Medicare and You! Questions and Answer Thread!

[Desiday]

How much more expensive would Part B, with Plan D or G be if I retired in Port St. Lucie, FL over Harrisburg, PA? I know I am being very specific, but I am on the fence between domiciling at my FL address or my PA address. Thank you.

[oatmeal]

Originally Posted by Desiday

How much more expensive would Part B, with Plan D or G be if I retired in Port St. Lucie, FL over Harrisburg, PA?

A lot of websites say they'll give you a quote but actually just take your information and call you back, but senior65.com gives actual quotes for five or six companies like Aetna, Humana, etc. You can go there an enter a zip code, date of birth, and gender and find out what various supplements will cost. I did it for those two cities and Harrisburg is significantly cheaper for a Plan G. And by the way, "top insurance provider" is United Healthcare.

You won't get the lesser known local companies, but it will give you an idea of the general price level.

You said "Plan D or G" but I assume you meant a Plan G supplement and (not or) a Part D prescription drug plan. For Part D prescription drug plans, you can go to the Part D plan finder at medicare.gov and compare plans and prices for different locations.

[Dieselboy]

Originally Posted by Desiday

How much more expensive would Part B, with Plan D or G be if I retired in Port St. Lucie, FL over Harrisburg, PA? I know I am being very specific, but I am on the fence between domiciling at my FL address or my PA address. Thank you.

That Florida location would run you around $215-$220 for a Plan G from a reputable company. This is in addition to the Medicare premium of $185/mo.

Harrisburg, PA would be roughly $140-$150/mo for the Plan G. Again, you have to pay your Medicare premium.

Your drug (Part D) coverage cost depend entirely on if you take any medication, what that medication would be, and the dosages they are.

There are obviously other considerations to take into account with your residency, but at least with these numbers you have an idea of the price difference between the locations.

[Souljourner]

This question is probably not exactly the intention of this very valuable thread (thank you DB!), but I figured with all the combined years of experience from others on this forum it would be a pretty good place to start.

I am currently covered under an Advantage plan with United Healthcare. I am planning an international trip this spring. I just called UHC to see what my medical coverage would be while traveling internationally and was told that I was 100% covered with no limitations for any medical care I needed while overseas, the only caveat being that I needed to pay the bills at the time of service and would then be reimbursed.

I don't believe everything I hear, especially from what I have found to be poorly trained and non-native English speaking "advocates", and figured I would look for confirmation from anyone on this forum who has traveled internationally and needed to file a claim with UHC.

I was about to purchase Trip Insurance, to include medical coverage as well as trip cancellation, but I'm now rethinking whether or not I need the medical coverage.

On the other hand, even with reimbursement in place, were there to be a catastrophic medical emergency, I'm not sure if I would want to pay out of pocket something that could be tens of thousands of dollars, if not more, in expenses. Wondering if travel medical insurance would be a prudent addition, even if I am to be reimbursed?

Does anyone have any experience with using UHC for medical expenses while traveling internationally, or any thoughts about having medical trip insurance even if expenses are reimbursed?

[Dieselboy]

Originally Posted by Souljourner

This question is probably not exactly the intention of this very valuable thread (thank you DB!), but I figured with all the combined years of experience from others on this forum it would be a pretty good place to start.

I am currently covered under an Advantage plan with United Healthcare. I am planning an international trip this spring. I just called UHC to see what my medical coverage would be while traveling internationally and was told that I was 100% covered with no limitations for any medical care I needed while overseas, the only caveat being that I needed to pay the bills at the time of service and would then be reimbursed.

I don't believe everything I hear, especially from what I have found to be poorly trained and non-native English speaking "advocates", and figured I would look for confirmation from anyone on this forum who has traveled internationally and needed to file a claim with UHC.

I was about to purchase Trip Insurance, to include medical coverage as well as trip cancellation, but I'm now rethinking whether or not I need the medical coverage.

On the other hand, even with reimbursement in place, were there to be a catastrophic medical emergency, I'm not sure if I would want to pay out of pocket something that could be tens of thousands of dollars, if not more, in expenses. Wondering if travel medical insurance would be a prudent addition, even if I am to be reimbursed?

Does anyone have any experience with using UHC for medical expenses while traveling internationally, or any thoughts about having medical trip insurance even if expenses are reimbursed?

Do not believe that agent on the phone. It sounds like they either didn’t mention, or you didn’t hear them say, that you have to go through an emergency room. Yes, that is covered under a UHC advantage plan for foreign travel, even if you receive 10’s of thousand of dollars of care. But you must go through the ER. And yes, you pay the bill and get as best of an itemized receipt for reimbursement.

I typically recommend to my clients to take out a short term travel benefit from a company like you have in mind. They aren’t that bad for a week or two trip.

[Souljourner]

Originally Posted by Dieselboy

Do not believe that agent on the phone. It sounds like they either didn’t mention, or you didn’t hear them say, that you have to go through an emergency room. Yes, that is covered under a UHC advantage plan for foreign travel, even if you receive 10’s of thousand of dollars of care. But you must go through the ER. And yes, you pay the bill and get as best of an itemized receipt for reimbursement.

I typically recommend to my clients to take out a short term travel benefit from a company like you have in mind. They aren’t that bad for a week or two trip.

Much obliged! Thank you for confirming my instincts. One of the biggest problems I’ve had UHC is their poorly trained advocates who are outsourced off-shore somewhere. I’m OK with getting outsourced customer support when I call a company like Amazon. But with something as serious as healthcare it boggles my mind that this is the choice of UHC. I have often called knowing more about my plan than the “advocate“, and I have often received conflicting information when I need to call back more than once about the same issue. I shudder to think what would happen if I had a serious medical issue and needed to speak with an agent about my coverage.

I was NOT told that any medical care I received needed to be as a result of an ER visit - and I asked lots of questions about limitations or conditions when I called. Thanks for the heads up! It sounded too easy to be true which is why I wanted a second opinion and posted here.

For the peace of mind it will give me I’m going to go ahead and purchase a travel medical policy. For the expenditure of a couple of hundred dollars it will give me peace of mind when I travel.

Thank you, as always, for being so attentive to this thread.

[TexasJeff]

After all the research I put into what Medicare covers, it appears I missed something that cost us a couple hundred dollars, but now that I'm aware, I'd like to get some perspective on it.

My DW went on original Medicare in December and signed up for Plan N. She went to my cardiologist for dizzy spells when occasionally doing things requiring a bit of stamina such as riding a bike, etc. He checked her out and her EKG looked fine. He talked of doing a CAT scan and I suggested maybe he do the same thing he did with me a decade prior and do a complete heart checkup. Even if things checked out normal, it would be a good baseline for future visits. He agreed and she went in for her CAT scan just the other day.

Here's the question: I was under the impression that OM basically covered visits and GAP Plan N meant that she paid $15 for office visits. Well, she was informed by the radiology office that the CAT scan wasn't covered and that she owed the negotiated price of $175. I did some research and found that if the scan was done as a diagnostic for a condition then it would be covered. She's now going to call the doctor back to see if this scan's billing code can be changed to reflect the original question of dizzyspells. Plus we're now hyper aware and will also ask if her cardio workup procedure is also not covered as that part isn't necessarily addressing the dizziness condition but just a checkup of her heart and carotid artery.

Does anyone have any experience being surprised by surprise bills under Original Medicare? I'm greatly interested in any words of wisdom here.

[NLOVNIT]

I can give some insight on the billing side. For years, I coded medical procedures to bill both Medicare & commercial insurance. Whether a procedure is covered & by how much is all in the code & your insurance provider's allowables.

For example, a routine yearly wellness check, mammogram or 10yr colonoscopy are normally covered 100%. There's a specific code for "preventative/screening" procedures which gets the procedure covered at 100%. But say that visit/procedure found something & the doctor called for a follow up test/procedure. That 2nd test is called a "diagnostic" & there's a different code for that & the insurance provider may or may not pay (or pay partial) for that 2nd test....leaving the patient with a bill due.

Always ask if the test/procedure will be covered & how much, ahead of time. The doctor or NP may not know, but their billing dept will. That's the only way you will know what you will or will not be on the hook for.

[oatmeal]

Originally Posted by NLOVNIT

For example, a routine yearly wellness check, mammogram or 10yr colonoscopy are normally covered 100%.

This is a good opportunity to make people aware that a "wellness check" is not a physical exam, like the yearly physicals people are accustomed to getting. An annual wellness exam/check is covered under Original Medicare; annual physicals are not (although most (or all?) Advantage plans do cover them as an extra benefit).

Here's the explanation on the Medicare website:
https://www.medicare.gov/coverage/ye...ellness-visits

Here's an excerpt from an AMA article called "What doctors wish patients knew about Medicare annual wellness visits:

"There are a lot of people who use multiple different terms interchangeably—annual wellness exam, annual physical, a checkup, a routine exam and, for pediatric patients, a well-child check," Dr. Hopkins said, emphasizing that "they really are not the same."

"When it comes to an annual wellness visit or an annual wellness exam, you come to see your primary care physician, they ask a lot of questions, they address health maintenance—the preventive care that is recommended for your age group," he explained. "A Medicare annual wellness visit is something that is totally different than what we think of as a regular annual physical."

Such carelessness with terminology "creates a lot of confusion and sets patients up for frustration, because they come with an expectation and what we deliver is not always aligned with their expectations," Dr. Hopkins said.

https://www.ama-assn.org/practice-ma...edicare-annual

[TexasJeff]

Good info, Nlovnit & oatmeal. With all the discussion about original medicare and which gap plans are better than the other, somehow the image was incorrectly received that OM having better coverage with fewer hassles somehow was the complete story. It is definitely not.

The cardiologist office called us back yesterday and explained that the CAT scans are not covered by medicare. Even if it were done because of her dizziness. But her echo-cardiogram and other baseline procedures like stress test are completely covered.

So, the moral of this story is to understand not only billing codes, but what procedures are always covered, sometimes covered, and never covered. At least that will keep the surprise factors down to manageable doses.

[Donskiman]

Originally Posted by UFO Pilot

Do individual insurers negotiate what they will reimburse providers? I have noticed lately on my EOB's that (for example) the approved amount was $350 and UHC paid $250. I have met my yearly max so I have no copay. I have seen this quite often lately.

My question is sorta related.

I also have UHC MA. Rounded from actual numbers in one EOB. Providers billed $20,000, UHC allowed amount was $1700, UHC paid $1550 and I paid $150. What happens to the other $18,300 the provider billed? Who pays that? Or is it some kind of accounting gimmick providers use to write things off?

At the end of 2023 and the beginning of 2024, providers billed more than $60,000 including various drugs. My out-of-pocket was around $1000. Procedures included 2 CT scans, 2 endoscopys and 1 colonoscopy, plus 2 visits to ER and multiple doctor/specialist visits. The only thing needing prior approval was the colonoscopy because I had one the year before.

My MA plan is $0, plus it also reduces the Plan B premium by about $60-70/month. I use the health club membership extensively as well.

[Dieselboy]

Originally Posted by Donskiman

My question is sorta related.

I also have UHC MA. Rounded from actual numbers in one EOB. Providers billed $20,000, UHC allowed amount was $1700, UHC paid $1550 and I paid $150. What happens to the other $18,300 the provider billed? Who pays that? Or is it some kind of accounting gimmick providers use to write things off?

At the end of 2023 and the beginning of 2024, providers billed more than $60,000 including various drugs. My out-of-pocket was around $1000. Procedures included 2 CT scans, 2 endoscopys and 1 colonoscopy, plus 2 visits to ER and multiple doctor/specialist visits. The only thing needing prior approval was the colonoscopy because I had one the year before.

My MA plan is $0, plus it also reduces the Plan B premium by about $60-70/month. I use the health club membership extensively as well.

In the scenario you described, the remaining $18,300 that the provider billed is essentially written off by the provider, as part of their agreement with UnitedHealthcare (UHC) and the terms of your Medicare Advantage plan. Here’s a breakdown of what happens:
1. Provider Billing: The provider initially billed $20,000, but UHC’s Medicare Advantage plan has a contracted rate with the provider, which is significantly lower (in this case, $1,700).
2. UHC Allowable Amount: UHC, as your insurer, negotiates and sets an “allowed amount” — in your example, that’s $1,700. This is the maximum they will pay for the service, and this is based on their agreement with the provider.
3. UHC Payment: UHC paid $1,550, which means they covered most of the allowed amount. In some cases, UHC might not pay the full amount of the allowed charge due to plan specifics, co-insurance, or deductibles that apply.
4. Your Payment: You paid $150, which could be your co-insurance, co-payment, or deductible portion, depending on the specifics of your plan.
5. The Write-Off: The remaining $18,300 ($20,000 billed minus the $1,700 allowed) is written off by the provider as part of their contract with UHC. This means the provider cannot legally collect that remaining amount from you. This is not an “accounting gimmick,” but rather a common practice in healthcare contracts, where insurance companies negotiate discounts with providers. Providers agree to accept these lower amounts in exchange for being included in insurance networks.

In short, the $18,300 is essentially forgiven by the provider due to the payment terms established with UHC, and you are not responsible for it. The provider cannot bill you for the difference because they’ve agreed to the allowed amount as part of their contract with UHC.

[Dieselboy]

Originally Posted by TexasJeff

Good info, Nlovnit & oatmeal. With all the discussion about original medicare and which gap plans are better than the other, somehow the image was incorrectly received that OM having better coverage with fewer hassles somehow was the complete story. It is definitely not.

The cardiologist office called us back yesterday and explained that the CAT scans are not covered by medicare. Even if it were done because of her dizziness. But her echo-cardiogram and other baseline procedures like stress test are completely covered.

So, the moral of this story is to understand not only billing codes, but what procedures are always covered, sometimes covered, and never covered. At least that will keep the surprise factors down to manageable doses.

Medicare will typically cover a CT scan if it’s deemed “medical necessity” but this leaves it wide open for interpretation.

You can 100% appeal the decision for it not to be covered and plead your case. I have had clients successfully appeal these types of things and get them covered. At which point they get reimbursed. It may be worth the effort.

And sorry for the late response. I try to check this thread daily.

[TexasJeff]

Originally Posted by Dieselboy

Medicare will typically cover a CT scan if it’s deemed “medical necessity” but this leaves it wide open for interpretation.

You can 100% appeal the decision for it not to be covered and plead your case. I have had clients successfully appeal these types of things and get them covered. At which point they get reimbursed. It may be worth the effort.

And sorry for the late response. I try to check this thread daily.

Thanks DB. I hadn't thought about appealing. Maybe we'll check in to that and see what happens and report back to this thread the results. It's worth a try.