Medicare Supplement - Do Networks Apply?
 

I am not yet eligible for Medicare, but will be early next year. Currently, my BCBS (FL Blue) individual Silver PPO medical insurance only covers specialists within the BCBS in-network list, so I am quite limited in my choices, and don't have my preferred specialist in the network. If I choose BCBS or any other supplement with original Medicare, am I understanding that as long as the specialist accepts original Medicare (which most do), that there is no more "in-network" to consider with a BCBS supplement? This would definitely widen the specialists I could see. I am specifically asking about supplements here, not advantage plans.

You need to contact SHINE ,
SHINE - Home,
as they will provide unbiased information that you need. They have on site meetings in TV at several rec centers. Very helpful people, and they saved us from making a very big mistake.

Yes, if you have original Medicare, the Medicare supplement will cover you as long as the provider accepts original Medicare. The supplement is basically a piggyback plan for original medicare. There are no networks, like Medicare Advantage.

Looking forward to when I turn 65, and being able to get on traditional Medicare with a supplement, so I can get away from “networks” and having to seek out referrals to see a specialist.

Be careful with terminology, I have heard the term supplement referred to both as Medigap plans as well as Advantage plans. Be sure you avoid Advantage plans and focus in on Medigap plans if you want to be sure to avoid both networks and referrals. Advantage plans can appear to be both cheaper and to offer different types of fringe benefits, but we will all eventually all need some expensive medical care and not want to be constrained by networks, not have to seek out referrals, have to worry about what is covered, and have to sort through copay and deductible bills for our health care. In the long run, traditional Medicare with a Medigap and part D prescription policy are the best way to go. Best of luck with your decision.

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

While I agree with the above, Supplements come at a price. My United Health Care Supplement Plan N comes at $185 per month and my Part D drug plan is $52/month. My former employer pays $1000 per year toward this expense.
Some folks can live within the networks and perhaps count the above expense as their savings.

For a family of two, having a supplement for two, that is a $4000 expense. That can mean a lot to some who are willing to contend with the network issue.

I don't know all the answers to your questions, but I wonder about some of your assumptions . . . Couple of years ago I was at an appointment with an ophthalmologist through my Advantage plan. She said she was retiring in a few months, and moving to Phoenix. She complained that most of the doctors in that area were full, and not accepting new patients. So, this belief, that you can see any MD who accepts original Medicare, may not be accurate. And in my experience, almost any medical professional has a full schedule for several weeks out or more. A primary doctor can get you in faster perhaps if they believe you need to be seen sooner. If my beliefs are accurate and widespread, your goals and means may not be realistic.

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.

Here is a big one -TVHS only accepts advantage plans once one is medicare eligible

You are right. Big advantage. Can visit most doctors nationwide & if you need a specialist, you can see the one you want, where you want.

I don't consider that an advantage at all. But to each his own.

55000 patients enrolled in TVHS most likely don't agree with you. Amazing that is over 1/3 the population of The Villages.

Absolutely 10000% true and well said. And that's from my perspective of providing primary care for 35 years.

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.

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)

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.

Obamacare income testing.

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.

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?

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?:1rotfl::1rotfl::1rotfl:

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.

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:1rotfl::1rotfl::1rotfl:

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

:boom: WELL SAID BY AN EXPERT ON THIS TOPIC

:bigbow:

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!)

Most likely when you disclose to Shine your employer is paying for your supplement as part of your retirement package they will probably recommend medicare plus a supplement.

I have the Massachusetts Blue Bronze and pay about the same as you and am counting the days until turning 65. There is only one reason I’m happy to be getting older, healthcare.

Well, I'm happy to be getting older, because I don't care for the alternative. :smiley:

You make a lot of assumptions, our decision was not cost based. We think our plan is best for us. It's not a one size fits all thing as you seem to be saying. Having options is a good thing.

I'll defer to Golfing Eagles, who by the way is a healthcare provider. I actually asked my longtime pcp in Indiana about this as well, he basically echoed golfing eagles.

Your commenting on something you really aren't up to speed on.
Again, how much actual research have you done on ALL the different advantage plans?
Btw, I know what SHINE was saying. Duh.

My point is you're trying to say all advantage plans are bad, and that's just flat wrong.
Over 50% of new medicare enrollees opt for advantage plans. Thats a lot of people. I don't think they're just blindly going that route for cost alone. I'm sure many did their homework and research just like we did.

But we can agree to disagree on this.

Yeah, I waited years to get my free Medicare, until I found out it costs me over $630/month. That took some of the fun out of turning 65.

How do you think a Physician becomes a "Specialist"? All Physicians are specialists in their area of practice that they spent many years of hands on training and even if they are in a shanty in East Bumfudge Egypt they're prepared to care for you. The variables here are people aka patients. Patients have no patience #1. Patients only think they are the one that matters because they only present in their time of need and expect immediate attention. Do you really believe that you're going to see a specialist while on vacation just because you want to? There are Patients that have never experienced pain, like the pain after hip or knee surgery. They transfer this pain onto the doctor because they may think another doctor could have done the surgery without postoperative pain. This false belief becomes a negative review of the doctor. They may never achieve full range of motion in their hip or knee because of the postoperative pain involved in physical therapy exercises and these exercises are the key to a successful joint replacement...... but this is not the doctor's fault yet the review will say it's the doctor's fault that the patient didn't complete PT. I could go on and on about people's distorted views of reality in the Healthcare system. Maybe you're saying that when you get cancer you're traveling to a big name hospital because you'll accept no less. Many affluent people do and it has sometimes worked out in the past. I will tell you that I'm coming from a recognized name in medicine and have seen that all hospitals bottom line is what's most important. The care environment in the hospital is dwindling since Covid, George Floyd and the nationwide HR push for diversity and inclusion. Recruitment and retention of quality patient care staff is more difficult as each day passes. Covid knocked out many quality caring Healthcare workers. If you remember, we HAD to work and it was a horrific time which led to many leaving the industry or seeking work outside hospitals. Don't be surprised now if your Nurse looks like Jellyroll with a nasty attitude. It pains me to say this because I poured my heart and soul into quality patient care because I loved the people we served and I loved my job and my coworkers. I can't say that to be so anymore and I'd be hesitant to jet off to a big name unless I needed a specialist and they were the only one, as Dr Ben Carson was. You're relationship with the doctor is paramount but hospital stays can taint your entire experience.

I'm ranting but there's a lot more to this than which insurance you pick. After my experiences and my knowledge base I don't have any problem with having a Villages UC Advantage Plan with HMO or PPO or AARP Advantage Plan. Not looking for the "freebies", but instead I feel confident that between what I know to be fact and a solid relationship with a PCP, I can get everything in Healthcare that I will need.

BrianL99....I've never had a PCP that worked for an insurance company. Physicians pick and choose which insurance companies they want to associate with after reading all the fine print. They choose to accept insurances that will let them operate with reasonable reimbursement while allowing their patients good benefits coverage. And then there's my Dermatologist that stopped taking Medicare patients because the reimbursement is so low and she wanted a bigger yacht and another rental property....true story

You'd win both bets, but I can't pay up since I'm spending 100x as much each month as OBB. (Actually, I think she owes me a thank you for subsidizing her premium:1rotfl::1rotfl::1rotfl:)

But then riddle me this: With all my expertise, I get Medicare in 2 months and have already signed up for my advantage plan. Am I stupid? Ignorant? Gullible? (on second thought, don't answer that:1rotfl::1rotfl::1rotfl:)

@golfing eagles and @BigDawgInLakeDenham thanks for your opinion. I, too, spent my entire career in health care delivery and have the opposite view: I would NEVER sign up for an HMO of any kind, including Medicare Advantage unless it was my only option. Yes, you will save some money. But you will also jump thru more hoops to go anywhere beyond PCP, and I have also heard horror stories of people being denied care they wanted/needed by the HMO. I'm sure it is a good option for many folks, but definitely not me.

It's your prerogative to pay more for the same or less....but please do share your knowledge of horror stories of people not getting what they actually need. It's not reported by any news media so I for one would love to hear how insurance killed subscribers. It will be interesting to analyze if the insurance actually denied necessary procedures without being litigated and responsible for harm.

What kinda of Healthcare worker were you? I'm curious why you fear navagating the system and why you believe insurance companies like United Health Care are evil while the Government is your best friend. I've shocked folks back to life but I've also prepared them for a family viewing and a body bag. I've worked with my orthopedic surgeon on the Trauma Team, when he was a resident, years before having him do my surgery only because of the great respect I had for him and his wonderful humanity. Being a Healthcare Professional does help me navigate the system because I was part of it and I also helped family members to the end of their lives. I've buried my parents, my Brother, my Sister, and most recently my Daughter of 27 years. They all had everything they needed and HMOs were never an issue.

As a Frontline Healthcare Worker that participated in lifesaving procedures I had a HMO my entire Adult life and I have never been denied and I've never had to spend A LOT out of pocket and I've seen many "Specialists" without ever seeing a "Hoop". Can you explain how I pulled this off having the evil managed care insurance? I had bilateral knee replacements and my copay was $100. I won't get that much of a discount on an Advantage Plan because that was a benefit of my Employer's plan but withThe Villages United Healthcare Plan my out of pocket maximum for the year would be $2700, even if I had a $100,000 procedure, and that's with no monthly cost........talk about a freebie.....but to each his own..... I'm done

$15,828/ month!! That would be $189,936 a year!!

Please tell me that is a typo!