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Post by chang on Jan 21, 2024 12:16:52 GMT
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Post by anitya on Jan 28, 2024 6:46:15 GMT
In this weekly Barron's, Medicare Advantage PPO was mentioned. I had thought all Medicare Advantage plans are HMO. Can some on please elaborate on the MA PPO plans and specifically, how much better they may be over MA HMO plans?
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Post by yogibearbull on Jan 28, 2024 11:15:21 GMT
Our Aetna MAPD (Medicare Advantage with Prescription Drugs) has both HMO and PPO options. MA-HMO has a slightly lower premium but comes with the restrictions of the HMO - mainly, that treatments must be recommended by a primary physician on the HMO network, and some HMO plan can be quite local. We never signed up for HMO - it was also available while I was working.
On the other hand, MA-PPO has more flexibility in that we can see any doctor. There may be different levels of coverage for doctors and hospitals in or out of the network, but this particular Aetna MAPD has the same coverage for in or out of network.
I have seen some reports that some doctors may refuse MAPD, but we haven't seen any difference. We have been on employer group plan, the original Medicare, and now employer/retiree MAPD (it's required if we want to be in the group), and we haven't seen any difference in the coverages. But we are with a large plan in a large metropolitan area, and may be things can be different in rural areas. I also don't see how the doctors and hospitals who deal with insurance companies routinely while people are working suddenly become bad when it comes to MAPD only. How suddenly the government becomes the best provider, and if so, why people in the US don't want a national health plan?
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Post by gman57 on Jan 28, 2024 15:58:12 GMT
I was on a POS plan and you had to go in network or cover out of network on your own. I didn't realize it at the time. I never had a problem but just thinking about it I changed to a PPO plan this year . PPO you still need to go in network (lower co-pay) but if you want to go out of network you can with a larger co-pay. This is with United Health. ADD: Whenever I have chosen plans in the past the most important factor I always looked at was max out of pocket. My current is $5400 and I can live with that for $0 premiums/dental/vision/gym/rx coverage etc... I also mentioned before, if I lived in a rural area I would have gone with traditionally Medicare but since I live where there is abundant different health care facilities I went with MA. 2nd ADD: I'm also thinking that at some point in the not too distant future the US will finally go to a universal one payer health care system.
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Post by anovice on Jan 29, 2024 0:02:10 GMT
gman57 "I also mentioned before, if I lived in a rural area I would have gone with traditionally Medicare but since I live where there is abundant different health care facilities I went with MA."
I think this mostly hits the nail on the head. The other questions to ask yourself are will I always reside where I have access to good healthcare and would I want access to go to the likes of the Mayo Clinic, Cleveland Clinic, MD Anderson, or Sloan Kettering. I reside within a few miles of a top 10 hospital for both general needs and cancer specialty as rated by U.S. News and World Report, and at 65 I went with original Medicare and a supplemental plan. The day that I can answer the question that I will remain in this area, is the day that I will switch to Medicare Advantage.
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Post by gman57 on Jan 29, 2024 1:28:19 GMT
The day that I can answer the question that I will remain in this area, is the day that I will switch to Medicare Advantage. Yeah, I'm here for good. I moved here and then over 10 years talked my kids into moving here from different places around the country. If I move now I won't have to worry about medical care as they will do me in!!
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Post by FD1000 on Feb 3, 2024 14:42:21 GMT
I joined Medicare about 1.5 years ago and selected OM(original Medicare) because at that time I could not find MA(Medicare Advantage) that included all my MDs. But, my research and several brokers did not do a good job and I found exactly what I want. I have enough money but the difference is huge and why I switched to Aetna Medicare Signature (PPO) | H5521-360( content.sunfirematrix.com/2024/Aetna-Y0001-H5521-360-PR11-SB24-M-2024-SF20231201.pdf). I also talked to several people who have it for a while and are very happy. Let's do a bit of math and compare to Plan G under OM.. Aetna Signature PPOMonthly premium: Instead of $155+15 =$170, it is zero = rounding $2000. BTW the $170 was $150 last year. I asked couple of friends in their 70 and it's about $250. Primary MD(actually it's per a group of MDs) = 0...Specialist=$25 (all my MDs and others are there). OM has $240 deductible, I don't. This mean up to 10 specialist I'm ahead. Prescription no deductible I have one prescription tier 3. Under OM I paid $1800, under AM only $800 = $1000 savings. Dental: preventive and comprehensive $2200 to any Dentist, including out of network, no deductible. Vision: free eye check + $260 for glasses = $330-350. Already used it. Extra Supports Wallet amount + High‑Value Provider Bonus ‑ additional $90 quarterly = $360 annually (you get a card). Already got the debit card and it's working. If you have chronic problems, and most have you get another $360. Silver sneakers=free membership to LA Fitness = 30 *12 = $360 Fitness reimbursment(camping, rowing, running equipment + classes) = $600. Already bought shoes and other equipment. Hearing aid = $500 Transportation+ meals = Several told me they used it for surgeries and after that. My friends used that when they went for a surgery. 2000(premium)+1000(drugs)+2000(dentist)+350(eye)+360(wallet support)+360(LA fitness)+600(health equipment) = over $6500The only worry what about max out of pocket. It is $5000 but far from reality. I also discussed the above plan with a broker who has over 900 people under this insurance that runs for years already and he also under it too + several people who have this plan and the most they ever paid was under $2000 annually which was rare. Several had typical surgeries(such as hernia and knee replacement) and had bills under $500. Several had 3 surgeries in one year and came under $1000. Because it's a PPO I can go to other Doctors/Hospitals and pay max out of pocket. Saving every year over $6000 is too much to miss. Even if you have tier 1+2 drugs, it's still $5500 savings. BTW, I also found I can buy a monthly insurance for $30 specializing in difficult situations, this insurance will provide $10K to cover repeatable cancer+others which will cover my max out of pocket. Wait, there is more. Aetna sent a PA home to check my general health, I got another $50. When I do my annual exam, another $50. Customer service is just amazing.
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Post by anovice on Feb 3, 2024 15:24:18 GMT
I joined Medicare about 1.5 years ago and selected OM(original Medicare) because at that time I could not find AM(Advantage Medicare) that included all my MDs. But, my research and several brokers did not do a good job and I found exactly what I want. I have enough money but the difference is huge and why I switched to Aetna Medicare Signature (PPO) | H5521-360( content.sunfirematrix.com/2024/Aetna-Y0001-H5521-360-PR11-SB24-M-2024-SF20231201.pdf). I also talked to several people who have it for a while and are very happy. Let's do a bit of math and compare to Plan G under OM.. Aetna Signature PPOMonthly premium: Instead of $155+15 =$170, it is zero = rounding $2000. BTW the $170 was $150 last year. I asked couple of friends in their 70 and it's about $250. Primary MD(actually it's per a group of MDs) = 0...Specialist=$25 (all my MDs and others are there). OM has $240 deductible, I don't. This mean up to 10 specialist I'm ahead. Prescription no deductible I have one prescription tier 3. Under OM I paid $1800, under AM only $800 = $1000 savings. Dental: preventive and comprehensive $2200 to any Dentist, including out of network, no deductible. Vision: free eye check + $260 for glasses = $330-350. Already used it. Extra Supports Wallet amount + High‑Value Provider Bonus ‑ additional $90 quarterly = $360 annually (you get a card). Already got the debit card and it's working. If you have chronic problems, and most have you get another $360. Silver sneakers=free membership to LA Fitness = 30 *12 = $360 Fitness reimbursment(camping, rowing, running equipment + classes) = $600. Already bought shoes and other equipment. Hearing aid = $500 Transportation+ meals = Several told me they used it for surgeries and after that. My friends used that when they went for a surgery. 2000(premium)+1000(drugs)+2000(dentist)+350(eye)+360(wallet support)+360(LA fitness)+600(health equipment) = over $6500The only worry what about max out of pocket. It is $5000 but far from reality. I also discussed the above plan with a broker who has over 900 people under this insurance that runs for years already and he also under it too + several people who have this plan and the most they ever paid was under $2000 annually which was rare. Several had typical surgeries(such as hernia and knee replacement) and had bills under $500. Several had 3 surgeries in one year and came under $1000. Because it's a PPO I can go to other Doctors/Hospitals and pay max out of pocket. Saving every year over $6000 is too much to miss. Even if you have tier 1+2 drugs, it's still $5500 savings. BTW, I also found I can buy a monthly insurance for $30 specializing in difficult situations, this insurance will provide $10K to cover repeatable cancer+others which will cover my max out of pocket. Wait, there is more. Aetna sent a PA home to check my general health, I got another $50. When I do my annual exam, another $50. Customer service is just amazing. FD1000, Approximately 50% of those on Medicare have a Medicare Advantage plan and 50% have Traditional Medicare. Medicare Advantage enrollment is growing faster than Traditional Medicare. It goes without saying that many Medicare Advantage plans offer more "value" to many, if you define value as vision, dental, hearing, and a gym membership. I don't. I get vision covered under Traditional Medicare because of cataracts (there is always Costco for around $120), I get two cleanings and x-rays from my dentist for $250 annually (besides, there is always a low yearly maximum benefit on dental plans), and a gym membership is of no moment to me. I purchase the Part D plan that meets my needs. My first and last concern is medical coverage. I do not put a pencil and paper to the equation. That's why I and many others have Traditional Medicare. As I have posted, if I want to go to the likes of the Mayo Clinic, Cleveland Clinic, MD Anderson, or Sloan Kettering, I want that to be my choice, not an insurance company who has a vested interest in keeping my medical costs within their budget. If I want to go the orthopedic surgeon for knee replacement 1,000 miles away because he invented the latest and greatest, that's what I want. My needs can only be met with Traditional Medicare. As a side note, good luck getting one of these hospitals or doctors to accept the insurance "specializing in difficult situations" and better luck fighting with them to accept the insurance "specializing in difficult situations" when you are in need of immediate care.
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Post by Karen on Feb 3, 2024 15:24:56 GMT
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Post by FD1000 on Feb 3, 2024 20:07:19 GMT
anovice , I know all that and why I was on original Medicare, but, all the best Doctors I have used are in my new advantage Medicare. If I really want to go to the Mayo Clinic, I can do it and pay extra which will still be lower longer term. Anywhere you go, I can go. I showed you an easy $5000+ savings, I'm not including hearing aids and meals, only the things I can use. Older people pay another $1000 in premiums. Dental used to be only cleaning but as you age it's more. My dentist is the best I ever had and charges accordingly and was never on any insurance, including the one I had from work which I had to pay for + a deductible. I agree that Original is better than many Advantage, but Advantage PPO in selected areas of the country beat Original and this one covers ATL metro which has over 5 million people and where I will live forever, even if I move. Out of network max is $8950 = $9K. So, mathematically I will be ahead. 20 years * 5K savings = $100K. If I need 2-3 years to go to the Mayo clinic and it's out of network, I'm still ahead. If I take the insurance for and pay $30-40 per month to cover the $10K max-out of pocket, I'm guaranteed to be ahead. This insurance has nothing to do with the Doctors, it cover just $10K which I have to file based on what I have, if it's cancer it will cover it. If max out-of-pocket is $9K, the 10K will make me whole. I'm still not doing that either. BTW, I just checked 2 of your hospitals on the list, the Mayo Clinic and MD Anderson. I called customer service and both are in network.
I never bought LTC either. I managed my portfolio as one bucket, I dedicated an imaginary $500K, 6 year ago for me and the wife based on $8K per month * 12 * 5 years. This $500K is already = one million and ahead if I paid LTC for years and still not fully covered. For me, it's always about the numbers, unless you can prove to me, I'm missing something.
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sgra
Lieutenant
Posts: 57
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Post by sgra on Feb 3, 2024 20:48:59 GMT
FD states a key point: Advantage PPO in selected areas of the country beat Original. For example, the Aetna plan he settled on is only good in Georgia, his home state. Aetna has no MA plans in my state (but it does offer a Part D, which I happen to use with Original Medicare). The MA plans available to me are vastly inferior to Original+medigap so my choice is easy. Health insurance boils down to availability, coverage, and cost. My Medicare, medigap G, and Part D is the best insurance I've ever had.
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Post by anovice on Feb 3, 2024 21:02:20 GMT
FD states a key point: Advantage PPO in selected areas of the country beat Original. For example, the Aetna plan he settled on is only good in Georgia, his home state. Aetna has no MA plans in my state (but it does offer a Part D, which I happen to use with Original Medicare). The MA plans available to me are vastly inferior to Original+medigap so my choice is easy. Health insurance boils down to availability, coverage, and cost. My Medicare, medigap G, and Part D is the best insurance I've ever had sgra: For example, the Aetna plan he settled on is only good in Georgia, his home state. Not from what FD1000 said "BTW, I just checked 2 of your hospitals on the list, the Mayo Clinic and MD Anderson. Both are are in network, I also called customer service and verified it" sgra: My Medicare, medigap G, and Part D is the best insurance I've ever had. That's because Medigap G is the best Medicare plan available.
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Post by win1177 on Feb 3, 2024 21:51:41 GMT
I started on Medicare this past November, when I turned 65.
I’m still learning the “whole system”, and it’s complicated as hell! Wound up signing up for traditional Medicare A and B, as I already had state retirement insurance (BCBS) as my secondary. It’s NOT as good as when I had state retirement as my “primary”, then I had ZERO copays for most medicines (as long as I did brief monthly “courses” on controlling BP, etc.), and very low copays for office visits. Now, my copays are higher but they are not “breaking the bank”. Looked at “advantage plans”, they looked real complicated and as if some of my physicians were NOT in the plans. So opted for “regular Medicare”, for now.
Win
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sgra
Lieutenant
Posts: 57
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Post by sgra on Feb 3, 2024 22:45:24 GMT
FD states a key point: Advantage PPO in selected areas of the country beat Original. For example, the Aetna plan he settled on is only good in Georgia, his home state. Aetna has no MA plans in my state (but it does offer a Part D, which I happen to use with Original Medicare). The MA plans available to me are vastly inferior to Original+medigap so my choice is easy. Health insurance boils down to availability, coverage, and cost. My Medicare, medigap G, and Part D is the best insurance I've ever had sgra: For example, the Aetna plan he settled on is only good in Georgia, his home state. Not from what FD1000 said "BTW, I just checked 2 of your hospitals on the list, the Mayo Clinic and MD Anderson. Both are are in network, I also called customer service and verified it" sgra: My Medicare, medigap G, and Part D is the best insurance I've ever had. That's because Medigap G is the best Medicare plan available. anovice: I clicked on the link that FD provided ( content.sunfirematrix.com/2024/Aetna-Y0001-H5521-360-PR11-SB24-M-2024-SF20231201.pdf) and it states under Eligibility, "Live in the plan’s service area, which includes the following counties: Georgia: Cherokee, Clayton, Coweta, DeKalb, Douglas, Fayette, Forsyth, Fulton, Gwinnett, Henry, Rockdale, Spalding"
Also, it's not just that medigap G is the best medigap plan, but it's the entire package as a whole: Medicare, medigap G, and my Drug plan D. This just applies to me; everyone has to evaluate their own circumstances.
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Post by yogibearbull on Feb 3, 2024 23:07:56 GMT
win1177 , check how people progress in your state plan. Our state (IL) plan has the following progression: 1. Employee and dependent group insurance while working 2. At age 65 or another for Medicare eligibility, original Medicare + state retiree supplemental plan. Typically, for the member first, then for the dependent spouse. Notably, after an employee retires, spouse's dependent coverage continues as normal. 3. When member and dependent spouse are both covered by original Medicare + state retiree supplemental, then both MUST join state retiree Medicare Advantage group. At any point, one could leave the state group and go with i) original Medicare + Medigap, OR ii) find another Medicare Advantage plan as individuals. As our state's benefit decrease at each step, some just quit the state group at step 3. But most stay with the state group, as we have done. All transitions were rather smooth. We know of friends working in private industry as well as who are self-employed, and we hear of lots of issues for their health insurance coverages .
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marg
Ensign
Posts: 34
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Post by marg on Feb 4, 2024 19:23:18 GMT
Is your MA PPO covers any expenses when you are out of state and need to see a doctor or hospital? ? I know HMO wouldn't cover. thanks
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marg
Ensign
Posts: 34
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Post by marg on Feb 4, 2024 20:49:31 GMT
In general, I think PPO do not need referral and prior authorization.
HMO, domestic hospital & emergency covered, but not doctors
PPO., doctors covered
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Post by anovice on Feb 12, 2024 17:13:31 GMT
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Post by FD1000 on Feb 12, 2024 21:49:15 GMT
I just found another $360. Aetna gave me another $90 (it's per quarter) for food or utilities. The next day I used my $90 to pay for most of my electric bill for last month. I can't predict the future, but the best companies such as Aetna with more clients should be able to insure its clients at a lower cost thru Advantage than Original Medicare because Gov/state have never been doing a great job. This is why the monthly premium should rise too for Original. Eventually, more clients would not be able to pay these prices and would select Advantage. If now it's around 50/50 maybe in several years advantage will grow to 60% which means, Original will have to charge even more and/or less MDs would accept Medicare patients because the pool is smaller. My new insurance also found a way to cover my tier 3 prescription for free. Regardless, I'm going to save $5000+. In fact, I may make money. If you use your imagination and look at everything I get, I can make money. I posted earlier that I go to a certain great Ortho group with 38 MDs. Only one accept new Medicare (Original or Advantage) patients, the only other way is if you were a patience before Medicare. Several of them don't accept any Medicare patients, no matter what. Why would a great vulture surgeon be OK with a much lower pay from Medicare when he/she can get much more from a younger patient insured by a good insurance at work. I don't know the future, but it will get worse.
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Post by anovice on Feb 13, 2024 19:18:37 GMT
FD1000: BTW, I just checked 2 of your hospitals on the list, the Mayo Clinic and MD Anderson. I called customer service and both are in network.
sgra: I clicked on the link that FD provided (content.sunfirematrix.com/2024/Aetna-Y0001-H5521-360-PR11-SB24-M-2024-SF20231201.pdf) and it states under Eligibility, "Live in the plan’s service area, which includes the following counties: Georgia: Cherokee, Clayton, Coweta, DeKalb, Douglas, Fayette, Forsyth, Fulton, Gwinnett, Henry, Rockdale, Spalding"
FD1000, Mayo Clinic in Rochester Minnesota and MD Anderson in Houston Texas, are not counties in Georgia. How do you reconcile this?
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Post by yogibearbull on Feb 13, 2024 19:35:18 GMT
anovice, that Aetna MAPD PPO coverage for those areas means that those people can sign up. Rates are regional. I have Aetna MAPD in IL too, but rates are probably different. It's not about coverage area for benefits. The next section has: Plan type: Aetna Medicare Signature (PPO) is a PPO plan. This is a Medicare Advantage plan that covers prescription drugs. You can use in‑network and out‑of‑network providers. You will typically pay more for out‑of‑network care. Referrals: Aetna Medicare Signature (PPO) doesn’t require a referral from a PCP to see a specialist. Keep in mind, some providers may require a recommendation or treatment plan from your doctor in order to see you.
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Post by habsui on Feb 13, 2024 20:19:13 GMT
I won't argue here with the quality received by MA. However, for the financial health of the overall MC system, MA is not that good.
I know family members who suddenly became "pre diabetic" after signing up with MA.
All I know is that the only way to make health care cheaper is through restriction of payments, care, ...
Good luck.
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Post by FD1000 on Feb 14, 2024 14:22:59 GMT
I checked again. I have a PPO, I don't need any referral to any MD/specialist in the US. I can just go to any Hospital/MDs. If they are in network, the pay is the same as in my area. For out-of-network the pay is the same all over the US. Basically, I can make an appointment and go.
They give examples: • Oncologists care for patients with cancer. • Cardiologists care for patients with heart conditions. • Orthopedists care for patients with certain bone, joint, or muscle condition
Max annual in network = $5500, max out of network is $8,950. The rep I talked today seems to know more. MD Anderson isn't in network, but the Mayo clinic is and it has centers in Rochester MN, Phoenix, AZ, and 6 hours drive from my house to Jacksonville, FL 32224. I can also do a search by any zip code for hospitals+providers. Suppose I'm on vacation and need to see an MD or go to an urgent care I just search near me which one is in network or call Aetna rep for help.
I also talked with a cancer patient under this plan, and she told me, she visited MD Anderson for a second opinion, but most/all of the rest is done in ATL. ATL is a major city with great MDs, it's not a village in the middle of Africa.
BTW, this plan covers me worldwide up to a max of $250K for ambulance, emergency, and urgent health care. Original Medicare does not have it.
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Post by anovice on Feb 15, 2024 12:08:40 GMT
FD1000: ATL is a major city with great MDs, it's not a village in the middle of Africa
I was raised in Tuxedo Park and am intimately familiar with the available medical care in Atlanta. I still return to Emery for my yearly physical exams.
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Post by anovice on Feb 20, 2024 20:52:07 GMT
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Post by FD1000 on Feb 21, 2024 4:21:14 GMT
A couple of years ago I visited my old country and found out that a relative of my wife is part of the committee that decides annually on next year available drugs. I asked her how they keep the price of expensive drugs much lower than in the USA. The answer was simple. The following was a real case: a certain US drug company has dozens of drugs with "normal" price but they wanted to charge $50K for one of them. They told this company we will pay just $10K, the company refused. They told this company, either you agree or we will cancel all your drugs...cased closed. In the same country every MDs must participate in national healthcare and must see patients. This MD can also see patients in private.
2 examples of common sense healthcare and why US Pharma + MDs will never be cheap in this country. Al the other excuses are just BS. Similar stuff happens with the US financial services. Another easy example from my old country. If you try to pulled money from an ATM and you don't have enough, the bank system just denies it without charges, why should it? after all, you don't have enough money. This is the default, you must change this option manually = be stupid to let your bank charge you money. You got it? the default protects customers, not the evil banks. Another common sense
HC + financial services are 2 groups that have been buying our politicians for decades.
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Post by anovice on Feb 29, 2024 9:30:11 GMT
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Post by FD1000 on Feb 29, 2024 12:15:01 GMT
Comments 1) Someone who does not buy Part B is negligent and deserves the consequences. Same with Medigap...or... Medicare Advantage. 2) Part B should be mandatory. If someone gets this benefit through an employer, this employer should compensate this employee. 3) US HC is ridiculous and outrageous. The Gov can solve and legislate everything as they do in many other countries.
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Post by yogibearbull on Feb 29, 2024 13:23:58 GMT
Late-penalties for Medicare Part B are 10% for each late year/12-months from the date of first eligibility, and they apply forever. This is to prevent people from rushing to Part B when suddenly needed. But it isn't mandatory. If one is already signed up for Social Security, Medicare Part A & B will start automatically at 65, but one can refuse them in writing and by returning the Medicare card. But gross medical billing without insurance coverage is also ridiculous. www.medicare.gov/basics/costs/medicare-costs/avoid-penalties
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Post by flipperxxx on Mar 1, 2024 1:46:53 GMT
my ex girlfriend was 5 or 6 years late on part b, thinking that since she had insurance through an ex husband and then cobra, both via blue cross, she didn't need to sign up for it when she became eligible. well, then blue cross finally got wind of this and started hitting her with massive bills over a three year period that my ex didn't deal with because she first had breast cancer, then a back fusion that failed, then a stroke that she survived in what her dr called a miracle, then another back fusion to fix the first. you can imagine what the bills were like that came rolling her way. at long last, i wrote a long letter to blue cross telling them about her travails and, another miracle, they stepped in and paid for everything that B would have paid for going way way back in time. had to do a lot of emailing to get it all sorted out but in the end -- god bless blue cross for doing the right thing. and yes, she got hit with that penalty from the feds for failing to sign up for B when she first should have but, once again, a few emails later, that, too, went away. so, as bad as things can get w/ insurance, sometimes the folks in charge can smooth things out. the trick, i found out, is to find the right person to talk to, the person who has the power to say yes.
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