Ah...The 'Crisis' Continues.......

[Anthony]

There is some good info here, and also some misinformation.

Medicare is a government run HMO plan. Unless a medical provider (hospital-doctor) has signed a contract with Medicare, the medical provider will not get a penny from Medicare for any services, as Medicare has no out of network benefits. Hospitals and doctors know that patients in general will not go to them unless the services are covered, which is why practically all hospitals and doctors are signed up with Medicare, and have agreed to accept medicare reimbursement rates for services rendered, at whatever rate Medicare has deemed to be appropriate and reasonable, with the balance of the charges to be written off by the medical provider. Medicare designed their plan in such a way so the enrollees would not overuse their benefits. They did this by setting the system up as a 80/20 plan, where the patient is still responsible for the 20% of the allowed amount. So, for an example, for an intial patient visit of $ 120, medicare would pay $96, and the patient would be responsible for $ 24. For a typical established office visit of $45, medicare would pay $36, and the patient would owe $9.

Medicare until recently did not cover any prescriptions, so in the past, the significance of any supplemental plan was to also cover a good portion of the prescription costs, and for a bonus, the extra 20% that the patient would normally be responsible for.

There are Insurance based Medicare plans, where as an enrollee, you decide to sign up with an insurance company, say BC/BS (Blue Cross and Blue Shield), their Medicare plan. What happens now is that you have agreed to sign up for, and are enrolled in the BC/BS Medicare HMO plan, and will now only be covered by medical providers who have signed up with BC/BS's Medicare plan, and not just any doctor who is signed up with Medicare. What is happening is that Medicare is paying BC/BS a set feee per month, for every individual on the BC/BS medicare plan, and Medicare stipulates that BC/BS must now be responsible for all medical services. BC/BS has bet that they will spend less on medical care for that particular enrollee than what Medicare is paying them, and therefore will make a profit. Often, they will have more benefit limitations in place than general Medicare, as well as the limitation on which physicians the enrollee can go to, whre as with standard Medicare, the enrollee has his choice of every doctor who has an agreement with Medicare.

Medicaid is also a government run HMO plan for the poor, but run and funded jointly by the Federal and State governments. The difference is that Medicaid covers basically 100% of the cost of any medical services, and the enrollees generally owe nothing, either for medical care or prescriptions. Again, like Medicare, the medical providers have to sign an agreement with Medicaid to be paid for any services, at a rate as set by Medicaid, which is usually about 70% of the medicare rate, which is why there are a significant number of doctors who opt out of providing care under this plan. Enrollees can have Medicaid benefits without Wellfare benefits (general living supplementation).

The bottom line is that if you are on Medicare, and healthy, basically on little or no medications, you may be better just to have basic medicare coverage with no supplemental insurance. If you have some illnesses and take considerable medications, you may be best to buy a supplemental plan, to cover the additional costs, the extra 20% and prescription costs. If you don't have the money to buy supplemental insurance, then you are better off to sign up with one of these insurance medicare plans, where in general, the vast majority of the medical costs and prescription costs will be covered, although you will be limiting your care as to which doctors, hospitals, and treatments you may be able to receive.

[Dan40]

Originally Posted by Anthony

There is some good info here, and also some misinformation.

Medicare is a government run HMO plan. [WRONG] ANY Medicare beneficiary may see ANY Doctor and/ or any hospital in the US. No change in coverage.

Unless a medical provider (hospital-doctor) has signed a contract with Medicare, the medical provider will not get a penny from Medicare for any services, as Medicare has no out of network benefits. [WRONG] False from beginning to end, SEE BLUE below

Hospitals and doctors know that patients in general will not go to them unless the services are covered, which is why practically all hospitals and doctors are signed up with Medicare, and have agreed to accept medicare reimbursement rates for services rendered, at whatever rate Medicare has deemed to be appropriate and reasonable, with the balance of the charges to be written off by the medical provider. Medicare designed their plan in such a way so the enrollees would not overuse their benefits.
[INCOMPLETE AND MISLEADING]
If ANY US Doctor treats ANY Medicare beneficiary, for any reason, the doctor is BOUND by Medicare rules. If the Doctor has NO contract with Medicare and does NOT accept Medicare assignment then he may charge 15% over the Medicare approved amount, and he may not bill the patient for any more than that OR make a separate agreement. AND, in an emergency, he MUST treat the patient and be bound by the rules.

They did this by setting the system up as a 80/20 plan, where the patient is still responsible for the 20% of the allowed amount. So, for an example, for an intial patient visit of $ 120, medicare would pay $96, and the patient would be responsible for $ 24. For a typical established office visit of $45, medicare would pay $36, and the patient would owe $9.

Medicare until recently did not cover any prescriptions, so in the past, the significance of any supplemental plan was to also cover a good portion of the prescription costs, and for a bonus, the extra 20% that the patient would normally be responsible for. [WRONG]
Prior to PART D only a couple of the 10 Medigap policies covered Rx and those plans were outrageously expensive and offered very poor coverage. I do not remember the exact wording but they had a $250 deductible, then only paid 50% of the drug cost [WITH NO PRICE PROTECTION] and only covered up to $2000, or $4000. For that coverage, the premiums were $1800 to $3600 higher than any other plan. So ONLY if the insured absolutely MAXED out the Rx limit, would they break even with the premium.

There are Insurance based Medicare plans, [ Point of order, Insurance based Medicare plans are the 10 standard Medigap plans] where as an enrollee, you decide to sign up with an insurance company, say BC/BS (Blue Cross and Blue Shield), their Medicare plan. What happens now is that you have agreed to sign up for, and are enrolled in the BC/BS Medicare HMO plan, and will now only be covered by medical providers who have signed up with BC/BS's Medicare plan, and not just any doctor who is signed up with Medicare. What is happening is that Medicare is paying BC/BS a set feee per month, for every individual on the BC/BS medicare plan, and Medicare stipulates that BC/BS must now be responsible for all medical services. BC/BS has bet that they will spend less on medical care for that particular enrollee than what Medicare is paying them, and therefore will make a profit. Often, they will have more benefit limitations in place than general Medicare, as well as the limitation on which physicians the enrollee can go to, whre as with standard Medicare, the enrollee has his choice of every doctor who has an agreement with Medicare.
The reason Medicare pays a monthly fee to an insurance HMO is that in joining a HMO the person RESIGNS from Medicare. So Medicare has no more risk from that person. Then Medicare sends that person's Medicare premium deducted from their Soc. Sec. check to the HMO. There WERE a few advantages to the VERY poor as they did cover Rx in the beginning, with only a small co-pay. Now the HMO's charge a monthly premium over and above the Medicare payment they receive and they have much higher co-pays on Rx and much lower limits on yearly Rx totals.

Medicaid is also a government run HMO plan. The difference is that Medicaid covers basically 100% of the cost of any medical services, and the enrollees generally owe nothing, either for medical care or prescriptions. Again, like Medicare, the medical providers have to sign an agreement with Medicaid to be paid for any services, at a rate as set by Medicaid, which is usually about 70% of the medicare rate, which is why there are a significant number of doctors who opt out of providing care under this plan. Unlike Medicare which is a 100% federal funded program, Medicad costs are shared by both the Federal and State governments (tax payers). I'm not a Medicaid expert, but the Feds fund the money to the State and the State administers the payout.

The bottom line is that if you are on Medicare, and healthy, basically on little or no medications, you may be better just to have basic medicare coverage with no supplemental insurance. If you have some illnesses and take considerable medications, you may be best to buy a supplemental plan, to cover the additional costs, the extra 20% and prescription costs. If you don't have the money to buy supplemental insurance, then you are better off to sign up with one of these insurance medicare plans, where in general, the vast majority of the medical costs and prescription costs will be covered, although you will be limiting your care as to which doctors, hospitals, and treatments you may be able to receive.

[not quite right] A person can have a PART D Rx plan without having a supplement plan, I do. And a person has to be really ill to make a supplement worthwhile. The wife and I together have 11 years on Medicare without a supplement. All of our 20%'s and PART A deductibles together DO NOT add up to a single years supplement premiums for either ONE of us.