I am three months away from qualifying for Medicare and everything is going smoothly. HHS already sent me a card, and a couple of days ago Kaiser Permanente sent me a signup form that looks like just what I want. But there is a weird little mystery that I can't figure out. Here is the Kaiser description of benefits for two plans, the standard HMO and the Value HMO:
There's not much difference. But the standard HMO is better: It has no inpatient hospitalization copay and the annual out-of-pocket is $1,000 less. Now here are the plan prices:
They are the same: $0. I don't suppose anyone cares much about this. Even I don't care much about it. But it seems awfully peculiar. Why bother having two plans that are close to identical in the first place? And if you do, shouldn't you charge more for the better plan? What's going on here?
Are the provider networks the same? Is there some other difference in the service levels, like other procedures or services covered at no charge, or priority for making appointments or choice of provider or some such? How about charges for meds or access to or charges for out-of-network providers? Just spitballing, but if they're otherwise identical then yeah, seems strange.
Another thought: they might be segmenting the market into high-care and low-care subscribers.
Kaiser doesn't have network providers... or more accurately, Kaiser *is* the sole network provider. Kaiser's entire business model is being both the insurer and the provider, so in the (limited) places where they offer insurance, they also have their own chain of medical facilities, which you have to go to for all medical services unless it's an emergency OR you're traveling outside a metro area with Kaiser facilities (e.g. one of the 40+ states that have none). There would be no difference in providers if Kevin picked from any Kaiser plan... it's not like KP operates a dual-tiered network of "gold" vs. "silver" facilities. Any Kaiser member can go to any Kaiser facility nationwide.
Right, KP is a cost efficient HMO, a closed system with its own facilities and physicians and also operates as an insurance company for non-Medicare people. It offers very good coverage under Medicare advantage, and medigap policies aren't needed or offered. Getting services from non KP doctors or facilities is difficult but possible in extreme situations. Medicare Advantage was created to transfer Medicare administration to the private sector and paying them for it. It's generous enough that most insurers will offer zero premium plans with extra coverage.
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Here in WA there is a state affiliated group you can contact for assistance in evaluating Medicare Advantage plans. No cost - the state is paying the consutltants. The consultant did a very thorough interview with me and with my wife to get detailed information on current conditions, medications, prior medical history, etc. About a week later we each got a list of a half a dozen Advantage plans with a lot of detail on coverage, copays for various services, prescription policies and costs, area coverage, and so on. All the my prescriptions turned out to be 0 copay, most procedures had modest copays with the plan accepting Medicare for the balance.
When we moved from King county to Whatcom county, we engaged the consultant again and he redid a list focusing on providers with good coverage in Whatcom. Also covered by WA.
You might want to check whether CA has a similar consulting service. We've been on Medicare/Medicare Advantage for 4 years now - no service denials, no problems getting scheduled for checkups or actual treatments.
Kevin - you need to listen to DButch, you need a Sherpa to guide you to making the right selections, very important considering your health issues.
Sounds like a question for David Anderson over at Balloon Juice.
I'm guessing it is an artifact of plan competition - there are a lot of odd-seeming games played in different markets with plan menu structure. But I'm totally just guessing.
There's value in the value plan--just not for you.
I'd guess they need the different plans for the government to check and for setting the amount the government will provide in terms of premium support. Akin to the situation with Obamacare with the premium support set to cover (most) silver plans, making bronze plans ridiculously expensive with co-pays, etc.
Why are you choosing a Medicare Advantage Plan at all ? When I was investigating this a year ago traditional Medicare came out much better than any Advantage Plan (i.e. fake Medicare). It's important to pick correctly when first going into Medicare, as it can be much harder to change plans later. We have Traditional Medicare A & B, a Medi-Gap Plan G, a Part D drug plan, and separate Dental. This way if your procedure is allowed by Medicare no insurance company can deny coverage. This question was enough to get me to register with your blog btw. The cost of our plans is greater than 0 however.
Thanks for pointing this out! I, too, was wondering why the obsession with Medicare "Advangage."
I think people who have existing coverage from Unions and good former employers an advantage plan can give you sone stuff that Traditional doesn’t and your Union insurance will fill in the gaps. My dad had not Union and employer coverage and used Traditional and had zero gaps ( they both had dental). Each his own.
I think it varies substantially by where you live. I'm not disputing your experience, but I ran the numbers when I first became eligible, and the Advantage plan available in our area was a great deal -- in particular, way better for my needs than the Medi-Gap plan I could have gotten. So, I would not call it "fake Medicare."
Definitely depends on the area and whether or not there is adequate competition. In Pittsburgh, I can get a Med Advantage plan for $0 monthly premium. I generally spend about a $1000 on copays, but I've had health problems. Medigap plans are more like $300 - $500 per month, so over a decade you're talking about $36K - $60K up front in premiums.
I think Medicare Advantage is a scam on the government and we shouldn't have this program (it costs Medicare more per patient than traditional Medicare, even though it tends to skim off the healthier "young old" patients), but given that we do, it is saving me a lot in premiums.
I've seen similar things as well, like two plans that are identical in every respect except for one tiny difference.
While I'm sure that the situation is different for you with Kaiser in suburban southern California, I can say from experience that in small-town Ohio, a PPO is a far better option than an HMO, even though it costs slightly more; with the HMOs available around here, virtually everything beyond the most basic of basics is out-of-network.
I haven't looked at Medicare plans yet, as I'm full time employed, but for regular ACA plans, you really have to look at the provider networks. I'd never go with an HMO over a PPO for just the reasons you mentioned.
But Kaiser may be a special case, since they control both the horizontal and the vertical.
I think KP Medicare plans are all Medicare Advantage (aka Medicare Part C) plans. And in many states, Medicare Advantage plans are regulated in what they can charge - usually it can't be more than what you would have paid for Part B + D (if the Medicare Advantage plan also includes prescription drugs). I wouldn't be surprised if CA is one of the states that doesn't allow Medicare Advantage plans to charge anything to anyone or at least anyone with an income below a high cutoff. Perhaps you, Kevin, fall under that cutoff and so your personal quotes for all the plans is $0. Someone else in another state and/or with higher income might actually see different values than $0 on your second screenshot.
Given the screenshots you've shown us, you should pick the non-Value option: it's cheaper per visit AND it has a lower annual out of pocket limit.
It looks like lots of people in California discover that Medicare Advantage plans are "free" to them because the state is somehow using federal dollars to cover what would be the monthly premiums, in exchange for the Medicare Advantage plan handling all claims (instead of having Medicare's own staff do it). My guess is that KP - being both the insurer and provider for its members - saves so much in doing so that its premiums are very low anyway, and the set amount Medicare gives to Medicare Advantage to manage the plans is higher than what the premium would be, so it's "free" to you the potential member.
https://insuremekevin.com/medicare-advantage-plans-are-not-free-federal-government-subsidies-in-california/
https://www.humana.com/medicare/medicare-resources/is-medicare-advantage-free?kc=0300041012
https://www.hhs.gov/answers/medicare-and-medicaid/what-is-medicare-part-c/index.html
If you sign up for the wrong one the Columbia Records and Tapes Club will send you a new selection monthly for the rest of your life
And you probably don't have anything that can play them any more.
My employer changed healthcare plans, so we went from having one to having 3 to choose from. But they all cost the same and offer very similar coverage. I suppose I can understand why they don't offer a more expensive heavy coverage plan (what I would want) and a lighter plan with more out of pocket because they pay a percentage. But the differences in the plans was very minimal, and they involved things that were hard to predict, so I had no idea which one would be best for my family. I suppose a few people with very specific circumstances might save with a particular plan, but for most of us, it's a crapshoot or a wash. It was pretty frustrating.
Competition is likely a part of the answer with regard to there being no charge. When I had Kaiser Medicare Advantage in SoCal, the premium was zero. When I moved to NorCal, the premium was about $80/month for the same coverage. I'm pretty sure there was less competition among insurers here in NorCal. But it's interesting that during the last two or three years, my premiums have decreased! Perhaps more competition up here now?
I've never heard of a second "premium" Kaiser plan, though Kaiser does offer optional optical and dental coverage for another $20/month. The dental coverage is minimal.
I have been in Medicare for some time. Best have an Advantage plan as around here, and many other places, doctors do not take patients with Medicare. Also, the bottom line is that Advantage pays for things that Medicare does not so you likely will have few or no bills. At least you can change yearly but just a heads up.
Also, if you move, many of the good plans of large areas are not available in the country. Kansas was arid of descent plans. Good luck..
Medicare Advantage plans don’t pay for things regular Medicare doesn’t. The federal government (aka taxpayers) pays for them. Medicare Advantage, instituted under GWB, is a grand fraud. They manipulate the risk rating of their own pool to make it look worse that it is, thereby getting a higher level of government support than they deserve. They then use those ill gotten gains to throw a few freebies (eyeglasses, dental, etc.) to their customers. I am appalled that Kevin’s readership is helping to enable this grand fraud
When I turned 65 and did my research on Medicare (in SoCal), what I found was that the "advantage" goes to the insurer. You have to go to a network provider, and it's easy to discover -- after you've gone to a network provider -- that someone who works there is NOT in the network and is charging an arm an a leg for, say, reading your X-ray and you get a huge bill. (This is just an example of one thing that can go wrong,)
Also, you are a person with a serious preexisting condition. Do you really want to argue with a gatekeeper doctor whether CAR-T is experimental and therefore not covered? The pricing anomaly you found at Kaiser is not relevant. In your position (cancer patient, adequate money available, low tolerance for bureaucratic bullshit) you should go with regular Medicare A & B, plus gap coverage and prescription (Part D) coverage. You can handle the initial bureaucracy, and after that it'll be easy. You'll get the care you need and want with minimal corporate hoo-ha in your way.
Also, HICAP (the Health Insurance Counseling & Advocacy Program) provides free and objective information and counseling about Medicare. (800) 434-0222.
The Biden Administration has a full court press on to stop those surprise out-of-network billings.
But can he get the job done? Or will the Supremes conjure up a bogus excuse to say he is not allowed to do that?
As a long-time member in Germany's very good healthcare system -- although it's by no means perfect and there's plenty to complain about -- it's always shocking every time I read just how complicated and obtuse things are in the US -- and Medicare is supposed to be the comparatively sane part of the US system! And $1000 out-of-pocket costs? I was in the hospital a couple of times this past year in Germany and had a daily fee of €10 to pay. In addition to €5 copays for prescriptions, those were the extent of my out-of-pocket costs. It's bizarre how such high out-of-pocket costs are standard -- isn't that what insurance is for?
You are being suckered into a Medicare Disadvantage plan. I have traditional Medicare and a Medigap plan that covers the some of remainder of that Medicare doesn't (MC leaves out usually 20%).
There are a number of Medicare Advantage plans but they all play games with you and lock you into their HMO empire. Original MC is accepted everywhere and has no fine print.
Back to MedigapL
There are a number of Medigap flavors, but ALL of them are carefully delineated and have to be the same benefit no matter who offers them.
I have Plan F ($ 250 or so per person, $500 some for my wife and I) and it covefs EVERYTHING. I never see a bill, never get surprises. MC is accepted everywhere by virtually everyone. My wife has an autoimmune problem with 4-5 figure cost every month, but we pay NOTHING beyond our premium.
"Plan F is a first-dollar Medicare Supplement insurance plan. First-dollar coverage means you’ll pay zero out-of-pocket outside the monthly premium. No matter your medical costs, you’ll never pay copays, coinsurance, or deductibles. If Medicare covers it, you won’t pay a penny."
Alas, if you're entering MC after 2020, plan F is no longer available. Good alternatives are:
Medicare Supplement Plan G: Plan G has become increasingly popular for several reasons. First of all, it covers all of the gaps in Medicare that Plan F covers, with the sole exception of the annual Medicare Part B deductible ($233 in 2022).
Medicare Supplement Plan N: Under Plan N, which tends to have lower monthly premiums than Plan G, seniors are similarly covered for Original Medicare costs. However, Plan N does require small copayments for most visits. Plan N will bill a $20 copay for office visits and a $50 copay for emergency room visits that don’t lead to hospital admission. Like Plan G, it does not cover the annual Medicare Part B deductible ($233 in 2022). This is a good replacement for high-deductible Plan F.
Plan F was discontinued for new enrollees because Congress wanted the consumer to have some deductible in the game....but if you have it, you can keep it.
Extending my comment elsewhere on this post, a lot depends on where you live. I live in a very rural area with few options for doctors and almost none for hospitals, so there are no games Advantage plans can play for "in- or out-of-network" if they hope to get your business at all. My Advantage plan (PPO, not HMO, btw) was a much better deal than any of the Medigap plans that were available to me.
Traditional Medicare for me, plus a good Medigap policy.
I don't need to worry about a hospital or other emergency facility I might need being out of network (I know of no decent hospital that does not "accept assignment" [the Medicare equivalent for being "out of network"].). I don't have to worry about prior approval. It's easy to confirm in advance whether any specialist I want might to see accepts assignment. I don't have to worry about deductibles or co-pays (my Medigap policy takes care of the 20% not covered by Medicare Part B). I chose a good drug plan (drug coverage in MedAd plans is not always up to snuff), and I independently pay for an excellent dental plan (that's better than most of what I've seen in MedAd plans that offer some dental coverage). I've had a lot of doctoring and expensive testing so far in 2023, and I haven't had to reach for my credit card once because Part A, Part B, and my Medigap policy are covering every cent of the costs.
I know MedAd plans are lobbying legislators hard to completely overtake traditional Medicare, and they're likely to succeed at that in not too many more years. I'm sort of hoping I'm no longer around when that day comes.
That they are spending all that money on lobbyists and campaign contributions tells us all that our health is not their primary motivation for being middlemen.
My vote is for either a requirement to have two different plans, or inertia-- initially having two plans with substantial differences that have morphed into each other after actuarial experience. But also this-- their offerings are notably location-based (this one is for only two counties!) and the two kinds might be very different in other parts of the state where different patterns are in play. Might be, but might not; just a WAG.
My wife is an Alaska State Plan One retiree, so we have a comprehensive Medigap through Aetna that the State pays for completely. It has been great, but the comment Heysus made about doctors not taking traditional Medicare is certainly increasingly true here in Vancouver WA. Our former husband and wife team that had their own clinic and were fantastically good doctors and great human beings closed down and took jobs with the VA system. They just couldn't pay for all the staff necessary themselves with the pressure the insurers levied on them.
It took me well over a year to find a "Primary Care Provider". I like him a lot, and he's very thorough and explains things completely, but he's pretty much a rarity these days. I'm glad I have him.
Kevin, I strongly urge you to consider traditional Medicare Parts A and B, plus some supplemental (that covers as much as possible). It is VERY important that you enter Medicare getting what you need, because adding features after the fact, though possible, is hard and comes with a financial penalty, AND can cause some serious billing screwups (and how much is your time and sanity worth, right?)
As you know from your own experience, a health issue can start at one time, but then services and providers can be added or changed as time goes on and your condition changes. This can last years. If your insurance changes midway, the providers' billing agents will, I can almost guarantee you, totally bollox up the billing protocols, and of course you won't find out about it for half a year or more, when you start getting nasty letters referencing things you won't remember ever happening. And you'll spend hours on the phone, and often still they won't get it right. Because insurance companies try like mad to deny claims.
So do the switch once, and as comprehensively as possible. Then try not to need medical help anywhere near the switchover date. And I know that's probably impossible for you, with the multiple myeloma. Do make sure that all your doctors and all their facilities (which as you know, will bill independently) have it on file when your switchover date is, and as soon as you get your Medicare cards, scan them and make sure all doctors and facilities have a copy image.
And then don't be surprised if six months down the road, you get paperwork stating your claims have been denied and you're responsible for a gazillion dollars. American exceptionalism.
I hope you're looking at regular Medicare and a Medigap policy and not a Medicare Advantage plan, Kevin.
I don't claim any special knowledge, but everything I've seen says the KP system is vastly different than anything that exists in any other part of the country, so I have to wonder how transportable is anyone's experience with Medicare/Medigap/Advantage coverage outside of CA to a KP region. Of course all options should be looked into for where anyone lives, but that's not quite the same thing.
I'm not on the Left Coast but in the semi-rural Northeast and I'm not sure I'll want to stay here for the longer term. My former employer subsidizes (at least that's what they say) an Advantage plan that caps out-of-pocket ex-drugs at 750 and treats all BCBS providers everywhere as in-network. That flexibility is what I wanted, even though the meds exception is potentially a huge drain. Kevin, otoh, seems very rooted, which seems similarly salient for him.
If Advantage is a rip-off for the feds-- something I'm easily willing to grant (the specter of Rick Scott floats over all federal medical spending, after all)-- does that make it a bad thing for people to use? Do they get less from providers, or end up paying more, because they have that kind of coverage?
I don't think there is an administrative chaos quite like Medicare in the US--and probably far beyond. I have been on Medicare for five years now and I have long ago given up understanding the fine points.
I was one year on Medicare Advantage and I switched back to "traditional" ASAP. The goodies you get are paid by offering low quality service (instead of a yearly doctor's exam where the stethoscope is applied and the doctor checks on the size of your prostate etc.) you get a "wellness exam", a telephone conversation with a low trained person which goes like this: "Are you healthy?"--"Yes"--"Ok, good", stretched out over half an hour. I should say this: This is likely not true (or not as true) for KP; I was never insured through them and they have a good reputation.