Originally Posted by Anthony
Dan, Medicare is really a HMO. To get what they call "out of network" medicare benefits, you still, as a provider still have to register with medicare as a "non-participating" provider, at which time you agree to accept the "non-participating" fee schedule, 15% more than the standard rate. If you never register with medicare, then you charge the patient anything you want, and are not bound by any limits, and can accept anything you want as a "true" out of network provider. If it walks like a duck, quacks like a duck, then it is a duck (HMO). What medicare calls "out of network" is really not "out of network". Any medicare beneficiary can see any doctor they want, but, if that doctor is not registered with medicare at all, then medicare pays that doctor nothing. There is nothing that states any doctor has to treat anybody in an emergency, only the ER is mandated to treat any patient that enters the ER. If I were not signed up with medicare, I could easily refuse to treat any medicare patient that I did not want to treat, for whatever reason.
As I stated above, Medicare will pay the 80% to ANY Doctor in the US. There is no in or out of network. YES a Doctor can refuse to make an appointment and treat a Medicare patient. But if he does treat the Medicare patient then he is bound by the Medicare rules with or without an agreement with Medicare. And he/she WILL be paid by the Medicare administrating agency, IF the Doc files a claim with Medicare. I specialized in Senior health care insurance, and taught the rules to agents, Chambers, and Senior groups.
As far as supplemental insurances ( I'm talking the 1980's-1990's, way before part D), I believe AARP, and various BC/BS plans, and other insurance companies have had prescription coverage, whether 50% , more or less, brand name vs. generic, I'm sure there were differences, but way before part D, there were numerous supplemental plans, called a secondary. Medicare primary, another insurance secondary. That's what I was talking about, not medigap. I was licensed with 50 or 60 insurance companies that offered Medicare Supplement policies. For many many years now there have been 10 Supplement plans STANDARD to ALL insurance companies. Not a single word of difference in all the plans of all the companies.
Again as I said above some plans [J & K] had Rx coverage prior to PART D. And as I said above the coverage vs the extra premiums was pitiful
Medicare Supplement Policy is the official name of any the 10 supplemental plans.
Medigap policy means the exact same thing. As does Med Sup, or just plain, supplement. All short, or slang, or nick names, for the same thing.
Our agency had tens of thousands of these policies in force and never had an errors and omissions claim against us. I'd say that meant we KNEW of what we spoke.
With Medicaid, I believe there's an arrangement with each state, such that the Fed matches a percentage of what each state puts into their Medicaid program, and there may be some other specific requirements as well. Medicaid is like Medicare as well, a HMO. If you are not registered with your states Medicaid program, you can charge and bill medicaid patients anything you want. I know this, because I opted out of my state's medicaid program for several reasons, about 10 years ago, and have been charging those patients cash, what I deemed to be a fair and reasonable amount.
I did not sell Medicaid, or teach it, or care about it, so I cannot and do not wish to argue with you about it. And yes, I know there is nothing to be sold with Medicaid.
As far as a patient resigning from medicare, I wouldn't call it resigning, as all of these patients still are under many medicare guidelines. I would call it choosing an insurance based medicare plan instead of standard medicare, which they have to agree to for a period of 1 year. And, I don;t believe Medicare sends this persons premium to the chosen insurance-medicare plan. I believe medicare still collects that premium from the patient, but in a separate arrangement, pays that insurance company on a negotiated amount per enrollee, a number that I believe is not the same as the patient's premiums, but actually a higher value.
I did not say the person was out of Medicare forever, but they do technically resign from it while in an HMO. Yes the Medicare premium is still deducted from the Social Security check, I never said it was not. But then it and possibly MORE, not less is sent to the HMO company.
If you are unfortunate enough to be ill, and require a great deal of multiple procedures, tests, then a supplemental plan would likely benefit you. If you are seeing 4 different doctor's every month, constantly getting multiple tests done, that 20% that you owe will add up fast
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