What is "straight Medicare"?

[clifffaith]

Cliff has had HealthNet HMO insurance for 30 years, the last 16 of this on Medicare. He has been happy up until now, and loves his PCP ( who has been both our doctors for over 20 years). His problem these last couple months has been the wait and process to get scheduled for skin cancer surgery.

First he has to recognize he may have an issue, then he has to get in to see the PCP (maybe two weeks, but not more than that). Then she sends in for a referral to the dermatologist which takes a week, then he calls for a dermo appt which takes 2-3 weeks. Then dermo requests a referral to oncologist, another week, then two weeks to see oncol, then a month to get surgery scheduled. That was for squamous cell carcinoma on his hand. Process started in June, today he had his final check up one month after the doctor was confident his complications had simmered down (hand blew up popping stitches and exposing tendons one week after surgery).

Then I agitated in August for him to get his cheek looked at. Repeat PCP/referral/dermo. Dermo said "meh". After a month of making him put a towel on his pillow because he wakes up bloody, I agitated for a repeat dermo visit. Repeat PCP/referral/dermo. This time (last Tuesday) dermo tells him he has squamous cell skin cancer and takes a biopsy. Today (10 days later) we have the referral to the doctor (different from hand Doctor) for Mohs surgery on his face. I assume we'll need a preliminary appt, then surgery will be scheduled.

My only problem with these two processes is that dermo dismissed him with a "meh" when we knew there was something going on. The timing didn't bother me (although the cancer on his hand tripled in size during the scheduling process). Cliff seems to think the wait times are all because he has HealthNet. Someone on his Motley Fool board is pushing "straight Medicare'. Because I am still a year away from having to choose a Medicare plan, I have no clue what that means. But it doesn't sound like something he should get involved with. Any insight would be appreciated so I can steer him away from this if it is a bad idea.

 

[Luanne]

I've never heard the term straight Medicare. Maybe it's Medicare Parts A and B and a Medicare Supplement plan? Can you go to the Motley Food board and ask?

I'm surprised about needing a referral to see a dermatologist. I went in for my first appointment to get a check up and just made the appointment and went. Didn't need a referral from my primary care doctor. I think you said Cliff has a Medicare Advantage Plan. Maybe that is the difference in why he needs the referral before seeing another doctor.

 

[isisdave]

Straight Medicare means "original Medicare" and that's parts A and B. You should include a Medigap policy to cover the exclusions and copays of Part B. We have the N plan, which is adequate. Others have G or F (which won't be available after 2019). All companies' policies are the same, only the price varies. You can go to any doctor who accepts Medicare. You can toodle right up to UCLA's dermatology department if you want. If you don't like that answer, pop on over to USC.

The alternative is Medicare Advantage plans, which are provided by private insurers. Most have very low or zero additional cost (beyond the Part B cost, about $134 per month this year). Almost all are HMOs, meaning you have to see their doctors and follow their rules. In fact, in our zip code, only one of about 30 is a PPO.

Cliff's current setup is an HMO. We would never have one. DW was a psychotherapist, and over 20 years saw 2 or 3 patients die because of the slowness of the referral system. You're experiencing this now, but a squamous cell carcinoma isn't life-threatening.

Another thing we discovered is that SoCal Kaiser (the most popular HMO, I think, in California) is a completely different system and management than NorCal Kaiser. They both have fans and detractors, but NorCal seems to be higher quality.

 

[Passepartout]

Some Medicare Advantage plans require you see your PCP for referral to a specialist, some don't. I am thinking Cliff's might be plain vanilla Medicare HMO, not Advantage, but it's really not clear.

I wish him well. I had both a squamous cell shaved and cauterized and Mohs on a basal cell on the end of my nose last week-the new nose is a thing of beauty! You'll both feel better when it's done.

Jim

 

[Luanne]

@isisdave, thanks for the great explanation. When dh became Medicare eligible he was still under my work insurance. When I retired he did his research and opted for a Medicare Supplement (Medigap) plan. I followed suit when I retired. We both have Plan F, which I "think" we can keep since we already have them. We feel they are more flexible, and yes more likely more expensive than some of the other options.

 

[tiel]

Both of us have Medicare A and B, plus a Supplemental, and couldn't be happier. We've both had major health issues since going with this option, and we were able to select the doctors we wanted and arrange for care that fit our and the doctors' schedules. Zero out of pocket costs, beyond the insurance premiums. We would not be able to tolerate the strict rules of an Advantage plan, but it may work fine for others.

 

[IngridN]

"Straight" Medicare sounds like what is called "original" Medicare which is Medicare with a Medigap policy and a separate Part D for Rx. The other Medicare is Medicare "Advantage" which is everything rolled into either an HMO or PPO-type policy. That's all I know about Advantage. The Advantage can have very low or no costs associated with it, however, the networks may be very limited. Possibly also, there are referral requirements. With Original Medicare, no referral is needed. Original + the Medigap + Part D Rx is NOT cheap. Many chose the Advantage policies for this reason.

In order to switch from Advantage to Original, one must pass medical underwriting; there is no guaranteed issue. HOWEVER, in Cali, for Original, there's called a "birthday month rule" when you can switch from your Original Medicare plan to another plan of equal or lesser coverage. DH did this last year. HOWEVER, I do not know if the "birthday month" rule also applies to the Advantage policies. I just Googled this and it says the birthday month rule does NOT apply to Advantage policies.

We went with the original for various reasons including some of the ones mentioned above.

Ingrid

 

[WinniWoman]

When my husband retires the end of this year (age 65+) we intend to get a Medigap plan for him as well. Maybe G or N. And D, of course. Same will be for me when I turn 65.

 

[Luanne]

"Straight" Medicare sounds like what is called "original" Medicare which is Medicare with a Medigap policy and a separate Part D for Rx. The other Medicare is Medicare "Advantage" which is everything rolled into either an HMO or PPO-type policy. That's all I know about Advantage. The Advantage can have very low or no costs associated with it, however, the networks may be very limited. Possibly also, there are referral requirements. With Original Medicare, no referral is needed. Original + the Medigap + Part D Rx is NOT cheap. Many chose the Advantage policies for this reason.

In order to switch from Advantage to Original, one must pass medical underwriting; there is no guaranteed issue. HOWEVER, in Cali, for Original, there's called a "birthday month rule" when you can switch from your Original Medicare plan to another plan of equal or lesser coverage. DH did this last year. HOWEVER, I do not know if the "birthday month" rule also applies to the Advantage policies. I just Googled this and it says the birthday month rule does NOT apply to Advantage policies.

We went with the original for various reasons including some of the ones mentioned above.

Ingrid

I was just looking and you can switch from a Medicare Advantage Plan to a Medicare Supplement during open enrollment period as well, which is October through December. I am attempting to switch carriers for my supplement plan as I've found a cheaper one.

 

[IngridN]

I was just looking and you can switch from a Medicare Advantage Plan to a Medicare Supplement during open enrollment period as well, which is October through December. I am attempting to switch carriers for my supplement plan as I've found a cheaper one.

This is state-specific. I mentioned Cali as OP resides here. In Cali one can only switch during their birthday month (+ one month prior or after or something like that). Open enrollment is meaningless for those of us with original Medicare Part A&B wrt to switching carriers.

Ingrid

 

[Luanne]

This is state-specific. I mentioned Cali as OP resides here. In Cali one can only switch during their birthday month (+ one month prior or after or something like that). Open enrollment is meaningless for those of us with original Medicare Part A&B wrt to switching carriers.

Ingrid

Are you sure? I thought I got my information from medicare.gov. I'll check again.

And I checked. I got my info from somewhere else. On medicare.gov it says open enrollment is Jan 1 to March 31. But my info, for me, came from the company that oversees my retirement benefits, and I think they are nationwide. So maybe it also depends on where your benefits come from.

And I don't understand your statement about open enrollment being meaningless for those with original Medicare A & B and switching carriers. I've done it once during open enrollment, and am hoping to do it again.

 

[rapmarks]

We have been on a Medicare advantage plan, ppo with in and out of network paying the same rate. Today we were refused service, even though the doctor is in network. We were told they will not accept any Medicare advantage plans

 

[bogey21]

Cliff's current setup is an HMO. We would never have one.

I'm with you on this. The problem is for those who can't afford the cost of the Medicare/Supplement/Plan D combination. Combining the deductions from my Social Security and premiums I pay directly on my Supplement and Plan D this combination costs me about $5,000 annually. For those who have limited income $0 premiumMedicare Advantage looks good...

George

 

[WinniWoman]

We have been on a Medicare advantage plan, ppo with in and out of network paying the same rate. Today we were refused service, even though the doctor is in network. We were told they will not accept any Medicare advantage plans

Wow!

 

[clifffaith]

I'm confused. Does Medicare Advantage = HMO plan?

 

[rapmarks]

I'm confused. Does Medicare Advantage = HMO plan?

No, ours is the most lenient plan, state of Illinois retirees. Medicare advantage ppo, but same copay whether in or out of network.

 

[IngridN]

Are you sure? I thought I got my information from medicare.gov. I'll check again.

And I checked. I got my info from somewhere else. On medicare.gov it says open enrollment is Jan 1 to March 31. But my info, for me, came from the company that oversees my retirement benefits, and I think they are nationwide. So maybe it also depends on where your benefits come from.

And I don't understand your statement about open enrollment being meaningless for those with original Medicare A & B and switching carriers. I've done it once during open enrollment, and am hoping to do it again.

Yes, I'm sure. I did a lot of research before we decided to go with original Medicare. In Calif the only time you can switch Medigap carriers with GUARANTEED ISSUE is during your birthday month. Open enrollment is meaningless for this. That said, you can probably switch from Medigap to Advantage during open enrollemnt and you can probably switch Medigap insurers BUT must go through medical underwriting. I believe Oregon is another state with the birthday month rule. Other states have different rules. The rules are STATE SPECIFIC and not dependent on where your carrier is located.

Part D is different in that you can switch to whatever plan you want during open enrollment. DH and I review the various plans each year during this time. I will most likely switch insurers because I hate mine. First year on Medicare and even if I have to pay more for another Part D insurer, the add'l premium will be worth it.

 

[IngridN]

And during open enrollment, you can probably change Advantage insurers if you wish. I decided pretty fast that original Medicare was for us and am well versed in those requirements. Not so for the Advantage plans.

 

[simpsontruckdriver]

To clarify, many Medicare Advantage plans are HMOs, and in many states, they also offer PPOs (Preferred Provider Organization). The biggest PPO provider is United HealthCare, but Humana and Aetna also have them. Check with a local independent agent to see what is offered this Annual Enrollment Period (AEP). If you read my other post about Medicare, don't rely on Medicare.gov to estimate costs, talk to an agent to get realistic costs.

TS

 

[Miss Marty]

Medicare & You Handbook 2020

Medicare should mail you a printed copy of the Medicare & You Handbook each year
but you can also view the 120 page pdf. online at Medicare. gov (Click on link below)

https://www.medicare.gov/sites/default/files/2019-09/10050-medicare-and-you.pdf

 

[simpsontruckdriver]

You can also get the "Medicare And You" book from any Social Security office, just walk in and ask, no appointment needed.

TS

 

[MULTIZ321]

Comparing and choosing coverage: How to use
the Sun Sentinel Medicare Guide.


https://www.sun-sentinel.com/health/medicare/


Richard

 

[pittle]

@isisdave, thanks for the great explanation. When dh became Medicare eligible he was still under my work insurance. When I retired he did his research and opted for a Medicare Supplement (Medigap) plan. I followed suit when I retired. We both have Plan F, which I "think" we can keep since we already have them. We feel they are more flexible, and yes more likely more expensive than some of the other options.

It is my understanding if you have Plan F, you can keep it. If you make changes, you cannot get it back. F was "grandfathered" in. We are very healthy, but choose to keep F for whenever we need it. As we get older, we will probably make up past years premiums sooner or later.

 

[geist1223]

As for Health Insurance I did my 20 years on Active Duty and Reserves for the Military Health Insurance that kicked in at 60. Then at 65 Medicare as Primary and Military as Secondary. So we do not have to worry about all the Medicare Supplement Plans.

 

[bogey21]

It is my understanding if you have Plan F, you can keep it. If you make changes, you cannot get it back. F was "grandfathered" in. We are very healthy, but choose to keep F for whenever we need it. As we get older, we will probably make up past years premiums sooner or later.

I have the High Deductible Plan F and like you I plan to keep it. For many years the savings on the Premium vs Regular Plan F have exceeded the deductibles I have had to pay. At some point in the future I will probably switch to Plan G...

George