- quote -

Is a "supplemental PPO" the same as what I've seen called "Medicare
SELECT?" From the literature, this choice seems puzzling when it comes to
choosing a provider. Is it the case that the provider has to be both:
- one that accepts Medicare (for the Medicare A&B part) and also
- be in the carrier's preferred list (for the PPO part)?

On Nov 3, 5:56 am, Avrum Lapin <avrum...[at]verizon.net> wrote:

- quote -

There are large differences in Medicare costs per state. See
http://www.cms.hhs.gov/MedicareFeefo...ds/HHAst05.pdf

Part of the cost differences are due to the general health of the
population (LA, MS, OK, TX, etc.), and part due to the cost of the
services (NY, CA).

--
Ron

In article <1194037575.229175.230900[at]d55g2000hsg.googlegroups.com> ,
Ron Peterson <ron[at]shell.core.com> wrote:

- quote -


Those numbers are for 2003. For CY 2008 Medicare will pay
$885.55/mo/enrollee ($10626) to MediCare Advantage plans ($54 less/mo
for the under 65 disabled) for San Bernardino County (60 miles east of
LA). They pay more in LA county and slightly less in Riverside County.
This excludes ESRD.

On Nov 2, 10:34 am, Avrum Lapin <avrum...[at]verizon.net> wrote:

- quote -

http://www.medpac.gov/publications/c...taBookSec2.pdf
states:
"Per capita expenditures increased by about $2,000 for each age group
over 65: Per capita
expenditures were $5,042 for those ages 65 to 74, $7,789 for those 75
to 84, and $9,243 for
those 85 and older. Per capita expenditures for Medicare beneficiaries
under age 65,
enrolled due to disability (both end-stage renal disease and non-
ESRD), were $6,513. On
average, Medicare spending per beneficiary was $6,602."

--
Ron

In article <Xns99DB715B416FDPJJGFZPLIpomegranate[at]216.196.97.136> ,
"pomegranate-man" <self[at]emailNot.nul> wrote:

- quote -

I have no idea of what a bypass surgeon charges but I expect that 20% of
that charge is in excess of $1024.

- quote -

approved amount for the procedure as payment in full (there is a
provision for a provider to charge and receive 15% above the MediCare
approved amount but in this area none of the providers do this).
MediCare then pays 80% of the approved amount and MediGap will pay the
rest. In larger MediGap plans the payment occurs seamlessly.

If MediCare does not cover something (say you exceed the 100 days in the
nursing home or have a tummy tuck) there is no product that I am aware
of that will cover you other than long term care insurance. MediCare
does not cover work done by a provider who does not accept MediCare.

So if you have a "vegetative" coma in your future you will be expected
to spend down your income and assets (less an amount for your spouse and
dependents still at home) and go on MedicAid (welfare)

For what it is worth the MediCare pends an average of $1000 per month
per person on the over 65 crowd. Memory suggests that MediCare still
takes in more than it spends but that trend is due to reverse in the
near future.

Thank you for the thorough and thoughtful response.

Unfortunately, I'm still puzzled over some details.

- quote -

I'm in California too. My knowledge of Medicare details is probably
faulty, so please correct any errors below.


- quote -

MediGap is one of the plans I'm trying to get my head around.

Surely you aren't suggesting it's sensible to pay $1,800/yr ($150/mo) to
protect against a possible loss of $1024. I'm in good health, but even
sickly people don't typically have major surgery every year. (My guess is
there's a typo in your surgeon dollar amount; plus, there are other
costly specialized services are involved in major surgery; plus, ...)

So typically, if somebody had severe episode like a heart bypass, how
much would MediGap pay in total dollars? And how much would the patient
pay after Parts A, B, D, and MediGap? Maybe there are a few examples from
experience. Is there a maximum dollar figure MediGap would pay?

It also seems that MediGap shields us from the first dollars of expense,
but (like Parts A and B) cuts off when the expenses pile up. I'm
referring to the limits of 150 hospital days and 100 skilled-nursing-
facility days per benefit period. As far as I can tell, nothing in the
Medicare menagerie extends these limits. Even Medicare Advantage plans
that tout "unlimited days" qualify it by saying "Medicare-covered"
charges -- I've asked, and this qualifier means that the "day" limits
still apply. Am I wrong to be concerned about these limits? There's got
to be some kind of really low-cost supplemental medical coverage outside
the Medicare system that kicks in when the limits are reached, but I
haven't found any. Nothing from my employment history applies. (I'm aware
that long-term-care insurance for custodial nursing-home or assisted-
living stays is a separate topic outside the scope of a Medicare
discussion.)

Parts of Medicare (including Parts B and D, if I'm not mistaken) are
subsidized from the taxes we've paid. So an individual can expect to
receive more in benefits than he pays in premiums, on average over time.
Is this true of MediGap?

Thanks again!

- quote -


This is a note I prepared for someone else in another newsgroup but it
might help.

As a trained SHIP (or HICAP as we call it in California) counselor I
have to correct errors in your post about the risks of using MediCare
Advantage (MA).

(SHIP does objective free counseling on MediCare - see www.shiptalk.org
also AARP has a number of understandable pamphlets on the subject.
Medicare's booklet "Medicare and You 2007" is also relatively readable
but do it one page at a time)

First a disclaimer - I have chosen to buy a MediGap policy rather than
enroll in an MA plan. See the last paragraph as to why.

Simplifying for brevity

Basic MediCare Part A covers admissions to hospitals. You will owe $1024
(in 2008) per admission as long as there are at least 60 days between
admissions. After 3 days in a hospital you get 20 days in a skilled
nursing home. Note that the Ambulance, the ER and day surgery are not
covered in Part A., Part A is free

Basic MediCare Part B covers doctors, the ambulance, the ER, day
surgery, labs and things like wheel chairs. You will pay 20% of
doctors, the ambulance, the ER, day surgery, and things like wheel
chairs. Lab work and diagnostic X-rays are free. There is a $992 cap on
the cost of the ER and day surgery (but not including the doctors
therein). Part B costs $96.40/month in 2008, withheld from your Social
Security

MediCare Part D covers prescription meds.

While 20% of an office visit (about $12 in my area) is reasonable, the
$1024 or 20% of a heart bypass surgeon may be hard to deal with.

If you are poor there is MedicAid, if you are rich you whip out your
check book. For the rest us it is either Medigap (also called MediCare
Supplement) or MA

In this area a decent MediGap (Plan C through Plan J) will cost you
about $150/month provided you enrolled within 6 months of age 65. You
also need Part D which will cost about $25/month. Medigap will
essentially cover all of your share of costs for services covered under
MediCare.

In this area MA comes in 3 flavors - HMO, PPO and PFFS. Since most of my
clients opt for HMOs I'll cover these first. In my area we have 12 HMOs
to choose from. 11 of the 12 HMOs have no monthly premiums. Office
visits typically run $10 (although they are free in one plan).
Typically a stay in the hospital is $250. An ambulance is $75. The ER
is $50, but Day Surgery, labs and X rays are free. All have the 20 days
in the nursing home but waive the 3 days in the hospital. All of the 12
plans include a Part D equivalent. Most offer some Podiatry and vision
care. What's the catch - you must select an primary care doctor and use
the specialists, and hospitals that he sends you too.

If you consider two people who have been told that they have lung cancer
and the recommended treatment plan is surgery followed by radiation and
then chemotherapy on an outpatient basis.

Mr MG has a Medigap policy and Part D. He has been paying $175 a month
since he was 65. He can choose any surgeon, hospital, radiation center
and chemo doctor that he wants as long as the provider accepts MediCare.
He will receive no bills except for the Chemo and any Rx. The chemo
stuff (but not the doctor) is covered under Part D. He will probably pay
1/3 of the cost of the chemo and soon arrive at the gap.

Mr MA has been paying nothing each month. He will use the surgeon (no
cost except $10 for office visits) chosen by his primary care doctor's
medical group. He will pay his $250 at the hospital selected by the
medical group . Later he will go to the selected radiation center
(paying $10 per visit) and the approved chemo place where he will pay
$10 a visit and the same amounts for the chemo as Mr MG. There are no
hidden costs, just the restrictions on who treats you and where. I
suspect that if there are multiple treatments available you will be
quietly steered to the least expensive.

It is obvious why a person living solely on social security (and there
are lots of them) would choose an MA plan. If being able to see whom
ever you want, where ever you want, and having some say in choice of
treatment is important to you and you can afford the $175/month then
MediGap is your choice. People who have multiple illnesses when they
start MediCare and are seeing various specialists find MA very difficult
to deal with.

In my area there are two PPOs - a free one with $1000 deductible and a
$50/mo one with a $500 deductible. Both come with an inclusive Part D
and have an out of packet annual cap of $3000 per year

The PFFS's run between $50 and $100 a month and an inclusive Part D.
PFFS are relatively new this year and there is still a lot of
uncertainty about which providers will take which PFFS. Typically PFFSs
pay providers about 1% more that PPOs pay in network providers.

Note that not all doctors take MediCare especially in affluent and rural
areas. MediCare does pay providers more than MediCal (Medicaid in CA)

"Ron Peterson" <ron[at]shell.core.com> wrote in message
news:1193287413.988448.250960[at]i38g2000prf.googlegroups.com...
- quote -

Be sure to know the provisions of your current plan before you defer signing
up for Medicare. Our insurance assumes, once 65, that you have signed up for
Medicare, and, at age 65, pays only what Medicare would not have paid. If
you haven't signed up for Medicare, you suddenly have much larger out of
pocket expenses.

Elizabeth Richardson

On Oct 24, 4:15 pm, "pomegranate-man" <s...[at]emailNot.nul> wrote:
- quote -

I am 73, on Medicare, and have a supplemental PPO that I am most happy
with. All the medical people and hospitals know what Medicare will
cover and what they will not. Do a Google Search on Medicare and you
can read for yourself what Part A, B etc. is all about. Between
Medicare and my PPO, about 95% of all my medical costs have been
covered. I have a few co-pays that make that 5% personal costs.

On Oct 24, 6:15 pm, "pomegranate-man" <s...[at]emailNot.nul> wrote:
- quote -

You don't need to sign up for Medicare as long as you are working and
have "good enough" medical insurance.

If you retire before age 65, you may sign up for Medicare A and B
starting in the month for which you turn 65 (allow 3 months for
paperwork).

If your employer has a variety of health plans, switch to one that
will be convertible to a supplemental and pick the one that allows
Medicare part D (drugs) exclusion. If your supplemental requires part
D, then sign up for that also.

You don't have to take SS payments to sign up for Medicare, you can
pay for that separately.

- quote -

Clinics and hospitals may handle the pre-approval paperwork for you.

You may want to pick a plan that has pre-approved providers in all
areas that you may live.

- quote -

Some are OK.

- quote -

Nursing home care or assisted living are outside the scope of
Medicare, you will need to find some other way to finance those needs.

- quote -

SS may reject your request for Medicare for a number of reasons, but
it doesn't happen often.

Clinics may refuse to accept you as a patient because of the lower
reimbursement rate of Medicare.

Medicare and the supplemental insurance company decides what they will
pay for, so get preapproval if you can. There are some procedures and
legal actions that you can use if you are denied.

--
Ron

Anybody out there of Medicare age? I'm approaching, and am trying to decide
which way to go.

There's lots of material out there about the plans, and I've been reading
up. What I'm looking for now is what isn't in the literature; basically,
the gotchas of the different approaches: bureaucracy, pre-approval
requirements, hidden limitations, customer-unfriendly policies or service,
stuff like that.

For starters, there's a choice between Medicare Advantage (HMO, PPO, or
PFFS) and Original Medicare.

I wouldn't choose an HMO (just not a fan of HMOs).

Currently, I have an individual PPO plan. I like that the preferred
providers are documented in advance and there's lots of choice. The company
I'm using now doesn't offer a Medicare Advantage PPO; the alternative PPOs
here are a possibility but the choices don't look all that appealing.

Medicare Advantage PFFS plans are puzzling. There seems to be no way to
know in advance what providers participate. A PFFS plan would be
interesting if it extended the number of hospital days and nursing-facility
days beyond the limits of Original Medicare, but none I've seen do this.

For Original Medicare, I'm curious about pre-approval. Is there any, and
who makes the decision? Likewise, are claims denied after the service is
done, and who makes the decision? Any examples of unreasonable decisions?

Advice based on personal experience would be helpful.