[OrangeBlossomBaby]

Originally Posted by BigDawgInLakeDenham

Why are you all so worried about specialists? Why aren't you worried about a solid primary Care doctor that can get to know you and manage your needs? Are you those people that don't have a doctor but want a specialist when you're really f'ed up? I'm really interested in how you come up with your way of thinking because I spent a career working with people coming into the hospital because they believed themselves to be healthy and would see a specialist if they ever needed, but because they didn't pursue primary care, like managed care or an advantage plan, they were too far gone for any "specialist" to save. The general public knows nothing about navigating the Healthcare system. I had an HMO for 40 years of work and have always had everything I've needed because you can get "specialists" and I get all of the same in my "mistake" of an Advantage Plan. You never admit that you can choose a PPO that gives you more doctors to choose from or do you not understand that concept. Please do tell us your health history and how it's negatively been impacted by Advantage Plans and how traditional Medicare has saved your lives. Never once was I told not to do CPR on someone because they had an advantage plan. Never once did I not do labs on an advantage plan patient. Healthcare Professionals don't see insurance in that moment you really need them. Actually I never heard anyone mention a patient's insurance. Other people's health and lives is nothing to tinker with and insurance choices are and should be personal. Everyone needs a Primary Care Physician to manage their care and to recommend appropriate treatment including a specialist, only if necessary. Seeing a specialist unnecessarily is abusing and burdening the health care system but entitled people don't see it that way. I'm done for now

It's not about that. When you go to your regular physician for a problem, and the physician says you need a specialist, you need to know if you can afford to go to the specialist. Knowing whether your insurance covers specialists in your area, especially if your regular physician refers you to a specific one or group - is incredibly important.

Getting a PCP is a no-brainer. There are dozens and dozens of them, and you just have to pick one that accepts your insurance. There aren't dozens and dozens of specialists in each specialty, and many of them don't accept medicare at all.

For instance - I know I need a hip replacement. My PCP doesn't do those. I need a specialist for that. So when it was time for me to select my health insurance plan, I had to consider the cost of the hip replacement in mind. They run around $25,000 for people who don't have any insurance and aren't in a poverty level to get a break on the price. My insurance has super low premiums - only $17/month. No deductible. But an out of pocket expense max of $9700. That means - if I need a hip replacement THIS year, I'll pay $9700, instead of $25,000, and other medical expenses for the year won't cost anything at all.

If I don't need the hip replacement this year, then I'll pay my co-pays throughout the year when I go to the doctor, UNTIL I've paid out $9700, and then I'll pay no more til next year. Right now I'm racking up $85/DAY in expenses because I'm undergoing radiation treatments for skin cancer. My PCP doesn't provide that service, a specialist is handling that. That's the co-pay for specialist services on my plan.

I'm not on medicare yet, not old enough yet. But the explanation of "why" people are concerned about specialist access is the same no matter which type of health insurance you have.

[golfing eagles]

Originally Posted by OrangeBlossomBaby

It's not about that. When you go to your regular physician for a problem, and the physician says you need a specialist, you need to know if you can afford to go to the specialist. Knowing whether your insurance covers specialists in your area, especially if your regular physician refers you to a specific one or group - is incredibly important.

Getting a PCP is a no-brainer. There are dozens and dozens of them, and you just have to pick one that accepts your insurance. There aren't dozens and dozens of specialists in each specialty, and many of them don't accept medicare at all.

For instance - I know I need a hip replacement. My PCP doesn't do those. I need a specialist for that. So when it was time for me to select my health insurance plan, I had to consider the cost of the hip replacement in mind. They run around $25,000 for people who don't have any insurance and aren't in a poverty level to get a break on the price. My insurance has super low premiums - only $17/month. No deductible. But an out of pocket expense max of $9700. That means - if I need a hip replacement THIS year, I'll pay $9700, instead of $25,000, and other medical expenses for the year won't cost anything at all.

If I don't need the hip replacement this year, then I'll pay my co-pays throughout the year when I go to the doctor, UNTIL I've paid out $9700, and then I'll pay no more til next year. Right now I'm racking up $85/DAY in expenses because I'm undergoing radiation treatments for skin cancer. My PCP doesn't provide that service, a specialist is handling that. That's the co-pay for specialist services on my plan.

I'm not on medicare yet, not old enough yet. But the explanation of "why" people are concerned about specialist access is the same no matter which type of health insurance you have.

Just one question: How did you get insurance for $17/month and no deductible when I've been paying $1600/month with a $7200 deductible (no health problems that would cause it to rated up)

[MX rider]

Originally Posted by BrianL99

There are really 2 choices in the Medicare world.

"Managed healthcare", where a provider manages your healthcare. An insurance company, who is in business to make a profit, is making your healthcare decisions.

Or "Self managed", where you yourself, directs your healthcare to your benefit.

It's a very simple equation. Who should be in charge of one's healthcare? A corporate entity, whose goal is to make profits or one's self, who's goal is to stay healthy and live a long and prosperous life?

Or, we could look it at another way. Name ONE "advantage" a Medicare Advantage Plan offers over a Medicare Supplemental plan, that isn't related to costs or "freebies".

It's a no brainer, unless financial constraints force you into a Medicare Advantage plan.

We're on AARP UHC Advantage and love it. They have a huge nationwide network so it travels with you. We needed that since we're snowbirds.

We did a ton of research and even talked with people on this plan, which I doubt you did. We even talked to SHINE, they said it was a very good option for us. It's also highly rated by Medicare.
We love the wellness benefits as well.

You're painting with a broad brush, and you're not fully informed.
All advantage plans differ by a lot.

[tophcfa]

Originally Posted by golfing eagles

Just one question: How did you get insurance for $17/month and no deductible when I've been paying $1600/month with a $7200 deductible (no health problems that would cause it to rated up)

Obamacare income testing.

[tophcfa]

Originally Posted by BigDawgInLakeDenham

Why are you all so worried about specialists? Why aren't you worried about a solid primary Care doctor that can get to know you and manage your needs? Are you those people that don't have a doctor but want a specialist when you're really f'ed up? I'm really interested in how you come up with your way of thinking because I spent a career working with people coming into the hospital because they believed themselves to be healthy and would see a specialist if they ever needed, but because they didn't pursue primary care, like managed care or an advantage plan, they were too far gone for any "specialist" to save. The general public knows nothing about navigating the Healthcare system. I had an HMO for 40 years of work and have always had everything I've needed because you can get "specialists" and I get all of the same in my "mistake" of an Advantage Plan. You never admit that you can choose a PPO that gives you more doctors to choose from or do you not understand that concept. Please do tell us your health history and how it's negatively been impacted by Advantage Plans and how traditional Medicare has saved your lives. Never once was I told not to do CPR on someone because they had an advantage plan. Never once did I not do labs on an advantage plan patient. Healthcare Professionals don't see insurance in that moment you really need them. Actually I never heard anyone mention a patient's insurance. Other people's health and lives is nothing to tinker with and insurance choices are and should be personal. Everyone needs a Primary Care Physician to manage their care and to recommend appropriate treatment including a specialist, only if necessary. Seeing a specialist unnecessarily is abusing and burdening the health care system but entitled people don't see it that way. I'm done for now

Whoever said patients with Medigap plans don’t have a PCP who helps them manage their health care? With a Medigap plan, if you need to see a specialist for a life altering condition, the PCP can refer to a top specialist in the USA, not whoever is practicing and accepting patients in your local network. If you happen to live in a rural area, there may not be an experienced specialist in your network, so you have to roll the dice with a generalist and hope for the best. Not optimal at all.
Also, with a part g Medigap plan, if that condition runs up a million dollars in medical expenses, all you pay is your approximately $250 annual deductible and never see another bill.

[Dusty_Star]

Originally Posted by OrangeBlossomBaby

Getting a PCP is a no-brainer. There are dozens and dozens of them, and you just have to pick one that accepts your insurance. There aren't dozens and dozens of specialists in each specialty, and many of them don't accept medicare at all.

This article (September, 2023) says about 1% of physicians have opted out of Medicare, with the specialty of Psychiatry having the greatest number of opt-outs at 7%. It does vary slightly by state, with Florida being in the 1% to 1.5 % range.

How Many Physicians Have Opted Out of the Medicare Program? | KFF

According to this very few physicians have opted-out of Medicare. Have you found this to be different in The Villages?

[retiredguy123]

Note that the OP's only question was, if they have original (traditional) Medicare and a Medicare supplement plan, is there a network of providers that they must use to be paid by the supplement plan? The question has already been answered and the answer is no. If the provider accepts traditional Medicare, then the supplement plan will cover all or part of the coinsurance.

[golfing eagles]

Originally Posted by retiredguy123

Note that the OP's only question was, if they have original (traditional) Medicare and a Medicare supplement plan, is there a network of providers that they must use to be paid by the supplement plan? The question has already been answered and the answer is no. If the provider accepts traditional Medicare, then the supplement plan will cover all or part of the coinsurance.

And since when does a definitive answer to a specific question end a thread on TOTV?

[OrangeBlossomBaby]

Originally Posted by tophcfa

Obamacare income testing.

It's a crappy plan. The basics are covered, I have to pay $85 per treatment, test, and specialist visit, and I have to keep paying that until I've hit $9700 out of pocket. That's just for me. Hubby has his own $9700 out of pocket, so the family benefit doesn't begin until we've eaten through $19,400 combined.

It's a Florida Blue bronze POS. And yes we're low income - not poverty though, or else we'd qualify for Medicaid. Last year the exact same plan was $187 premiums every month. I don't know why it went down so much this year but I'm not complaining. The year before, we were paying $267/month for a Silver plan.

[golfing eagles]

Originally Posted by OrangeBlossomBaby

It's a crappy plan. The basics are covered, I have to pay $85 per treatment, test, and specialist visit, and I have to keep paying that until I've hit $9700 out of pocket. That's just for me. Hubby has his own $9700 out of pocket, so the family benefit doesn't begin until we've eaten through $19,400 combined.

It's a Florida Blue bronze POS. And yes we're low income - not poverty though, or else we'd qualify for Medicaid. Last year the exact same plan was $187 premiums every month. I don't know why it went down so much this year but I'm not complaining. The year before, we were paying $267/month for a Silver plan.

Amazing. I also have Florida Blue Bronze plan. $15,828/ month, single coverage, no significant health issues, $7,200 deductible and about $13,000 out of pocket max. Prescription meds run another $40/mo. Over the past 9 years I've put in about $110,000 into health insurance premiums and received back about $1.98 in benefits. Bottom line---better to be the insurer than the insured. At least I only have to pay April and May and then I'm on Medicare.

[BrianL99]

Originally Posted by MX rider

We're on AARP UHC Advantage and love it. They have a huge nationwide network so it travels with you. We needed that since we're snowbirds.

We did a ton of research and even talked with people on this plan, which I doubt you did. We even talked to SHINE, they said it was a very good option for us. It's also highly rated by Medicare.
We love the wellness benefits as well.

You're painting with a broad brush, and you're not fully informed.
All advantage plans differ by a lot.

No they don't "differ by a lot". They all have the exact same premise. The Insured doesn't get to control their medical services, the Insurer does and they're a profit making entity.

Advantage Plans are cheaper & give away "freebies" as you mentioned.

The fact that SHINE said "they're a very good solution for you, doesn't make them better or even equal to Medicare + a Supplemental. It means that in your particular financial/health position, it's a good option.

They're a cost based solution, for folks trying to save money. There's nothing else anyone needs to know about them.

[golfing eagles]

Originally Posted by BrianL99

No they don't "differ by a lot". They all have the exact same premise. The Insured doesn't get to control their medical services, the Insurer does and they're a profit making entity.

Advantage Plans are cheaper & give away "freebies" as you mentioned.

The fact that SHINE said "they're a very good solution for you, doesn't make them better or even equal to Medicare + a Supplemental. It means that in your particular financial/health position, it's a good option.

They're a cost based solution, for folks trying to save money. There's nothing else anyone needs to know about them.

I thought I had dispelled that myth in post #15. Oh, well, this is TOTV after all

[Caymus]

Originally Posted by golfing eagles

Amazing. I also have Florida Blue Bronze plan. $15,828/ month, single coverage, no significant health issues, $7,200 deductible and about $13,000 out of pocket max. Prescription meds run another $40/mo. Over the past 9 years I've put in about $110,000 into health insurance premiums and received back about $1.98 in benefits. Bottom line---better to be the insurer than the insured. At least I only have to pay April and May and then I'm on Medicare.

...and then you will meet "IRMMA".

[BigDawgInLakeDenham]

Originally Posted by golfing eagles

Sorry, but I'm forced to disagree, and I probably know a bit more on the subject

The "insurance company" is NEVER "managing " your care under an advantage plan, it is primary care physician. Are there networks and limitations---yes, but it's easy to get an exception. In 35 years, not a single patient of mine was denied anything they needed anywhere they needed it. All that has to happen is that your primary care physician calls the medical director of the insurance plan. While I had a 100% success rate, I'm sure overall that rate is over 95% as long as the proper effort is put in. Remember, while that medical director is "safeguarding" the insurance co. $$$, they want absolutely no part in any decision that might adversely affect outcomes. Simply not worth the hassle for them, and the primary care physician will usually get an approval in 2 minutes.

As far as the second choice---"direct you own medical care", I cannot emphasize how bad an idea that is----kind of like deciding to build your own home nuclear reactor for cheap energy. Most often, it will blow up in your face. That is unless anyone thinks they can match 11+ years of medical education and years of experience by "googling" something. And surprisingly, there is a whole cadre of idiots who think they can do just that.

WELL SAID BY AN EXPERT ON THIS TOPIC

[BrianL99]

Originally Posted by golfing eagles

Sorry, but I'm forced to disagree, and I probably know a bit more on the subject

The "insurance company" is NEVER "managing " your care under an advantage plan, it is primary care physician.
...
While I had a 100% success rate, I'm sure overall that rate is over 95% as long as the proper effort is put in. Remember, while that medical director is "safeguarding" the insurance co. $$$, they want absolutely no part in any decision that might adversely affect outcomes. Simply not worth the hassle for them, and the primary care physician will usually get an approval in 2 minutes.

As far as the second choice---"direct you own medical care", I cannot emphasize how bad an idea that is----kind of like deciding to build your own home nuclear reactor for cheap energy. Most often, it will blow up in your face. That is unless anyone thinks they can match 11+ years of medical education and years of experience by "googling" something. And surprisingly, there is a whole cadre of idiots who think they can do just that.

Originally Posted by golfing eagles

I thought I had dispelled that myth in post #15. Oh, well, this is TOTV after all

I'm not sure that anecdotal evidence, dispels anything. As with any business (& you surely know medicine has become a "business"), human nature and human competency, always trumps theory. In this case, the theory being that Advantage programs should be offering a level of medical care, consistent with other options. They all don't and at minimum, all depend on the competency, dedication and (your word) effort, of one's PCP.

As for "directing one's healthcare", I agree that folks shouldn't be relying on Google, but on a trusted, competent physician ... unencumbered by the corporate policy of a profit-making conglomerate.

(& I understand that Medicare has it's own standards and "rules", but manipulating and navigating Medicare rules, when the government is the overseer, seems much simpler to do, than negotiating/arguing/challenging/maneuvering through a structure controlled by competent, corporate America professionals.)

We can agree to disagree.

(& I'll bet a dollar, that the $1700/Month you're paying for your health insurance, with that huge deductible, allows you to see any physician you want and bet another dollar, it's a BCBS program!)