Talk of The Villages Florida
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Talk of The Villages Florida (https://www.talkofthevillages.com/forums/)
-   Medical and Health Discussion (https://www.talkofthevillages.com/forums/medical-health-discussion-94/)
-   -   Traditional Medicare (TM) or Medicare Advantage (MA) (https://www.talkofthevillages.com/forums/medical-health-discussion-94/traditional-medicare-tm-medicare-advantage-ma-360064/)

Rainger99 07-20-2025 03:05 AM
Quote:
Originally Posted by tophcfa (Post 2447083)
Some states use attained age ratings, some use issue age ratings, and other states use community age ratings. as I get older.
I didn’t know age was so variable.

Attained Age Ratings premiums are based on the policyholder's current age at the time of renewal or premium calculation.
- Premiums increase as the policyholder ages, reflecting the higher risk associated with older age.

Issue Age Ratings Premiums are based on the policyholder's age at the time the policy is purchased.
- Premiums remain constant based on the issue age and do not increase as the policyholder gets older, though they may rise due to inflation or other factors.

Community Ratings Premiums are the same for everyone in a specific geographic area or "community," regardless of age or other individual risk factors like health status.
- Premiums may vary by location or plan type but not by individual age or health.

In Sumter County, most insurers use attained age.

kingofbeer 07-20-2025 08:02 AM
Quote:
Originally Posted by Rainger99 (Post 2446403)
Before I went on Medicare a few years ago, I thought that Medicare was free. People were always saying that the answer to the health problems in this country was “Medicare for All.” So after paying into Medicare for about 55 years, I expected that I would not have to worry about ever paying for medical coverage again.
To my surprise, I found out that even though I had retired and was not making much money, I still had to pay for Medicare.

I was also surprised to learn that the amount you pay for Medicare depends on how much money you make. The more you make the more you pay.

Married Filing Jointly:
$212,000 or less: Standard premium ($185 in 2025)
Above $212,000 to $266,000: $74.00 surcharge
Above $266,000 to $334,000: $185.00 surcharge
Above $334,000 to $400,000: $295.90 surcharge
Above $400,000 to $750,000: $406.90 surcharge
Above $750,000: $443.90 surcharge

I have learned a lot about Medicare since I retired.
It's a stupid rule to charge extra if you have higher income. The medicare premium should be zero for all.

kingofbeer 07-20-2025 08:03 AM
Quote:
Originally Posted by biker1 (Post 2447040)
What is a "gold Medicare supplemental plan" ?
The best plan with the most coverage.

retiredguy123 07-20-2025 08:08 AM
Quote:
Originally Posted by Rainger99 (Post 2446403)
Before I went on Medicare a few years ago, I thought that Medicare was free. People were always saying that the answer to the health problems in this country was “Medicare for All.” So after paying into Medicare for about 55 years, I expected that I would not have to worry about ever paying for medical coverage again.
To my surprise, I found out that even though I had retired and was not making much money, I still had to pay for Medicare.

I was also surprised to learn that the amount you pay for Medicare depends on how much money you make. The more you make the more you pay.

Married Filing Jointly:
$212,000 or less: Standard premium ($185 in 2025)
Above $212,000 to $266,000: $74.00 surcharge
Above $266,000 to $334,000: $185.00 surcharge
Above $334,000 to $400,000: $295.90 surcharge
Above $400,000 to $750,000: $406.90 surcharge
Above $750,000: $443.90 surcharge

I have learned a lot about Medicare since I retired.
Note that the "surcharge" is added to the standard $185 rate. The actual rates are:

Part B IRMAA:

Single:
$106,000 or less: $185.00 (standard premium)
$106,001 - $133,000: $259.00
$133,001 - $167,000: $370.00
$167,001 - $200,000: $480.90
$200,001 - $500,000: $591.90
Over $500,000: $628.90

Married Filing Jointly:
$212,000 or less: $185.00 (standard premium)
$212,001 - $266,000: $259.00
$266,001 - $334,000: $370.00
$334,001 - $400,000: $480.90
$400,001 - $750,000: $591.90
Over $750,000: $628.90

Blueblaze 07-20-2025 09:22 AM
Every time this thread is restarted, it degenerates into the same few folks defending their decision to stay with TM, for reasons easily debunked, such as doctor availability and costs. I think people just tend to defend their choices, regardless of what they are. So I'm going to defend mine, right now.

We've been on Medicare Advantage since we became elgible, and have never had anything we needed rejected, including my wife's week in the hospital from a stoke last year, or any of the dozens of tests that followed.

Yes, I complain about the lousy primary care doctors that are available here in-network, but I'm not convinced that paying an extra $1000/month between the two of us would improve our choices much in this healthcare desert, 45 minutes from the nearest city. We had great in-network doctors in Houston on the Kelsey-Seybold Medicare Advantage plan.

Our current Humana "Giveback" PPO plan is free and even refunds the Social security deduction for Medicare. It includes Moffit Cancer Center in Tampa in-network. Even our great Kelsey plan in Houston didn't include MD Anderson, in-network. But either way, since we always choose a PPO, we can see any doctor we want if we don't like the in-network doctors, and it still covers 80%. That's the same as my old employer's United insurance, that cost me $500/month.

I confess, I don't understand how MA stays in business giving insurance way for free. I suspect it has something to do with those $500 office call visits they bill the gooberment, that used to only cost me $25, back before doctors started billing insurance companies instead of patients. But after paying 3% of my wages for 50 years on a promise to get some back if I lived to 65, I see no reason to shell out $1000/mo of my life savings at the back end of this scam, for the same thing I can get for free.

Rainger99 07-20-2025 10:26 AM
Quote:
Originally Posted by Blueblaze (Post 2447191)
Our current Humana "Giveback" PPO plan is free and even refunds the Social security deduction for Medicare.
What is your current plan?

HappyTraveler 07-20-2025 10:57 AM
Quote:
Originally Posted by Rainger99 (Post 2447207)
What is your current plan?
He mentions the very name which you posted.
It's probably either the second or third one down, here: https://plans.humana.com/plans
Like with all of them sort by zip code and county for your options.

Aces4 07-20-2025 11:06 AM
Quote:
Originally Posted by Blueblaze (Post 2447191)

I confess, I don't understand how MA stays in business giving insurance way for free. I suspect it has something to do with those $500 office call visits they bill the gooberment, that used to only cost me $25, back before doctors started billing insurance companies instead of patients. But after paying 3% of my wages for 50 years on a promise to get some back if I lived to 65, I see no reason to shell out $1000/mo of my life savings at the back end of this scam, for the same thing I can get for free.
Do some indepth research on how private insurance companies are reimbursed for each MA individual and you may see the correlation between how they are making their money by trumping up a patient's conditions that allow for greater reimbursement. And all those goodies you tout, don't get used to them because the insurance companies profits are being eaten into and there is talk of cutting some bennies MA individuals now receive.

Don't trust a forum, do research.. past AI, and put in some of the questions you have. It makes me laugh when MA recipients state they have never had anything rejected. That is because you don't know what tests that should have been performed for you and maybe for your wife prior to her stroke, which may have ameliorated that incident for her.

HappyTraveler 07-20-2025 11:55 AM
Replying to comment #80. Good comment overall.

Quote:
Originally Posted by Blueblaze (Post 2447191)
Yes, I complain about the lousy primary care doctors that are available here in-network, but I'm not convinced that paying an extra $1000/month between the two of us would improve our choices much in this healthcare desert.....
I am unconvinced of this also. Just because a claim is made with TM that you can choose whatever specialist you want doesn't mean that Doc is taking new patients. Many of the experienced ones aren't; they're full.

Quote:
Originally Posted by Blueblaze (Post 2447191)
I confess, I don't understand how MA stays in business giving insurance way for free. I suspect it has something to do with those $500 office.....
If I understand what you're saying here... you mean how does the insurer stay in business? It is as follows (I'm no expert here if anyone wants to provide more detail on this).

The Fed Gov pays insurers approx $1000 monthly for each Advantage plan enrollee they have. So, Humana is getting about $12,000 p/year for you. BCBS gets the same for me. They're insurers so, they know how to manage risk, benefit and P&L. So, they can offer benefits back to enrollees from the money they're taking in every month.

In the plan you chose, they kick back part of the $1000 to you as reimbursement for what you mandatorily pay into Medicare each month ($180 or so). I could have chosen one of those plans but, decided to pick a BCBS plan that, instead of that, offers a generous allowance - $3500 p/yr - that can be used for dental (no implants), vision or hearing -- or any combo of those. I was anticipating dental work this year so....

I'm trying to use some of that this year but, haven't been happy with the periodontal practice I chose. So, am going to go to another one. But, here I can answer the question posed in comment #54 - asking whether others have had treatments denied by an MA insurer. It's a classic example of the devil is in the details.

I had one denied by BCBS related to this dental work. But, guess what? It was the vendors fault, they installed something in the treatment plan that is not covered and that exception (bone grafting, implants) is fully disclosed up-front in the plan so, I don't know why they did that. That part of the authorization was denied, of course. So, it makes you wonder how many of the denials of treatment related to MA plans are actually screw-ups by the med practices? Either erroneously filed outright (like my case) or the wrong procedure codes were used causing a denial. See?

Two more things to add: I do see in the details of the work I want to have done that the insurer isn't going to cover every aspect of the procedure - some aspect codes I would have to pay out-of pocket. So, for the total procedure, I may have to pay for about 40% of it. I don't love that and it feels a little like a bait-and-switch but, I also get that they're not going to let someone just easily blow that $3500 - they want them to have skin in the game and that probably helps keep the medical provider from simply selling a patient on anything to get their piece of that allowance.

Also, the other allowances related to my plan are $135 p/quarter to spend on OTC items (via a loaded debit card), Silver Sneakers membership, regular annual dental care, eye exam and new glasses every year, no cost for Tier 3 and 4 prescriptions. No monthly premium for the plan.

I mention all that because it's not just the lack of paying a monthly premium that is saved, BCBS is actually paying me. If I use all of the allowances provided, it will net me over $4000 p/yr.

Lastly, I would caution anyone, regarding any life issue against making a decision today for a 'maybe' of what might happen a two decades from now. That could cost a boatload of money over time and many things are going to change anyway, that's guaranteed.

Aces4 07-20-2025 12:03 PM
Quote:
Originally Posted by HappyTraveler (Post 2447243)
Replying to comment #80. Good comment overall.



I am unconvinced of this also. Just because a claim is made with TM that you can choose whatever specialist you want doesn't mean that Doc is taking new patients. Many of the experienced ones aren't; they're full.


If I understand what you're saying here... you mean how does the insurer stay in business? It is as follows (I'm no expert here if anyone wants to provide more detail on this).

The Fed Gov pays insurers approx $1000 monthly for each Advantage plan enrollee they have. So, Humana is getting about $12,000 p/year for you. BCBS gets the same for me. They're insurers so, they know how to manage risk, benefit and P&L. So, they can offer benefits back to enrollees from the money they're taking in every month.

In the plan you chose, they kick back part of the $1000 to you as reimbursement for what you mandatorily pay into Medicare each month ($180 or so). I could have chosen one of those plans but, decided to pick a BCBS plan that, instead of that, offers a generous allowance - $3500 p/yr - that can be used for dental (no implants), vision or hearing -- or any combo of those. I was anticipating dental work this year so....

I'm trying to use some of that this year but, haven't been happy with the periodontal practice I chose. So, am going to go to another one. But, here I can answer the question posed in comment #54 - asking whether others have had treatments denied by an MA insurer. It's a classic example of the devil is in the details.

I had one denied by BCBS related to this dental work. But, guess what? It was the vendors fault, they installed something in the treatment plan that is not covered and that exception (bone grafting, implants) is fully disclosed up-front in the plan so, I don't know why they did that. That part of the authorization was denied, of course. So, it makes you wonder how many of the denials of treatment related to MA plans are actually screw-ups by the med practices? Either erroneously filed outright (like my case) or the wrong procedure codes were used causing a denial. See?

Two more things to add: I do see in the details of the work I want to have done that the insurer isn't going to cover every aspect of the procedure - some aspect codes I would have to pay out-of pocket. So, for the total procedure, I may have to pay for about 40% of it. I don't love that and it feels a little like a bait-and-switch but, I also get that they're not going to let someone just easily blow that $3500 - they want them to have skin in the game and that probably helps keep the medical provider from simply selling a patient on anything to get their piece of that allowance.

Also, the other allowances related to my plan are $135 p/quarter to spend on OTC items (via a loaded debit card), Silver Sneakers membership, regular annual dental care, eye exam and new glasses every year, no cost for Tier 3 and 4 prescriptions. No monthly premium for the plan.

I mention all that because it's not just the lack of paying a monthly premium that is saved, BCBS is actually paying me. If I use all of the allowances provided, it will net me over $4000 p/yr.

Lastly, I would caution anyone, regarding any life issue against making a decision today for a 'maybe' of what might happen a two decades from now. That could cost a boatload of money over time and many things are going to change anyway, that's guaranteed.
Ouch... I hope all those considering signing up for Medicare Advantage read this!

HappyTraveler 07-20-2025 01:49 PM
Quote:
Originally Posted by Aces4 (Post 2447246)
Ouch... I hope all those considering signing up for Medicare Advantage read this!
Ouch, I also hope they recognize that you make no argument at all in that obtuse comment.

But, I will point something out from your comment further up;
Quote:
That is because you don't know what tests that should have been performed for you and maybe for your wife prior to her stroke, which may have ameliorated that incident for her.
Indeed, that might be the case....or not.

What people also need to consider is, no matter their insurance plan, whether the surgery or procedure a specialist is recommending is actually needed? It's estimated than 12%+ of surgeries/procedure in the USA every year are unnecessary. That is something like 2.5 million+ people undergoing the knife who don't need to be. Think about that. How many of them died b/c of it? How many suffered adverse outcomes?

I know countless stories of people who later realized they didn't need the surgery they had gotten (me also) and some who realize that they didn't seek less invasive options before agreeing to be cut into. So, the easier it is for many Docs to sell you something, well, that's what they're going to do. KA-CHING!

Rainger99 07-20-2025 02:32 PM
Quote:
Originally Posted by HappyTraveler (Post 2447224)
He mentions the very name which you posted.
It's probably either the second or third one down, here: https://plans.humana.com/plans
Like with all of them sort by zip code and county for your options.
There are two that seem to fit his description. I am trying to find out which one he recommends.

HumanaChoice Florida Giveback H5216-452 (PPO)

Humana Full Access Giveback H5216-393 (PPO)

HappyTraveler 07-20-2025 03:06 PM
Quote:
Originally Posted by Rainger99 (Post 2447291)
There are two that seem to fit his description. I am trying to find out which one he recommends.

HumanaChoice Florida Giveback H5216-452 (PPO)

Humana Full Access Giveback H5216-393 (PPO)
Definitely best for you to choose yourself.
There are literally no blanket recommendations in these matters given the particulars for every one of us are different.
Btw, other insurers offer reimbursement plans like that....BCBS has at least one that does.
Do some keyword searching on it and you'll likely find a list of all insurers that do.

biker1 07-20-2025 05:59 PM
The majority of people have Plan G, Plan F, or Plan N. The coverage is essentially the same with the exception that Plan F covers the Part B deductible and Plan N may have up to $20 copays and excess charges (which are pretty rare). For these differences in costs, Plan N typically has the lowest premiums and Plan F the highest. For our area, you may find that the differences in premiums between Plan F and Plan G (or Plan N) is greater than the Part B deductible. Many people would save money by switching to Plan G (or Plan N) from Plan F if they can do so without having to go through underwriting. Some providers allow you to switch between plans without underwriting. Folks now enrolling in Medicare for the first time at age 65 are not eligible for Plan F. There are also other plans including some high deductible options.

Quote:
Originally Posted by kingofbeer (Post 2447166)
The best plan with the most coverage.

Aces4 07-20-2025 06:28 PM
Quote:
Originally Posted by HappyTraveler (Post 2447281)
Ouch, I also hope they recognize that you make no argument at all in that obtuse comment.

But, I will point something out from your comment further up;

Indeed, that might be the case....or not.

What people also need to consider is, no matter their insurance plan, whether the surgery or procedure a specialist is recommending is actually needed? It's estimated than 12%+ of surgeries/procedure in the USA every year are unnecessary. That is something like 2.5 million+ people undergoing the knife who don't need to be. Think about that. How many of them died b/c of it? How many suffered adverse outcomes?

I know countless stories of people who later realized they didn't need the surgery they had gotten (me also) and some who realize that they didn't seek less invasive options before agreeing to be cut into. So, the easier it is for many Docs to sell you something, well, that's what they're going to do. KA-CHING!
Research regarding your MD may be the answer if you've run into a "cut happy Dr". I am sure I am not the only person not to have Drs. that try to sell me something. I'm talking about tests that could help with the prevention of strokes, heart attacks, aneurysms, etc. for which the elderly have a propensity. Ct scans, MRIs, Doppler ultrasound testing are great tools for diagnosis without a scalpel in sight. As far as the KA-CHING for Drs. treating Medicare patients, have you ever seen a traditional Medicare statement? Yeah, those Drs. are rolling in the dough, lol.


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