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A basic Math puzzle for those of you who would like to tackle one. After calling my Insurance agent today and not getting much clarity, and then hours spent going through 18 months of Medicare statements, it looks like my insurance company has been making BIG money on my Supplemental (Medigap) policy. The company has paid only 20-25% of whatever Medicare Allowable Billing was submitted during that time, for all my doctors and/or hospitals. The difference averages out to be 4 times what I THINK I'd have paid those hospitals or doctors!

But I don't know...and since this insurance policy is going up a hefty 20 percent starting next month, it's a burning question! I know this could get to be a complex topic, but I have an agent, have asked lots of questions, yet remain puzzled about something I think they may not have explained clearly to me, and wondering if perhaps that's a part of the "sales pitch" of any insurance company rep. You know: In CASE of a catastrophic medical condition....whereas in 10 years of having Medicare I haven't seen any such bills from the many providers and hospitals I have visited.

So I'm really wondering why couldn't I just keep my Medicare Part B (that is automatically deducted from benefits) and just pay that 20 percent of any medical bills I incur, and maybe come out far ahead if I'm not going "out of network" anywhere? All the hospitals and doctors I have seen accept Medicare billing.

My fear is if one doesn't have a Supplemental Policy, do hospitals and doctors suddenly come out and demand their 'full amount' from the patient, if all they present at admission is their Medicare Part B? Or must the hospitals and doctors adhere to billing through Medicare (as I understood) and I just would pay the 20 percent of that much lower amount? All my doctors and hospitals fully accept Medicare Assignment.

I know it could be a different situation, if one had to go somewhere they did NOT accept Medicare Assignment.

Thanks in Advance....

[This message edited by Superesse at 12:32 AM, Thursday, May 28th]

I should have put in the Title "Medigap" or Supplemental Medicare Insurance. THAT's what the post is about, not basic Medicare which has been kind to me.

When we were signing up for Medicare and looking at supplement(gap) plans, we did NOT go to an insurance agent. Not even a broker.

Our state has an advocacy agency (SHINE) which has volunteers that work with you to figure out what is the best supplement plan depending on YOUR priorities (not some insurance sales person). I think most states have a similar advocacy organization. But my state also has some pretty strict guidelines for insurance companies that want to offer their services to Medicare patients. And fwiw... I can't tell you how many people told me NOT to get an Advantage Plan - the only person I know who got one, went in and changed her option during the grace period.

Yes, you could keep just your Medicare B and drop the supplement, but yes, if there's a catastrophic event, are you prepared to pay all of the co-pays? If so, then that might be your priority. You're asking some good questions and the answers are all personal depending on the risks you're willing to take. Personally, I've had enough serious medical events (prior to Medicare) that make me realize how expensive it can get. I think you're right about most health care professionals taking Medicare. My PT does not; and my therapist/psychiatrist does not. But again, MA is pretty strict with insurers who want to do business here, so because there's a shortage of therapists/psychiatrists who take Medicare, our supplemental plan is required to offer Medicare benefits to patients who see out-of-network therapists. I do have to get an invoice from her, then submit it myself, but they actually pay 100%!!

Good luck figuring it all out!

Thank you number4! I just wonder what sort of catastrophic event wouldn't involve going to either a hospital/med center/specialist, who DOES accept Medicare? Scratching my head....

I do understand about drug costs getting crazy, because my cheap, zero-monthly-premium Plan D drug insurance doesn't include the brand-name Rx my cardiologist would prefer I take, and for some reason the release of a generic of that popular drug has been held up for several years - but only in the USA. I also wonder if I'm missing something in the definition of what we call "catastrophic."

"Skilled nursing facilities" may or may not be covered for adequate time frames (As I know from volunteer work at a local Assisted Living Facility.)

But this all reminds me of playing at a gaming table in Las Vegas...Like...GUESS what is going to happen to YOU, and purchase accordingly...

I would think that a long hospital stay's co-pays would add up really quickly. In 2014, I had a 5-night hospital stay on the telemetry floor for sepsis. While there were negotiated rates with my then insurance company, my co-pay was still in the thousands of dollars. H was still working then so we had a decent income and could pay for it. Now that he is retired, that co-pay would suck to have to fork out. What the Medicap would cover would more than pay for the monthly premiums we pay for a year.

Another example - my grandson was hospitalized this past winter with complications from Flu A. Again, five nights. I guess their co-pay for stay added up quite a bit. But his parents are both employed, so it wasn't quite the hardship that it could be when you're drawing down on retirement savings.

You mention cardiologist-recommended drugs, so I take it you have a cardiac condition. If you ended up hospitalzed for some event related to cardiology, it adds up very, very quickly.

What medigap level did you choose - A, B, C, etc.? What are the costs of Medigap policies? (I'm curious, and I don't want to give my contact info to any of the web ads I see. I have an employer-provided plan that isn't actually medigap, but I wonder if I should switch.)

My plan doesn't pay for normal Medicare expenses until I hit $4L+ in spending, but it covers expenses that Medicare doesn't (including docs who have opted out of Medicare, and lots more PT than Medicare/Medigap covers), including hearing aids every 3 years.

Are your premiums based on your age, or do all insureds pay the same?

For me, it's the annual and lifetime caps that keep me insured with my quasi-medigap policy. But then my father and his father both dies from cancer, and my policy is pretty good on branded meds. Also, it was very helpful that my mom's Medicare A, B, and medigap took care of all her medical expenses except dental and hearing; that really made taxes and check-writing as simple as it could be.

Likely the reason my insurance costs for Medigap are so high is that I have had the "Cadillac" Plan F that is no longer sold by my insurer; I'm "grandfathered in." Plan F pays for Medicare Co-Pays, but the premiums are much higher.

The agent suggested I could switch to a Medigap Plan G and lower my monthly premiums from $345 to $210. Initially that sounds like a better use of healthcare dollars. However, Plan G does NOT cover Medicare Co-Pays. And that could become significant, as number4 kindly explained here: 20 percent of a lengthy hospitalization stay would add up real fast. Honestly, I hadn't really considered that since all my historic health issues have been dealt with on an "Out-Patient" basis. I should learn more about co-pays for hospital stays this summer as I will stay one night (at least) after getting a cardiac ablation. They require that for out-of-town patients before they travel home, just to make sure everything goes well. I suppose I should keep the Plan F policy with it's premiums at least through that time until I have more data to evaluate.

But basically, it's a gambler's game, isn't it? In 10 years with Plan F, I have paid the equivalent of a small car purchase with very little outlay the company has had to reimburse any health care providers. I think the highest bill they have ever paid is around $246. one time! Got me to thinking. I see lots of $2.00 t0 $9.00 payments to my medical bills that started out as $1,000!

Either way it's like we bet against our own health by "investing" in a more comprehensive policy, OR we take a gambler's bet that we'll be lucky enough not to need the "catastrophic" coverage.

There is a "High Deductible" Plan F my company doesn't offer, which sounds like what you have, sisoon. It's an out of pocket floor you spend up to before it kicks in.

I guess this is the time of every year when people on fixed incomes find out how little they'll have to live on after paying sudden increases in their property taxes (mine jumped 20% over last year) and having their health insurer demand another 20% increase in premiums in the same week! Not to mention the current 25% increase in fuel costs and the rising electricity rates nationwide.

I was just trying to play with the numbers and see if there is any other solution. Good luck to us!

Edited to add: on the phone I asked the agent if my increased premium was the result of my claims history, and was told "No, just rising costs, across the board." Then I asked if it was due to my Plan F policy's shrinking participant pool, since it is no longer being offered, and again I was told "No." HOWEVER, I was ALSO told if I want to switch to Plan G, I'm not a "Guaranteed Issue" so they will need to do a complete health questionnaire before granting me the lower premium policy! Hmmmm. I feel like maybe they have their thumb on the actuarial scale, and I'm a bad risk, but are just not telling me every aspect of how they work.

[This message edited by Superesse at 4:43 AM, Friday, May 29th]