I follow this guy, he teaches me something which I never paid enough attention almost every video
Medicare 2026 Update Vid
- Thread starter Pablo
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My wife and I watched it last night. I'm a little concerned with his objectivity with his affiliation with Chapter. Just a little, but he wasn't trying to push people toward Medicare Advantage. We do enjoy his videos.
I've complained here before about this, so here it comes again. Our plans in the NY area changed, and it wasn't for the better, in fact they're much worse now........... Rant off I feel better now.
Oh yea so much for the 2.8% increase in SS. I love how Uncle Sam makes the math work for him.
Yeah I don't feel I need to trust the guy, but it's a decently quick (detailed) summary
I never knew about there being a premium kicker if you don't work 40 qtrs (and pay Medicare tax, I assume)
I never paid that much attention to the detailed steps for the penalty tax for having a killer income. I'm making sure my wife healths up. I go into this single, that limit drops down into danger territory. Note: Rich loafers at some point just bale on the whole scheme I suppose and just pay as needed for medical.
I never paid that much attention to the detailed steps for the penalty tax for having a killer income. I'm making sure my wife healths up. I go into this single, that limit drops down into danger territory. Note: Rich loafers at some point just bale on the whole scheme I suppose and just pay as needed for medical.
It's insane in NY, hey CT and others up there not far behind you. It's what people blindly vote for. Many of the Northeastern and some others passed laws allowing Medicare recipients to switch between medigap and Advantage plans without underwriting. Sounds great right? Well yeah but everyone pays for it.
SO you can sign up for an Advantage plan, get very ill and switch to a medigap plan the next year. People take advantage of the system. This is why once in Advantage Plans you are stuck for life in most all the country if you want to switch to Medigap you would have to go through underwriting and you will be denied for any reason they wish if you have any conditions that they do not want. HOWEVER you can switch to Medigap in these states IF your Advantage plan no longer is offered the following year. (I did that for 2025 and my cancer treatments) I am almost certain to go back to an Advantage for 2026. However in my state, like many in our country, Advantage plans are still reasonable I think because of this (but getting harder to find) yet if I go to a Advantage for 2026 plan. I can get a killer plan with an MOOP (max out of pocket of $3,500 which is a no brainer. Includes drugs, $300 for contacts, $2,500 for dentists, and $50 every 3 months for over the counter stuff. On top of that, every medical network I would go to which is many including Duke Cancer Center is in the HMO network.
I was shocked when I checked out what happened to your Advantage plans on Long Island where I use to live. INSANE with an out of pocket limit of $10,000 in network and more out of network!
So let's say you need some type (god forbid) Chemo OR even an injectable allergy medication that has to be administered once or twice a month in a medical facility. That falls under Medicare Part B not Part D and with an Advantage plan most all of them require you pay 20% of the cost up until your Max out of pocket (MOOP) of $10,000 or more.
What is worse is if you start getting treatment towards the end of the year and runs into the next year you could be on the hook for another $10,000
Im an example, I have a reaction to coming off the cancer meds. It will eventually go away I am almost certain. I am going to a speciality Allergy place day after Thanksgiving. There is a drug called XOLAIR that I suspect I will be given as a standard antihistamine is not working (ER three times since Sept, for steroids and out in 2 Hours) It is administered in most cases once a month in a medical setting, up to twice a month for some. The annual cost is $15,000 to $30,000 for the drug without insurance. Granted even in an Advantage plan the price is going to be pennies compared to the uninsured price (maybe) but it can be unsettling. So having a $3,500 MOOP is a nice feeling. I feel for you up there in the Northeast - Costs are Crazy. Even the Medigap plans I compared what I am paying now and the same plans are hundreds more a month up there. ..
2025 pay $150 a month for Plan N here and $0.00 dollars a month for Part D currently. On top of that my Plan D drug coverage paid, actual payments over $14,000 this year for my prostate cancer drug. The same exact plan in my old hometown of Long Island is from a low of $110 more a month to $300 more a month and there are only 6 companies offering it. TH apart D drug plan is $45 a month extra compared to the $0.00 I pay now
After this another long post on the subject. Depending on lack of government funding increases (which took place around 2021 to 2024) 2025 was the first year an increase in funding for Advantage plans. I may one day be back in Medigap/ I'll never settle for exposure of $10,000 and more per year. I would rather skip all the plans and just keep Part A and Part B plus part D with no supplement possibly
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This is a valid concern. All these videos offer some kind of service but you can learn the workings of the system pretty completely.
So you watch a few different people to best balance the picture.
I am self educated in Medicare and I can say that this guy is one of the more straight forward honest ones if not the most honest one telling things as they are, sure he offers a service but he is much better to not skew the data to fit an agenda. It's something I would be doing too if I was him. Explaining things as they are.
There are some videos (from others) out there that look to scare people. As an example, one is really blatant. Keep repeating how so many one million plus lost (companies cancelled) their advantage plans for 2026 like it was the end of the world and this isnt true.
It can be a godsend to many, as it was to me for 2025. Once your Advantage plan is cancelled by an insurance company you can A. choose a new one or B. go to a Medigap (ex plan n or g and drug D) with guaranteed acceptance/no unwiting. You do it right ton your medicare website. A couple clicks and the government PUTS you in a new plan, either medigap or advantage.
Simple stuff some others makes it sound like the end of the world. They also (some) further takes very high costs of Advantage plans like $500 a day for the hospital and on top of it does not mention this is for the first 5 or 6 days only and zero cost after. Honestly in my area even then it is NO WHERE near $500 a day.
Yeah, Like his videos too. Im kind of into this stuff which some may know. I love shopping for good deals *LOL* I'll tell you out of any government entity Medicare and Social Security system is fantastic. I paid into all my life and I am glad to see it works incredibly well.
In my hospital, the average cost of an inpatient day (the cost to the hospital) is $4,000 plus $400 for the physician. I don't know how a hospital can only charge $500 per day and still be in business for longer than a week.
The hospital doesn’t charge $500 a day.
Your insurance company will pay all costs and your co-pay will be up to $500 a day for 5 to 6 days and then zero dollars per day for the policy owner after that.
In our state, it’s more like $$250-$350 per day for 5 to 6 days is your co-pay and then after that everything is covered 100% at zero co-pay.
Another example. I’ve been to the emergency room three times in the last two months. At most about two hours each time. Each time the bill was over $2000.
My co-pay was $50 and my insurance company pays the rest
BTW- if you choose not to have an advantage plan, Medicare Part A is what the average American gets for free, you are covered at 100% for your in hospital bills except for a $1726 deductible. Then if you elect for part B, which is just over $200 a month and most all Americans are automatically signed up unless you Opt out are taken out of your Social Security check and that covers all other medical expenses and doctor bills, you have to pay 20% of the Medicare approved charges Medicare pays the rest.
It’s only if you want an alternative to the above do you choose a Medigap plan or an advantage plan.
My opinion (and many others) is Medicare is a fantastic program, truly something the government gets right.
I don’t think anything is bad.
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Exactly right, and why I won't pay for a supplemental plan. I researched it to the max and decided for the reasons you mentioned it is not worth it for me here in NY. Worst case Heaven forbid I take advantage of the no underwriting loophole for lack of a better term. FTR IIRC there was only one PPO plan and a few HMO plans with doctors we never heard of, so we passed and went with the PPO. Oh and I didn't vote for this nonsensical plan or the person responsible for the mess it is still causing years later.
Just changed to G high deductible
$53 month. Screw high premiums. I’ll take care of the 20% up to the max.
$53 month. Screw high premiums. I’ll take care of the 20% up to the max.
Yeah, depending on your health and also very important location. The cost of other plans varies widely.
My plan N in my old Long Island NY zip code would cost $260 a month or $325 a month for plan G I pay $150 for plan N here in NC or if I opted $180 for G. SO makes high D more palatable in NY.
On top of that, my Plan D here would cost $3.60 a month and in NY it starts at $36 a month.
I took a close look at the G high. I kind of know I am going to blow through the approx $2,872 deductible in 2026. So I might as well pay nothing upfront with a $3,500 MOOP including drugs, dental over the counter etc.
Tough times, lots of changes every year. It's fun shopping though. Each person can try to plan for what they think their expenses may or may not be.
The thing about the deductible..........well yes, if you don't stay healthy, it's a bit of a wash.
The $2870 is the Medigap’s deductible (to Premera, the insurer).
So once you pass the Part B deductible ($257), then Medicare pays 80% and you pay 20% up to the $2870, so it's like a light smack on the finances.
If one stays healthy, then it's a win.
Agree 100% not sure if I typed something that sounded different. In my area I would have to pay $480 for the year for a High G plan. Plus the magical $287 which everyone pays, plus all other costs up to $2870. SO an outlay of $3,350 before I see any bills paid.
SO when I calculate the cost to me I add in what my physical will cost that I have to pay the full amount and any other specialist such as my annual cardiologist appt. As you know with me, that is on a good year *LOL*
Anyway from a cost perspective G High cost me $480 and exposure of another $2850 which is a good deal for some. I actually find this plan interesting. HOWEVER, people may not be aware in the majority of states you do not have a guaranteed right to switch medigap plans if you ever want to get out of a high deductible G plan. . So once in that plan for the majority of us you are in it for life, if you do get sick with ever increasing deductibles and costs, you need to plan on always paying that or switch to an Advantage without underwriting. Actually right now, I only casually tried, I cant get past the second page on an application to switch my medigap plan to another. AS soon as I am forced to click that I had cancer and another click for heart disease. Im rejected without going further. This was just one national medigap insurer. I didnt try any others, for fun I did it.
Right now, for me, at a cost of $1,800 a year. Im covered almost 100% for anything so other costs that are significant. Plan N has small co-pay when you see a doctor but if being treated for something (like cancer) the co-pay is for that illness not every time you see the doctor for the same illness and treatment.
Ok, with that said I am going to decide if I stay in Plan N or leave it and go to a Advantage Plan with a $3,500 MOOP (max out of pocket) I mean, that plan is the deal. No cost, no deductible just small co-pays $0 for primary and $5 for specialist. In fact if I dont get sick I come out way ahead and at worse case break even with the High G. Simply because of free physicals, vision $300, dental $2,500 and $200 over the counter
They really are all good plans DEPENDING on ones situation AND even MORE important what state, even what county you live in. New York is horrific right now.
It's a fascinating subject that deserves its own thread, that I am about to start! I have a REALLY good video on it. Though the majority does not examine things as much as us*LOL*
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It is interesting that the automated policy application process has pre-screening integrated to disqualify you from underwriting based upon certain pre-existing conditions. It is good that they do this since I always assumed you would submit the application and the insurer would evaluate you after applying. Always concerned that if you opted out of a current Medigap plan and was rejected for a different Medigap plan (e.g., going from G to N) you would be locked out of returning to the previous plan.
That sounds like a good deal for your location and situation. Isn't there a referral (and possibly pre-authorization) requirement to see a specialist under all Advantage plans?
Pre-screening would be the way any particular insurance company works. Some I assume will review your application simply because they will take pre-existing conditions but at a MUCH higher premium.
With Medigap you dont cancel your existing policy until approved by the new one that you area applying for. Actually from my experience you are warned not to cancel anything. Any changes I did are right through my account at medicare.gov They handle everything with precision.
If you are dealing with Advantage Plans, everything is automatic right through your Medicare Portal. You click the plan you want for next year and you have it. IN fact you can go back two days later and click another plan and that one will supersede the one you signed up for two days earlier. The plan that you last click is the one that goes into effect on the cutoff date which typically ends Dec 7th.
I would never accept a plan that requires a referral from my primary care doctor. Really only for one reason, if I want to go to a specialist. I dont want to go to my primary first. Either way you will get to see the specialist but silly to me as a first step. SO to answer your question directly, I have been in 3 HMO Advantage plans from 2021/22 to 2025 and the last year in Plan N and D.
All my HMO plans never required a referral to see a specialist and I have sadly had quite a few. I was always SUPER healthy, still see myself that way but wow, ever since I retired .. well another story! GEEZ!!! *LOL*
. I HAVE never had any delay in getting treatment under my HMO plans, From Cardio Stress tests, to Cardio Angiograms, to multiple Prostate Biopsies, MRI's and this was the big one in DEC 2024 A PSMA Pet scan. All under my HMOs. IN fact I had more of a problem NOT under medicare for my first ever prostate biopsy when I was employed and under my employee's health care plan.
Ok, with that said, if you go for a HMO plan, of course check all medical centers and doctors that you may want. In our area of lower costs for example the plan I may go to. EVERY single network is in the plan.
TO ANSWER YOUR QUESTION directly. I would be careful to READ the coverage of any plan HMO included. The documentation is FANTASTIC with all medicare plans and with an HMO it CLEARLY will state whether or not a referral is required. Last I knew there are still some plans that require a referral however I have not run into any of those plans in my area lately. IT will be clearly stated if one is needed or not.
Another thing about ANY of these plans if Medicare Part A and Part B covers a procedure ANY Advantage plan MUST do the same. (With the exception of TRIAL or Experimental treatments but even then they will work with you, its possible Medicare will pay it themselves) "Pre-Approvals" are required for some procedures in Advantage plans and I think to myself, so what? Just about every employee health plan in the USA requires a reapproval for certain things, however with medicare, if medicare covers it, the Advantage Plan MUST cover it. If they dont, you appeal directly to Medicare and they will take care of it for you, I think something like 80% of denials are overturned by Medicare.
Full disclosure, I am an unlicensed Medicare hobbyist. medicare.gov is a great source of information to
research.
The bottom line is, medicare regulates all plans, for the insurers to be able to insure you Medicare MUST approve the plans being offered. Medicare pays the companies with the Advantage plans. I think something like $1000 a month.
I will say what is a little unsettling lately is a lot of Advantage plans are closing up shop. What happened in around 2021 for about 3 years the Government.Medicare stopped giving increases to what they pay the Advantage plans, so out of pocket limits, set by medicare are going up in my opinion to unrealistic maximum out of pocket limits but maybe for those with means 5 digit out of pockets isnt unreasonable. So depending on your area, Advantage might not be worth it at all, Like possibly to some on Long Island NY. Insane out of pocket limits.
IN my area, anything under 5k is acceptable with that said, the choices are fantastic for everyone! I love the system, it works.
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