From there you can make one of three choices.

1. 1) Do nothing. Just keep Medicare Part A and Medicare Part B (aka Original Medicare) as your insurance coverage and add Medicare Part D presciption drug plan. Of course, with just Medicare Part A and Medicare Part B and no other coverage, a person still has unlimited financial risk should you get sick or injured. Your portion of the medical costs may result in financial hardship.
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3. 2) A second option is to increase your insurance coverage by enrolling in a Medicare supplement plan and use that coverage in addition to Medicare Parts A and B.
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5. 3) A third option is to trade in your Medicare Part A and Medicare Part B for a Medicare Advantage Plan.

In Medicare, the two ways a person can limit their financial risk is to either increase their insurance coverage by selecting a Medicare supplement plan or by trading in their original Medicare coverage for a Medicare Advantage plan.

• Most Medicare Advantage PPOs have a separate MOOP for approved out-of-network services. Typically, that MOOP is much higher than in-network services.  Of course, any procedure that is not approved or is performed by an out-of-network doctor that does not agree to accept your insurance is not included in your MOOP.
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• The out-of-pocket costs that help you reach your MOOP include all cost-sharing (deductibles, coinsurance, and copayments) for Part A and Part B covered services that you receive from in-network providers.  Part D cost-sharing does not count towards your plan’s MOOP. All  Medicare Advantage Plans must set an annual limit on your out-of-pocket costs , known as the maximum out-of-pocket (MOOP). This limit is high but it may protect you from excessive costs if you need a lot of care or expensive treatments. After reaching your MOOP, you will not owe  cost-sharing for Part A  or Part B covered services for the remainder of the year. Some plans may also apply the MOOP to supplemental benefits, such as vision, hearing, or dental. 

In 2024, the MOOP for Medicare Advantage Plans is $8,850, but plans may set lower limits. If you are in a plan that covers services you receive from out-of-network providers, such as a PPO, your plan will set two annual limits on your out-of-pocket costs. One limit is for in-network costs and the other is for combined in-network and out-of-network costs.

The three most popular medicare supplement are the Plan F, Plan G and the Plan F. 

Plan F (Pays everything medicare does not pay) Your maximum out of pocket cost are simply your monthly premium. You have no out of pocket costs. Medicare Part A and B pay first, then Plan F supplement pays all of the rest. You have no MOOP other than your monthly premium.

Plan G Supplement pays everything Original Medicare does not pay except the annual Part B 240 dollar Medicare Part B annual deductible. Your maximum out of pocket is your monthly premium and the $240 dollar annual deductible.

Plan N Supplement pays everything Original Medicare does not pay except the $240 Part B deductible, but once you hit that deductible there is a doctor office visit copay of between $0 up to but never more than $20 dollars per office visit. And there is $50 dollar emergency copay. (Plan N does not cover excess charges.) 97% of doctors accept medicare assignment. The 3% that don’t accept medicare assigned rates can charge 15% over that assigned rate. It rarely ever comes into play and there is an easy way to avoid excess charges. Plan N has far lower rate increases than Plan G and Plan F, and they do not accept chronically ill folks with no underwriting or health questions, but the Plan G (if you were under 65 on January 1st of 2020 and the Plan F (if you were over 65 on January 1st of 2020) must accept sick folks with no health question or underwriting required if they have a Guaranteed Issue Right. Plan N offers lower projected rate increases as well.

Medicare Advantage plans have restrictive doctor and provider networks that are designed to maintain the health of their patients in a cost-effective manner. These managed care plans offer Healthcare coverage with a network that may be confined by your county or a local area the size of most counties.

Typically, you must stay within the network of medical providers. 98 Percent of these plans are either HMO’S OR PPO’S

With and HMO if you go utside of the network you have no insurance, except for emergency and possibly urgent care. In other words, if you see a doctor not in the HMO network, you will pay 100% of the cost.

With most HMO’s you must designate a Primary Care Physician (PCP). That Physician will control your healthcare, is contracted with the HMO and typically compensated for helping the HMO control their costs.

You must obtain permission from your Primary Care Physician to see another doctor like a specialist. Without permission, the HMO will not pay for your care.

Medicare Supplement insurance policies also offer you the most freedom of access to providers. You have the freedom to choose your own doctors and hospitals from among the 900,000+ Medicare providers in the country. Patients do not need referrals to see specialists on this type of coverage and  have the flexibility to visit any doctor or medical facility across the United States and its territories, as long as they accept Original Medicare. Although your Medicare supplement premium may increase over time, the benefits provided by the plan remain consistent and never change. With a Medicare supplement plan, Medicare acts as your primary insurer, ensuring that decisions about your healthcare are made directly between you and your doctor. The Medigap plan has no say in your insurance coverage.

Prior authorization was “intended” to ensure that health care services are medically necessary by requiring providers to obtain approval before a service or other benefit will be covered by a patient’s insurance.here are some concerns that current prior authorization requirements and processes may  create barriers  Inspector General. CMS runs This is CMS’sdelays  to receiving necessary care, as well as exacerbate complexity for patients and thei.

Today, 99% of Medicare Advantage members are in plans that require prior approval  for services including inpatient admissions, skilled nursing facility stays, mental health services, home health care, chiropractic services, outpatient surgery and services, ambulance transport, medical equipment, diagnostic tests, and laboratory and radiology services. (Plans cannot require authorization in emergency situations.)

Medicare rarely ever requires a prior authorization for anything, but with a Medicare supplement plan, Medicare acts as your primary insurer, ensuring that decisions about your healthcare are made directly between you and your doctor. The Medigap plan has no say in your insurance coverage.Also, you have the flexibility to visit any doctor or medical facility across the United States and its territories, as long as they accept Original Medicare. Although your Medicare supplement premium may increase over time, the benefits provided by the plan remain consistent and never change.

Originally, the Social Security Act did not authorize any form of “prior authorization” for Medicare services. The law was subsequently changed to allow prior authorization of limited items of Durable Medical Equipment and physicians ’ services. Currently, Medicare does not pre-authorize coverage of any item or service that will receive payment under Part A or B, except for custom wheelchairs. Please advise all staff and inform your Medicare patients, as appropriate, that Medicare does not currently pre-authorize coverage for any item or service other than custom wheelchairs. 

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Prior Authorizations are the biggest reason why I steer folks towards original medicare with a supplement rather than managed care HMO style advantage plans run by huge for profit insurance companies that are accountable to stockholders. The most important issue for people on Medicare today is the improper use of prior authorizations by insurance carriers. Whether you are new to Medicare or have has Medicare for years this is important information if you ever decide to consider a Medicare Advantage plan.

Linked below is a brief  report by the US Office of Inspector General for the U.S. Department of Health & Human Services.  Inspector General. CMS runs This is CMS’s  ( Center for Medicare & Medicaid Services to receiving necessary care, as well as exacerbate complexity for patients and thei r providers.

Inspector General did that ran from 2014-2016. In brief, the report found that each year more than half of all  Medicare Advantage plans were denying Services or payment for procedures that are medically necessary and should have been performed. While the majority of the denials that were appealed were approved as a result of the appeal, the report found that only 1% of the beneficiaries that were denied service even attempted to appeal the process. This is not good.  This means that people are harmed and even die because of delays or denials in care and are not receiving the medical treatment they need, deserve and expect from their Medicare insurance. 

In addition, the Inspector General found that insurance companies were denying payment of approved services after the fact. In other words, the beneficiary would get the medical procedure they needed, but after it was complete the insurance company would deny payment, forcing both the health care provider and the beneficiary into financial hardship 

“The high number of overturned denials raises concerns that some Medicare Advantage beneficiaries and providers were initially denied services and payments that should have been provided.”   IG report dated September 2018

Please complete the quote request below if you would like more information on the Medicare supplement plans in your area.

You can read the Inspector General full report here full report here:

U.S. Department of Health and Human Services
Office of Inspector General Report on Medicare Advantage Plans

One thing I tell each and every client after we have helped them with their Medicare supplement is that if you ever have a problem. If you are denied coverage you believe is medically necessary, if you have a denied payment or incorrect doctor bill, don’t bang your head against the wall trying to resolve these issues on your own. That’s our job! We help all our client through this process. I have on staff people with associates degrees in Medical billing who have been Medicare Analysts or who have managed billing departments for major medical facilities.   WE CAN HELP and we love doing it.  In the past two weeks alone we helped a client reverse an unpaid claim for $4500 down only $25. We helped another who needed a particular MRI that was denied, and we appealed and get the test approved. When you become a client of May Rivier Medicare Agency you have the comfort of knowing we have your back!  

Please complete the quote request below if you would like more information on the Medicare supplement plans in your area.

You can read the Inspector General full report here full report here:

U.S. Department of Health and Human Services
Office of Inspector General Report on Medicare Advantage Plans

What should you do about prior authorization?

MAY RIVER MEDICARE has helped our clients with these requirements for 13 years. After determining that prior authorization applies in a specific situation, we follow a process that works

• 1) Find a copy of your insurance company’s form or process. Check the website or call a plan representative. Your physician may need it and you’ll know exactly what information must be included.
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• 2) Confirm that whoever in your physician’s office is in charge of this process knows that you need an authorization and the date due.
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  Please complete the quote request below if you would like more information on the Medicare supplement plans in your area.

3) Double check that documentation is submitted, and that approval is received before the service. You may want to confirm your costs.
• You can read the Inspector General full report here 
  
• Remember, if you move forward without authorization, you might have to pay the full cost.

Medicare Advantage Plan Agent Commissions for someone turning 65 New to Medicare or or new to Part B or you under 65 but new to medicare because of a disability, agents get paid a $611 dollar commision with a lifetime $306 dollar renewal. Short sighted agents will go to any lengths to steer you into these “free” managed care plans without explaining the pitfalls of these plan. 

The average Medicare Supplement commission rate is 22% with a 12-month advance. The average yearly premium for Medicare Supplement plans FOR MY CLIENTS is $1200 which has a renewal rate of $29.33/month. Agents can earn renewal commissions for at least six years.

So on a $100 dollar per monthly premium, agents are paid a $264 dollar commission, much less than a $611 dollar advantage plan. After year one, we get $22 dollar per month renewal commission as long as they stay put as our clients. Now you can understand why you are bombarded with calls, mail, and TV commercials.

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