关于Medicare（4）

无论在哪里生活， 每个人都要为自己老年后的安排早做打算，尤其是关于医疗费用的考虑。
在US，老年人的医疗费用主要依靠Medicare支付。

作为外来归化的美国人也许不是每个人都十分清楚关于Medicare的有关条例。以下分享仅作为学习笔记，欢迎讨论
接着前面的话题
关于Medicare（1）
关于Medicare（2）
关于Medicare（3）

这一部分用于讨论Medicare Advantage ( Medicare Part  C )。

从个人角度考虑：
综合前面（1）（2）(3) 所述，65岁之后如果还希望享有比较全面而自付部分不高的医疗保险，Original Medicare + Medigap + Part D 是一个不错的选择。这个选择最大的好处是看病不会受到地区和医生的限制，即使生活在海外也有一定的基本保证（当然这个取决于Medigap计划的选择）。

有利必然有弊， 此选择的弊处是每月还有一定的月费需要支付，每月支付额度根据个人退休后的收入和Medigap计划的不同而有所不同。按最高收入计算（年收入大于75万）及最佳Medigap计划每月保费支出近 $1000.

从国家基金角度考虑Original Medicare + Medigap + Part D给了个人最大的利益选择，必然造成国家基金较大的支付负担。 

为保证Medicare基金的正常运行并合理支付退休人员的医疗费用，私人医疗保险公司于1985年开始被逐步引入Medicare的运作，经过几次更名目前名为 Medicare Part C or Medicare Advantage (MA),有兴趣的同学可以在这里看看它发展的历史和未来走向： 

Medicare Part C 的历史

总体来讲Medicare Advantage ( Medicare Part  C )是私人保险公司在政府监管下执行的Medicare一览计划。 

根据每家私人保险公司的不同，它的计划覆盖Medicare Part A + Medicare Part B , 有些还会涵盖 Medicare Part D， 和一些Medicare本身不包含的支付项目，比如牙齿，眼睛，和听力。部分计划甚至提供每月少量补助，允许受保人自行购买OTC药物及需用品。

 相对于Original Medicare + Medigap + Part D 的退休医疗计划选择，Medicare Advantage ( Medicare Part  C )最吸引人的部分在于它号称提供0月费支付。即如使用 Original Medicare计划，每人每月至少需要支付$164.9，而如果使用 Medicare Advantage ( Medicare Part  C )有可能做到每月支付$0.

Medicare Advantage ( Medicare Part  C )是如何做到0 支付的呢？
首先私人保险公司的Medicare Advantage ( Medicare Part  C )计划也是由社保基金支付的，只是交由保险公司制定计划和管理。 

其次讨论一下美国的医疗管理系统。 

传统的美国医疗系统是由医生提供服务，保险公司提供财务管理。即保险公司按照医生的服务标准和服务次数负责收费。

目前美国的医疗保险系统主要分为HMO和PPO

PPO接近于传统的医疗系统。 由医生，医疗服务人员，医院与保险公司签订协议，提供双方同意的in-network 减额服务费用。医生根据服务收费，病患可以随意选择医生， 唯一的区别是in-network 医生的费用较低，out-network医生费用较高。 另外，PPO计划，病患不需要家庭医生，也不需要家庭医生推荐，可以随意看专科医生。PPO计划整体费用较高。 

HMO是新型的管理方式，由HMO提供医疗和财务的共同管理。HMO一般按月收费，同时也有每次看病的copayments , copayment 一般不高， 以Kaiser 为例 一般$10 或$25 .为了降低总体的医疗费用HMO重视疾病的预防，和防止大病和特病的发生。HMO通常要求每个保险人有家庭医生，家庭医生作为疾病预防和把关的负责人，提供日常服务。需要看专科医生时也需要有家庭医生的推荐才可以预约。HMO通常以特定地区为单位，比如County ， city ，如不在HMO所属地区，是无法加入HMO的服务的。  通常在人口比较多的地区 HMO的选择和服务会相对好一些。

绝大多数 0月付的Medicare Advantage ( Medicare Part  C ) 计划属于HMO类型，因此在医生选择和专科看诊的服务上会有所限制。

多数保险公司的Medicare Advantage ( Medicare Part  C )也会提供PPO计划，但这样的计划一般不会完全免费。具体的费用和包含的服务项目需要查看不同公司的计划进行比较。

Medicare Advantage ( Medicare Part  C )通常以county为单位提供。 随着Medicare Advantage ( Medicare Part  C )的流行，同一county中有可能有十几家或数十家保险公司计划可供选择。如何发现适合自己的计划， 需要提早多方了解，或请有执照的经济人代理。 Medicare 的经纪人不应向他的客户收取任何费用，他们的佣金来自于保险公司的提成。因为所服务对象多为65岁以上长者， 政府保险机构对 Medicare 的经纪人有着严格的管理。

 

 

 

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关于Medicare（3） 关于Medicare （2） 关于Medicare （1） 我的LDL及其他 听来的故事（一）

你的有关Medicare的信息很实用，请问你是保险经纪人吗？另外，我也想发个帖，但发不出去。不开博就不能发帖吗？多谢指教。

个见 Medicare Part C 不是一个好的选择

看上去没有premium好像不错 实际上并没有起到保险的作用。真有大病 个人承担太多。医保不是为了小病 而是保万一有大病 尤其是年长的人。

medicare A/B/C 都没有封顶的保护，你需要另外买medigap。

Medicare C 就是私人公司施行的Medicare A/B。覆盖上和A/B一样，只付80%，没有封顶。

如果你考虑要模拟雇主医保的out of pocket maximum, 你需要买medigap Medicare Supplement Plan.  有了那个覆盖，你看病花到一定程度就不用再付了。

+1, just a key correction: MA 0 plan also need to pay Part B

to SSA (not to the provider), the same as original Medicare. The difference is you don't need to pay Medigap and Part D.

是的 我到时会买plan G 我认为是最好的选择 虽然premium高 但安心

C是与A和B不同的系统 如果买了C 将来想退出买其它的附加保险很难

有人说，起码你交税交的少！

不想多交税，就是上大学要多花钱，看病要多花钱，成天心里慌慌，还说自己比欧洲好。

所以，Part C 主要就是为政府和保险公司量身定做的，慎用。

medigap is for A/B, medicare C 你可以买覆盖低的和A/B一样的，或者买覆盖更好的

Your choice

Medicare A+B   OR　Medicare C  basic plan (both pays 80% only, no out of pokcet maximum)

A+B + medigap  OR Medicare C, expensive plan that covers on top of A/B. 

Medigap plan G really covers all the gap from AB, but part C

does not.

什么是“ Medicare C, expensive plan that covers on top of A/B”， 有封顶吗

什么是“ Medicare C, expensive plan that covers on top of A/B”， 有封顶吗

哈哈 是的 我老了宁愿买最好的医保 多交点premium

用不上是自己的福气 交的钱等于捐给了其他人 有万一的话也可以安心治疗 不给亲人负担

唉。。。投坛不仅我老了，大家都老了，社保金，讲到老年医疗保险，下一个话题是老人院，再下一个就是福寿园了？

This?

https://www.anthem.com/medicare/learn-about-medicare/what-is-medicare-part-c

Medicare Advantage plans also cap your out-of-pocket costs for Part C covered services. Once you reach the cap, you pay nothing for the rest of the year. That’s one of the added benefits of Medicare Part C.

 

我是不是来介绍一下投资墓地的计划，哈哈。

Thanks for correcting , I'm actually confused about that

I do have a few questions want to ask :

 1. do all the MA need to pay part B or only MA 0 needs to pay part B ? 

2. Initially Part B depends on the income , what if my income change in a few yrs ? would it be easy to adjust the Part B income base ? 

3. As someone mentioned , would it be hard to switch from MA to Medicap ? how about other way around ? 

 

Thanks very much  

 

what are you talking about?

Some plans, like Medicare Advantage (Part C), have an out-of-pocket maximum. This caps your out-of-pocket costs to help protect you from an excessive financial burden.

https://www.ncoa.org/article/what-you-ll-pay-in-out-of-pocket-medicare-costs-in-2023

 

哈哈 来投坛是向大家学习投资的 医保也算一种投资吧

Try to answer as I understand below:

我也有同样的问题，只能跟帖，不能发帖，怎样问一下网管中心？

many thx !

Correct. Plan B premium tied to AGI on tax return

As you said, the Plan C premium = to Plan B premium, in most plans / large retirees counties, directly deducted from your SS benefit.  Some counties Plan C still requires Additional premium payment - that part is paid to the insurance company if I understand it correctly.  In other words, the member would pay a premium in the form of deduction from Social Security benefit, PLUS an additional premium to insurance company.  We have a friend in SFO is on Kaiser Plan C, he still has to pay some $$ on top of the deduction from his Social Security benefit.  In Florida Broward and Miami-Dade counties, virtually No Plan C has additional premium. 

Each year's open enrollment time, Medicare will send you a thick book listing all plans in your county for you to do comparison shopping, as you can only change plan during the Open Enrollment time frame.

Depends on plans. Humana FL Gold Plus has maximum

Unlike traditional Plan A/B,  it has no deductible.  It does have maximum out of pocket each year, a few Ks if I remember it correctly.  Unless you fear you would get Very Sick, with some weird cancers or whatever, your out of pocket spend is really very little because hospitalization is ZERO copay - yes 0, but with a limit of days per admission.  Outpatient actually has $160 copay.

What still costs you is the annual drug benefit - that is based on Medicare Plan D benefit.  I gather you know about the term "Donut Hole"?  This year the threshold to fall into donut hole is $4,400.  For example, the No.1 drug on Beiden's 10 drugs to negotiate price is Eliguis.  This is the best drug to control blood clot danger for AF patients.  The drug costs $585 to $610 30 days supply depending on where the prescription is filled.  FDA actually approved a generic in 2019, but Bristol Meyer Squip filed modification and it blocked the generic, extended the patent till 2026 as the drug accounts for 1/3 of the revenue but 1/2 of the profit.  It is co-developed with Pfizer. 

So an AF patient would go into donut hole by August ($600 x 7 = $4200, only $200 to the donut hole threshold of $4400 in 2023).  When you are in donut hole, you pay 25% of the drug cost + 100% of the dispensing/handling fee (CVS, Walgreens, WalMart, etc who fill the prescription).   You will get out of donut hole once your out of pocket spend on drugs reach $7400.  Then you enter the Catastrophic Stage.  Your plan will then pay MOST of your drug costs.

Cancer patients of course can easily go into donut hole and then easily go out of it due to the cancer drugs are so expensive.

not necessarily. Family members on Plan C over 20 years

If I need to give an evaluation, I would give it an A-.  Why A-?  because sometimes there would be decoupling between the service providers claim filing (most the time with wrong codes) and the claim approval.

Over the 25 years there is NOT a single denial.  Hospitalization used to be $100 copay.  In last several years, it is a big fat ZERO. 

Drugs is 0 copay for generic.  $5 to $10 copay for drugs that cost $600, even to the insurance company because of brand name drugs. 

Plan C very much depends on WHERE you live, and WHO is the insurance company.  I can tell you FL seems to have the best plans offered.  CA plans are much inferior than what FL has.

A generalization on Plan C is always bad when you are really sick, is Too Misleading.  You need to research your OWN locale. 

Finally, a GOOD PCP is Very Important in any plan, but particularly in Plan C, as it is an HMO, all needed procedures are coordinated by your PCP with the specialists you need to see.  Usually PCP would tell you which specialists you need to see for your particular situation.  Either you do your own research to find a well-qualified, board certified specialist or ask your PCP for recommendation.  I do not see there is any difference to choose good doctors whether you are on HMO or PPO.  You make an appointment with specialist, who then sends a request to the PCP on why the patient needs to consult with specialist.  PCP then submits a request to Humana to ask for authorization for treatment.  Humana then approves the request so the PCP issues a Referral.

In 2021 and 2022 there were 2 hospitalization episodes - the bills of course looked horrendous, one was $90K+ for 3 days and the other one was $60K+, but Humana got a huge discount, basically paid about 15 to 20% on what the hospitals billed.  The patient's copayment is ZERO.

The patient sees a cadiologist and PCP every 6 months as maintenance for his AF condition which he was diagnosed 25 years ago.  There are other kinds of small issues though often just needs to make a call to PCP's office and he would order what needs to get done or prescribe some medication.

Again, your perception is not correct.  It TRULY depends. 

read your previous posts , very helpful , thx !

thx for sharing your thoughts here, I do have a question

1. You mentione that "PCP then submits a request to Humana to ask for authorization for treatment." Normally how long will this take ? The story I heard is sometimes the authorization is not granded due to the wrong code or some other reasons , it will take some time to solve.  In that case , what can patient do ？ For some situation , timely treatment is critical...... 

2. Is MA HMO plan local ? can your PCP  refer you to out-network or out state specialist ? 

Totally agree with you that Medicare choice really depents on each person's situation , people need to do their home work . 

Best,