Many of our patients ask our opinions about the best Medicare plan they can purchase. As Dayton’s leading independent Orthopedic clinic, we treat thousands of Medicare patients a year and deal with nearly every insurance company licensed in the State of Ohio.
We are intimately familiar with the inner-workings of each insurance company – how often they agree with our treatment plans, whether they tend to pre-authorize most things we ask for or whether they fight tooth and nail over every dime. With that in mind, let’s go through a quick ‘Medicare 101’ lesson!
Traditional Medicare vs Medicare Advantage
If you are eligible for Medicare you can chose between getting Medicare benefits through traditional Medicare (also known as original Medicare) or a Medicare Advantage (MA) plan. Making this choice is personal and requires individuals to consider their circumstances, including their health, need for flexibility, budget and tolerance for financial risk.
If you meet the requirement of at least 40 quarters of employment paying into Social Security, you automatically qualify for Medicare Part A, with no required monthly premium.
Part A covers hospital care (hospital care, skilled nursing facility care, home health care and hospice care).
Part B requires the payment of a monthly premium. It covers medical insurance (e.g. doctor visits, medical equipment, outpatient procedures, home health care, lab tests, x-rays, ambulance services and some preventive services).
Outpatient drug coverage must be purchased separately, which is known as Part D coverage.
Traditional Medicare has no out-of-pocket maximum or cap on what you may spend on health care. You may also have to pay for deductibles, coinsurance and copays, if you don’t purchase Medigap coverage.
Medigap Coverage (Medicare Supplement Insurance)
Medigap plans (also known as Medicare Supplement Insurance), are private health insurance plans that help pay for the “gaps” in payment for Medicare-covered care left by traditional Medicare; these include copays, coinsurance, and deductibles. In many cases, someone with traditional Medicare must purchase a separate Part D drug plan as well as a Medigap plan to supplement their Medicare benefits.
Medicare Advantage Plans
Nearly every major private insurance company offers a Medicare Advantage Plan. Aetna, Blue Cross, United Healthcare, Caresource… You name it, they’re willing to take your money! We have experienced the good, the bad and the downright ugly in this section.
Purchasing a Medicare Advantage Plan is somewhat like buying a new car. Some cars can look great from the outside, but are an expensive nightmare to drive and maintain. Others appear to be small and humble from the outside, but will surprise you with their comfort and reliability.
Medicare Advantage plans wildly vary in price based on the number of bells and whistles they come with. Do you want the equivalent of a fully-loaded Jaguar, with vision, dental, gym memberships and a ‘free’ tote bag? Or are you happy with the equivalent of the unassuming Toyota Corolla, that will get you from point A to point B safely and reliably? Choosing the best Medicare plan for you is a difficult decision that requires a careful accounting of your finances and risk tolerance.
Medicare Advantage plans promise to cover you at least as well as traditional Medicare. But the reality is that insurance companies are not in the business of spending money. They will do everything in their power to reduce, deny and delay your claims until you stop asking. This is not exclusive to certain companies either – it is endemic to all.
Enter: The insurance claim adjuster
Claims adjusters, who are never medically trained, are the people standing between you and the treatment plan we suggest. It is their job to question whether you really need this treatment, and whether they are going to pay for it. Their bonuses and promotions depend on how much money they can save the company.
Traditional Medicare also has claims adjusters, but they are government employees. They are paid the same, no matter how many claims they approve or deny. They are often the only insurance adjusters who truly ask the question “is this medically necessary” rather than simply denying the claim and hoping you will not fight their decision.
As a result of this, traditional Medicare approves our treatment plans FAR more frequently, with fewer modifications and with much less fighting.
Unfortunately, we can not come right out and say ‘stay away from this company’ or ‘this is the best Medicare Advantage plan’. But we can tell you that in our experience, traditional Medicare will approve our requests for treatment with much greater frequency and ease than Medicare Advantage plans.
There is a substantial difference between these 2 healthcare delivery systems. Medicare Advantage programs, while having sometimes a $0 premium, will have deductibles, copays and require precertification for many services that Medicare routinely covers without a headache. Payments to physicians are routinely delayed by these offshoot programs. Most physicians are of the opinion that patients receive varying degrees of lesser quality care as a result of the for-profit nature of these non-traditional programs. Furthermore, many doctors are no longer accepting these Medicare Advantage contracts. Next time you are offered a free gym membership, say “no thanks” and stay with your traditional Medicare. You won’t be sorry!Dr Jonathan Paley – Head Surgeon at Dayton Orthopedic Surgery
If you have the financial freedom to pay for the best Medicare Advantage plan that money can buy, consider the fact that your private insurer will likely spend an enormous amount of time and resources second guessing your doctors, denying your claims and trying to get away with paying as little as possible. Traditional Medicare, on the other hand, saves money by reducing the time taken to administer your claims. As far as traditional Medicare is concerned, the less time they spend looking at your file, the better.
So while we can not say ‘this is the best Medicare Advantage plan’, we CAN say that traditional Medicare, paired with comprehensive Part D drug coverage and excellent Medigap coverage, will cause you (and us!) a WHOLE LOT fewer headaches and hassle.