered any problems.
Well said, exactly the same reasons why I chose to stay in Original Medicare Plan F.
May I also add that I just spoke to a friend of mine who is a retired NYC schoolteacher. He told me that when the City first rolled out its Medicare Advantage Plan, the retirees were assured that any doctor who accepts Original Medicare would also accept the City's new Advantage Plan. However, all of my friend's doctors told him that they do not accept any Advantage Plan, period. They most frequently mentioned the onerous procedure they would have to follow of obtaining access to critical medical care for their patients through pre-authorizations.
As I said, as I get older, one thing less to worry about in my life might be worth the extra $372 a year.
If I ever want to change plans, I am lucky to live in a state where you have Medigap Open Enrollment year-round with no medical underwriting.
My wife and I switched to Tufts Access PPO a year ago and have never given any care a second thought, even after I was hit by a car and needed all sorts of expensive care. BCBS has something similar and competitive.
Zero or low costs for all our meds too (Optum, Costco, CVS).
I am studying 2025 details to see what is going to get worse. But anyone in Mass. who has not delved at least Tufts Access PPO may be missing out bigtime.
Drug plans often get little attention when comparing MAPD plans. For most people there's little difference - generics, preferred or otherwise, are either "free" or dirt cheap on most plans. But when it comes to brand name drugs, the difference between plans can be huge.
Over the past few years, drug plans, both Part D and MAPD, have been moving from copay (flat amount per item) to coinsurance (percentage cost). Brand name drugs with four (or more) digit costs are becoming way more expensive.
Consider Prolia, a brand name drug used by many for osteoporosis. (I know a few people using it.) Plans typically list it as a tier 4 (brand name, non-preferred) drug. The manufacturer gives its list price (wholesale acquisition price) as $1,786.12. It is injected twice yearly.
Tufts Preferred Access PPO charges 50% for tier 4 drugs. That would come to $1,786 yearly. (Medicare.gov says $1,62x).
BC/BS Blue SaverRx charges 49% copay for tier 4 drugs. That comes out about the same as Tufts. (Medicare.gov says $1,59x.)
Or you could get a BC/BS PPO plan that charges just $285/dose ($570/year), but it comes with an $87/mo premium. The all in cost is about the same, at $1,614.
One point here is that what looks like an obvious candidate can instantly become dubious depending on one's individual situation.
Another point is that drugs can shift the whole landscape, even tilting it toward MA plans.
Medicare.gov shows no Part D policy charging under $1,900 in Boston when one includes Prolia. But it reports that Mass General Brigham PPO's all in cost, including Prolia, is "just" $600/year. That's a $1,300 difference.
One might be willing to pay the cost of a Medigap plan for the peace of mind that comes with Original Medicare. Many people are. But adding yet another $1,300 on top of that due to Part D costs could give one pause. The good news is that starting in 2025, drug costs will be capped at $2,000, so exposure isn't unlimited.
Good to know! Great information. My Part D is a Wellcare Plan. Going to a ZERO premium in 2025. I use the plan for most of my oodles of 'scripts. The expensive ones, I order from North of the border. It does not count toward deductibles and out-of-pocket maximums, but that Plan is designed to drive you into poverty before coverage kicks-in, in the old 80/20 standard sense. They play word games. ... So, I call Winnipeg. The drugstore might be in Mauritius. And it gets sent to me via the Danish Mail? I dunno how they make that work, but I still come out ahead.
https://www.pocketpills.com/drug/prolia
The Premium - (in my case, it is embedded in my Medicare Advantage Premium)
The Deductible - (Full out of pocket Cost of the RX up to a specific $...in my case $200)
The Co-payment - (A percentage of the RX cost based on the tier of the drug up to a $ Amount... in my case, $2000).
I assume my deductible and my copay are additive ($200 +$1800 = $2000). At that point the cost of meds are fully coverage by my plan...whoopie!
For 2025:
All must pay for:
Medicare Part B - which looks like it will be about $185/M (plus IRMAA adjustments)
Next select between:
- A Supplemental Plan (Some may include benefits for hearing, eye care... maybe even dental?) or
- Medicare Advantage Plan (Hearing, Eye care , Dental or Part D may be included)
Select a Part D Plan (Costs = Premium + as much as $2K of deductibles and co-pays)
Some Non - required Coverage I plan on having:
- Dental (My local Dentist offers an in house care plan) - $280 - Covers basic Care - 2 cleanings, x-rays, exams
- Hearing (Hearing Tests and Hearing aid allowances) - I found that Costco or Easter Seals in our area offered affordable services
- Eyecare (Eye Tests and Eye glass allowances) - I found that Costco offered affordable services
Snapshot of maximum Health care costs for 2025:
Part B= ($185*12) = $2,220
Medicare Advantage = $1200 (Includes Part D Premium) + Max $2000 Medical Deductible + Part D Potential out of Pocket Max cost of $2000
Dental Plan - $280 (50% discount of other procedures)
All of the above costs are close to $7700
In years where I have mostly Wellness visits I would have costs close to $3700
Most of this is HSA eligible for reimbursement so I will have decisions to make on how I manage that account going forward.
Lots to continue to learn and do.
GoodRx shows pricing between $1,700 and $1,800 per dose (two doses per year).
Though not listed as a specialty drug in formularies, it is obtained from a specialty pharmacy that ships it to a doctor's office. It is refrigerated.
Also, as @Crash said, even if you could get Prolia on the side, you wouldn't get credit for it against your $2000 out of pocket drug cap.