Medicare 2026 Update Vid

[alarmguy]

This site you can click on your state to look at some details regarding Medigap. It told me that my home state of Missouri has anniversary rights to change Medigap plans but it's only for the same plan number from another company.

https://www.medigap.com/medicare-supplements-by-state/

I'm currently being told it's illegal for a Medigap policy to be pushed by sales agent if one has Medicaid?

I like this site for information you just have to keep in mind they are looking to sell policies. So first, it says at the top the last time it was updated was 2023/
I assume the pricing is 3 years old for 2026. I also noticed the pricing is the lowest possible price, for example in the charts they state rates based on 65 year old female. I THINK it also mentions some plans offer a first year discount. That discount I see as dishonest and it is NOT the website that is dishonest, its the insurance company marketing, those prices are even on the government website but they have to disclose its special pricing, thing is we tend to read what we want to read, in order for a company to get the lowest price shown for their plan over others some mention something like sing on special, I could be wrong I think I am seeing less of this?.

I know the prices stated no longer exist for my state. However as you point out, for a handful of states they pass laws allowing more freedoms and services. I definitely do not want more freedoms and services. Part of the reason for higher prices in some states and also the reason for companies leaving those states and cutting plans.

I can see the wisdom of allowing to change Medigap plans of the same plan number/ one would think why not allow that?
With that said, an insurer takes on risk when someone signs up and the risk gets averaged among the policy holders. So those costs might be higher for some Medigap issuers than others. It could led the draining away of some healthy people, resulting in even higher costs for the company stuck with sick people is one thought. Still a win for you though, but I suspect it will be on your rate if it is more costly to the insurers.

Anyway, as far as rates go medicare.gov is current with all the providers in your state based on age and sex. That website medigap.com is a company website and it does contain helpful information. Once you learn from it, get pricing and available plans on medicare.gov unless of course you need help then by all means call someone. Still it's good to be armed with information from the plans on the government website Medicare.gov when you do call someone, Being informed makes a great conversation when you ask questions of an agent. (this isnt for you, just for some reading this, obviously you already are informed)

 

[fantastic]

I like this site for information you just have to keep in mind they are looking to sell policies. So first, it says at the top the last time it was updated was 2023/
I assume the pricing is 3 years old for 2026. I also noticed the pricing is the lowest possible price, for example in the charts they state rates based on 65 year old female. I THINK it also mentions some plans offer a first year discount. That discount I see as dishonest, in order for a company to get the lowest price shown for their plan over others.

I know the prices stated no longer exist for my state. However as you point out, for a handful of states they pass laws allowing more freedoms and services. I definitely do not want more freedoms and services. Part of the reason for higher prices in some states and also the reason for companies leaving those states and cutting plans.

I can see the wisdom of allowing to change Medigap plans of the same plan number/ one would think why not allow that?
With that said, an insurer takes on risk when someone signs up and the risk gets averaged among the policies holders. So those costs might be higher for some Medigap issuers than others. It could led the draining away of some healthy people, resulting in even higher costs for the company stuck with sick people is one thought. Still a win for you though, but I suspect it will be on your rate if it is more costly to the insurers.

Anyway, as far as rates go medicare.gov is current with all the providers in your state based on age and sex. That website medigap.com is a company website and it does contain helpful information. Once you learn from it, get pricing and available plans on medicare.gov unless of course you need help then by all means call someone.

I didn't know they were selling something. Woops

 

[alarmguy]

I didn't know they were selling something. Woops

Yeah, it used t happen to me searching in my first year before signing up and I am sure most people, if it does not end in .gov it is a medicare sales site. HOWEVER these sites are chock full of information! Nothing wrong with it. You can learn from them and then go to Medicare.GOV to read more. I still use them all the time and learned a lot. I also spent an incredible amount of time reading every single thing on the .gov site many times over.

YouTube is also a nice source keeping in mind they are also selling. But you can take what you learn and compile that with what you learn from all the other information out there and put it all together in what works for you.

One nice thing when it comes to pricing is medicare.gov has all the companies offering plans in your area. Some websites might only be selling plans from a more limited number of companies that they have agreements with. You dont pay commissions. But the insurers pay for customers.
So if someone sees a plan they like on the .gov website but still wants to talk to an agent (certainly nothing wrong with that and advisable for some) They can write down that plan and pricing, talk to the agent about it.

My feelings are Medicare system and offerings is the best system in the nation. You are well protected no matter what company or plan you choose. They all have to cover what Medicare dictates for coverage.

 

[alarmguy]

Correction to post 142. My time to edit ran out so I am correcting here.

A

Post in thread 'Medicare 2026 Update Vid'

Nov 24, 2025

I actually have the means to fully self-insure my medigap (including a few mega-expensive health events) and could actually afford to have no gap coverage at all and pay the 20% difference myself, pocketing all medigap premiums.
...

To me, this is actually a good option. I have thought about it myself, seriously. The 20% difference is not as expensive as some might think. With that said I could be wrong in certain situations because I havent looked into details.
What I have done, after being in the system for 4 years now briefly on the fly roughly figure out what my cost would be...

• alarmguy

EDIT - correction to post 142 above = . The chart in post 142 are my Total expenses that were processed for the 1st quarter of 2025. (In error I said they were for the month of March) The first quarter was close to 6 weeks of radiation and all associated costs including imaging, set up, I mean everything, doctors for the first 3months of the year, a doctor who saw me after each radiation treatment etc.

If I only had Part A,B & D My cost would have been $1,593.03 Since I had plan N and D my cost was $16.93. Chances are I also paid less than a few hundred for the initial Part B deducible.
Not included above was the Part D drug bill. I initially paid roughly less than $1000 for the Drug and the Part D plan actual payment for 6 months worth that they paid was just shy of $13,000.00

 

[Jim Rogers]

Ok, with the above said, Im not sure if everyone understands. Your hospital Part A coverage is free (assuming you put into the system what was required) Part B covers everything else and you pay 20% This is KEY. You pay 20% not of what the medical institution, practice, lab or doctor charges. You pay 20% of the Medicare contract price. Meaning Medicare pays 80% of their contract price for the service and you pay the other 20%. You dont pay the retail cost. Which in MANY cases is greatly lower than retail but there are times I am surprised it come close to actual charges. x

You may have seen this in another post, this was one month billing cycle a 6 week radiation treatment. The costs seem huge but the Medicare contract price is much lowers. Im pretty sure but unsure the bill covers the treatment not the month. This was the highest 1 months of the year though I was seeing doctors and continue for a few more weeks.
SO if I didnt have Plan N I would have owed $1,593 for the month out of the $50,947.00 retail price.
View attachment 311839

With this post (and the numbers you shared in it), you have brought something to my attention of which I was not previously aware: That the Medicare contract prices represent such a steep discount.

I knew there was a discount but didn't realize it was that steep.

I was able to confirm your point independently, and I agree with you that this fact makes full self-insurance of the Medicare gap far more actuarially feasible.

Given my earlier post where I showed how high Supplement premiums will get in later years ($1,500-2,000/mo.), understanding of this discount rate makes going without gap coverage and paying the full 20% (discounted) seem like the cheaper option than buying a Supplement.

In fact, this new understanding has caused me to re-consider Advantage:

It is true that, with those discounts, I could easily just self-insure, pocket the gap insurance premiums I would be avoiding, and apply that money to paying (highly discounted) gap costs.

However, there is no need to do that when $0 premium, relatively low MOOP Advantage plans exist (and even I agree work well early on).

It would seem the best idea is to get the highest-quality Advantage plan that has $0 premium and the lowest MOOP, and go ahead and harvest all the no-denial gap coverage, drug, dental, vision, and hearing coverage, and everything else the Advantage plans will provide early on.

At the same time, I could start saving every month the premium money I would have been paying with a Supplement.

If you (alarmguy) are right and the Advantage plan will not deny anything at end of life, then great! I had low-cost, excellent healthcare right up to the end.

However, if I'm right and the Advantage plan starts increasing the denial rate for even reasonable coverage as the years progress, I start using the avoided premium funds I had been saving over the decades (plus any of my current assets) to self-pay whatever Advantage denied.

In words, I don't fully self-insure, I just self-insure any gaps in the Advantage gap coverage. Sort of like "gap co-insurance" that is self-funded out of my premium savings.

As you have now made me realize, with the discounted Medicare contract rates, that "Advantage gap" coverage might not even be all that expensive.

E.g., I looked into it, and the cost of the later-life, full 100‑day stay in a Skilled Nursing Facility (that I've been worrying about because I believe Advantage has a high probability of denying) is ≈ $16,000 out‑of‑pocket in today’s dollars, and by year 20, with inflation, that might be closer to $25,000–30,000.

But given that Supplement plans are expected to have premiums of up to $2000/mo., that represents the amount I could be saving every month for the preceding decades by not paying Supplement premiums.

Thus, paying ~$25K out of pocket (using those accumulated premium savings) for a denied SNF stay in later life would actually be cost-effective vs. paying for a supplement.

In addition to the actuarial soundness of this approach, doing this means that I will be able to harvest the subsidy money the federal government is willing to contribute to my healthcare (that is expressed in the form of the federal subsidy the Advantage plans get).

Full self-insurance of the whole 20% gap would mean turning my back on federal subsidy funds that I am owed as I contributed greatly to that pool through my near 50 years of payroll tax payments.

In summary:

--With full self‑insurance under straight Medicare and no gap coverage, I would essentially saying: "I’ll pay the 20% coinsurance myself and decline any supplemental pooling." That means that not only do I have to bearing all volatility, I'm also declining the federal subsidy that flows through Advantage plans.

--With Advantage + my asset reserve (the majority of which will come from the savings of not paying gap insurance premiums), I will have:

1) Harvested the government’s subsidy to which I contributed for many years

2) Harvested pooled benefits in the early years when Advantage plans are generous and denials rare.

3) Saved the Medigap premium equivalent as a reserve, so I can self‑pay only the late‑life gaps that matter to me.

4) Be allowed to benefit should I be wrong and there are no Advantage denial problems near end-of-life.

So, perhaps the "Advantage + self-insuring and Advantage coverage gaps using premium savings funds" approach is the "split all the differences" strategy I've been looking for.

What is your take on this?

 

[alarmguy]

@Jim Rogers
Ill at some point in the coming week (possibly sooner) get back to you on post#145 A busy few days coming up.
I have a full half day specialist appt 50 miles away Tuesday all afternoon. I just filled out and printed 18 pages of questions and info for them. I hope they need it all now that I did it. I found the forms on their website. They told me to come in early to fills out forms. I hope those were the ones. *LOL* It was easy doing it in PDF form and printing out.

Not sure if I will have time Tuesday morning. The following day we will be on the road (4 hrs each way) for an Early Thanksgiving event with Family and then local one on Thanksgiving day.

I want to reply without rushing.

 

[Jim Rogers]

@Jim Rogers
Ill at some point in the coming week (possibly sooner) get back to you on post#145 A busy few days coming up.
I have a full half day specialist appt 50 miles away Tuesday all afternoon. Not sure if I will have time in the morning. The following day we will be on the road (4 hrs each way) for an Early Thanksgiving event with Family and then local one on Thanksgiving day.

No problem, no hurry.

I've been busy myself for other reasons that you'll be interested in (and hearing about soon).

Enjoy the holiday.

 

[fantastic]

With this post (and the numbers you shared in it), you have brought something to my attention of which I was not previously aware: That the Medicare contract prices represent such a steep discount.

It is true that, with those discounts, I could easily just self-insure, pocket the gap insurance premiums I would be avoiding, and apply that money to paying (highly discounted) gap costs.

However, there is no need to do that when $0 premium, relatively low MOOP Advantage plans exist (and even I agree work well early on).
It would seem the best idea is to get the highest-quality Advantage plan that has $0 premium and the lowest MOOP, and go ahead and harvest all the no-denial gap coverage, drug, dental, vision, and hearing coverage, and everything else the Advantage plans will provide early on.

As you have now made me realize, with the discounted Medicare contract rates, that "Advantage gap" coverage might not even be all that expensive.

Even if you get a PPO always go to an in network provider! There are providers that will except your MA plan but NOT be in network so even though you'll get your MA to pay the 80% discounted rate the remaining 20% will not be discounted rate (Medicare rate for non-Providers).

The first bullet point is what @alarmguy is talking about the discounted rate. ($5,000 bill but you went to an in network provider so they agreed to accept a $1,500 discounted rate total payment. MA pays $1200 (80%) & you pay $300 (20%).

As an example of what Humana explains on one of their plans.

• If your cost sharing is a coinsurance (a percentage of the total charges), you never pay more than that percentage. However, your cost depends on which type of provider you see:– If you get covered services from a network provider, you pay the coinsurance percentage multiplied by our plan's reimbursement rate (this is set in the contract between the provider and our plan.)–
• If you get covered services from an out-of-network provider who participates with Medicare, you pay the coinsurance percentage multiplied by the Medicare payment rate for participating providers.
• If you get covered services from an out-of-network provider who doesn’t participate with Medicare, you pay the coinsurance percentage multiplied by the Medicare payment rate for non-participating providers.(Our plan covers services from out-of-network providers only in certain situations, such as when you get areferral, or for emergencies or urgently needed services outside the service area.

Non-participating providers can charge up to 15% more than Medicare’s approved amount for the cost of services you receive (known as the limiting charge). This means you are responsible for up to 35% (20% coinsurance + 15% limiting charge) of Medicare’s approved amount for covered services. --->I don't know if this is exactly how this is but gives you an idea. It may have a higher cost. ($5,000 bill but you went to an out of network provider but they accept Medicare & a $1,500 discounted rate payment but not in total. MA pays $1200 (80%) & you pay $300 (20%+up to 15% additional) $225 additional charge that you must pay (15% more than $1500). (This example may only come into play with PPO's? Since HMO's plans are only in network.) LINK

E.g., I looked into it, and the cost of the later-life, full 100‑day stay in a Skilled Nursing Facility (that I've been worrying about because I believe Advantage has a high probability of denying) is ≈ $16,000 out‑of‑pocket in today’s dollars, and by year 20, with inflation, that might be closer to $25,000–30,000.

I have no idea but I thought most people go to Nursing Home which would be considered Unskilled facility. That I believe is where state Medicaid system picks up the tab and then puts a claim against your estate once you pass to recoup their money. Who wants to go to a nursing home though! ha!

 

[Jim Rogers]

Even if you get a PPO always go to an in network provider! There are providers that will except your MA plan but NOT be in network so even though you'll get your MA to pay the 80% discounted rate the remaining 20% will not be discounted rate (Medicare rate for non-Providers).

The first bullet point is what @alarmguy is talking about the discounted rate. ($5,000 bill but you went to an in network provider so they agreed to accept a $1,500 discounted rate total payment. MA pays $1200 (80%) & you pay $300 (20%).

As an example of what Humana explains on one of their plans.

• If your cost sharing is a coinsurance (a percentage of the total charges), you never pay more than that percentage. However, your cost depends on which type of provider you see:– If you get covered services from a network provider, you pay the coinsurance percentage multiplied by our plan's reimbursement rate (this is set in the contract between the provider and our plan.)–
• If you get covered services from an out-of-network provider who participates with Medicare, you pay the coinsurance percentage multiplied by the Medicare payment rate for participating providers.
• If you get covered services from an out-of-network provider who doesn’t participate with Medicare, you pay the coinsurance percentage multiplied by the Medicare payment rate for non-participating providers.(Our plan covers services from out-of-network providers only in certain situations, such as when you get areferral, or for emergencies or urgently needed services outside the service area.

Non-participating providers can charge up to 15% more than Medicare’s approved amount for the cost of services you receive (known as the limiting charge). This means you are responsible for up to 35% (20% coinsurance + 15% limiting charge) of Medicare’s approved amount for covered services. --->I don't know if this is exactly how this is but gives you an idea. It may have a higher cost. ($5,000 bill but you went to an out of network provider but they accept Medicare & a $1,500 discounted rate payment but not in total. MA pays $1200 (80%) & you pay $300 (20%+up to 15% additional) $225 additional charge that you must pay (15% more than $1500). (This example may only come into play with PPO's? Since HMO's plans are only in network.) LINK

Good advice, and I do plan on following that.

I have no idea but I thought most people go to Nursing Home which would be considered Unskilled facility. That I believe is where state Medicaid system picks up the tab and then puts a claim against your estate once you pass to recoup their money. Who wants to go to a nursing home though! ha!

Skilled nursing facilities are where you go for recovery from serious events like a stroke or extensive orthopedic surgeries after a bad fall.

Nursing homes are unskilled facilities for those that cannot live on their own but aren't suffering from anything that needs skilled nursing. Definitely would not go to a nursing home if you needed serious rehabilitation procedures delivered by skilled nursing staff.

I've heard nightmare stories about the costs of skilled care, with Advantage denials being fairly common.

However, with this new information on Medicare contract rates being so low, my premise that skilled nursing care is all that expensive (for those with even a moderate amount of assets) is under serious question, so I'm reviewing it now.

 

[alarmguy]

Even if you get a PPO always go to an in network provider! There are providers that will except your MA plan but NOT be in network so even though you'll get your MA to pay the 80% discounted rate the remaining 20% will not be discounted rate (Medicare rate for non-Providers).

The first bullet point is what @alarmguy is talking about the discounted rate. ($5,000 bill but you went to an in network provider so they agreed to accept a $1,500 discounted rate total payment. MA pays $1200 (80%) & you pay $300 (20%).

As an example of what Humana explains on one of their plans.

• If your cost sharing is a coinsurance (a percentage of the total charges), you never pay more than that percentage. However, your cost depends on which type of provider you see:– If you get covered services from a network provider, you pay the coinsurance percentage multiplied by our plan's reimbursement rate (this is set in the contract between the provider and our plan.)–
• If you get covered services from an out-of-network provider who participates with Medicare, you pay the coinsurance percentage multiplied by the Medicare payment rate for participating providers.
• If you get covered services from an out-of-network provider who doesn’t participate with Medicare, you pay the coinsurance percentage multiplied by the Medicare payment rate for non-participating providers.(Our plan covers services from out-of-network providers only in certain situations, such as when you get areferral, or for emergencies or urgently needed services outside the service area.

Non-participating providers can charge up to 15% more than Medicare’s approved amount for the cost of services you receive (known as the limiting charge). This means you are responsible for up to 35% (20% coinsurance + 15% limiting charge) of Medicare’s approved amount for covered services. --->I don't know if this is exactly how this is but gives you an idea. It may have a higher cost. ($5,000 bill but you went to an out of network provider but they accept Medicare & a $1,500 discounted rate payment but not in total. MA pays $1200 (80%) & you pay $300 (20%+up to 15% additional) $225 additional charge that you must pay (15% more than $1500). (This example may only come into play with PPO's? Since HMO's plans are only in network.) LINK


I have no idea but I thought most people go to Nursing Home which would be considered Unskilled facility. That I believe is where state Medicaid system picks up the tab and then puts a claim against your estate once you pass to recoup their money. Who wants to go to a nursing home though! ha!

I only read the first paragraph of your op post, but it’s incorrect so I stopped there. At least incorrect in the sense I wasn’t talking about anything with Medicare advantage plans, and paying Medicare approved prices. That would strictly be part a part B where you would be responsible for 20%.

When you have a medical advantage plan, some are PPO and some are HMO.
When you get the plan, you know what your maximum out-of-pocket is for a PPO plan and HMO plan.
For PPO plan, you will know what your maximum out-of-pocket is for in network and your maximum out-of-pocket for out of network. Sometimes it’s the same number..

Some things are given in advantage plans that you will pay 20% of part B drugs, for example. There will be set copayments for most of the things in out of network almost like you posted you could be responsible for 40% of costs however you will still always have that out-of-pocket limit. As far as what number they based on, I saw your post about Humana and understand how they might use other pricing for whatever reason up until you’re out of pocket

Everything else is a set co-pay.. but if you do have a medical advantage, PPO plan, of course you read through the contract because there will be significant differences up to your out-of-pocket expense that you will pay for going out of network

It’s extremely rare that a Doctor who participates in Medicare, but not Medicare pricing would be an issue. Well over 90% of doctors who accept Medicare except the Medicare program and its pricing.
But if it’s something that concerns someone they can certainly ask. I don’t know if anybody ever does.

A Medicare advantage plan is complete. It’s true you would be more protected in an HMO environment, but even in a PPO you know what your maximum out-of-pocket amount is.

And in the rare case, if you do part B chemo you will be responsible for 20% up to your out-of-pocket. Other regular medical expenses that might also go for things like radiation. The plans very widely on your responsible costs.
All these things are spelled out in your contract for your Medicare advantage plan. With the PPO plan you are correct with some of those plans. Your co-pays are greatly higher out of network. But you will always have that out-of-pocket maximum. Believe it or not it’s one reason why I like HMO’s. I check before I get the plan and make sure every health institution is available to me and then I don’t even have to worry about anything else.

I posted this as best as I can. Hope it makes sense. It’s been a long afternoon with doctor appointments ha ha

 

[alarmguy]

@fantastic
Hope my post made sense. I literally just got home from afternoon doctor appointments, and blood draw.. I corrected a few times so I wanted to let you know excuse the typos.
My time is limited the next few days, but wanted to say that

 

[fantastic]

I only read the first paragraph of your op post, but it’s incorrect so I stopped there. At least incorrect in the sense I wasn’t talking about anything with Medicare advantage plans, and paying Medicare approved prices. That would strictly be part a part B where you would be responsible for 20%.

When you have a medical advantage plan, some are PPO and some are HMO.
When you get the plan, you know what your maximum out-of-pocket is for a PPO plan and HMO plan.
For PPO plan, you will know what your maximum out-of-pocket is for in network and your maximum out-of-pocket for out of network. Sometimes it’s the same number..

If you’re talking paying 20% of part B drugs, such as chemo that is administered in a medical building that’s pretty much the only thing 20% of any Medicare advantage plan is. Everything else is a set co-pay.. but if you do have a medical advantage, PPO plan, of course you read through the contract because there will be significant differences up to your out-of-pocket expense that you will pay for going out of network

It’s extremely rare that a Doctor who participates in Medicare, but not Medicare pricing would be an issue. Well over 90% of doctors who accept Medicare except the Medicare program and its pricing.
But if it’s something that concerns someone they can certainly ask. I don’t know if anybody ever does.

A Medicare advantage plan is complete. It’s true you would be more protected in an HMO environment, but even in a PPO you know what your maximum amount of pocket is.
And in the rare case, if you do part B chemo, they’ll be responsible for 20% up to your out-of-pocket, that might also go for things like radiation.
All these things are sad spilled out in your contract for your Medicare advantage plan

Thanks, When I was referring to what you are talking about the discounted rates. I was just trying to use a Humana example on MA plans but sorry if I was mistaken. MA also have those discounted rates as well but you already know that.

There seems to be
"Reimbursement Rate" <---MA plan approved discounted rate
"Medicare Payment Rate" <---Out of Network for your MA Plan but they still accept Medicare
"Rate for Non-Participating Providers" <---Get your wallet out?

@fantastic
Hope my post made sense. I literally just got home from afternoon doctor appointments, and blood draw.. I corrected a few times so I wanted to let you know excuse the typos.
My time is limited the next few days, but wanted to say that

Certainly don't want to misquote you & I appreciate telling me anything I've said as well as what you've brought to the forum about your Medicare experience. You have a good idea of what's going on & bring some experience about having both types of Medicare plans MA + OM/Medigap. I've been at it for about 8-10 yrs now on MA plans only & I've focused to learn a lot about federal rules regarding billing protections w/low income households (QMB, SLMB, QI etc.) out of necessity which brings whole new topics to these conversations I don't try to really get into since It doesn't really apply to everyone (Low income).

 

[alarmguy]

Thanks, When I was referring to what you are talking about the discounted rates. I was just trying to use a Humana example on MA plans but sorry if I was mistaken. MA also have those discounted rates as well but you already know that.

There seems to be
"Reimbursement Rate" <---MA plan approved discounted rate
"Medicare Payment Rate" <---Out of Network for your MA Plan but they still accept Medicare
"Rate for Non-Participating Providers" <---Get your wallet out?

Certainly don't want to misquote you & I appreciate telling me anything I've said as well as what you've brought to the forum about your Medicare experience. You have a good idea of what's going on & bring some experience about having both types of Medicare plans MA + OM/Medigap. I've been at it for about 8-10 yrs now on MA plans only & I've focused to learn a lot about federal rules regarding billing protections w/low income households (QMB, SLMB, QI etc.) out of necessity which brings whole new topics to these conversations I don't try to really get into since It doesn't really apply to everyone (Low income).

I think I may understand what you are saying. Also keep in mind I am coming here short on time the next few days. I have zero experience with Medical Advantage PPO plans and if by choice I never will your leaving that out of many posts. So I dont know about PPO plans and never have looked at the specifics and at this point, I can't see a reason I ever will be in one. Important for anyone reading that they understand what you are saying pertains to MA PPO plans, not HMO plans. It caught me off guard at first.
Even your own history with MA plans, your not specifying HMO or PPO including when referencing me.

Ugh... to simplify. Any of my posts are Medicare Part A and B You pay 20% of the Part B rate that Medicare pays and they pay 80% when another was talking about Plan G high deductible.

I had 3 years of HMO Medical Advantage plans. One year of A,B,N,D,
IN the HMO plan I know my expenses because you stay in-network.
Here is an example of a low out of Pocket HMO (im open if you find something I am not seeing)
https://www.humana-medicare.com/BenefitSummary/2026PDFs/H1036335001SB26.pdf

Other Contenders would be the HMO's here from BCBSNC. I like the $40 a month one a lot however the free essential plus is nice too
https://shopper.bcbsnc.com/medicare-plan-finder/pdfs/2026-BlueMedicareHMOSummaryOfBenefits_508.pdf

There are many others, I like three of these HMO's
My Past HMO's were two years of UHC and one year of Aetna. AS stated this year is Original Part A & B plus Supplement N and D
Pretty much covers all medical for $150 a month extra.

Maybe I am headstrong but only because we do not live in a high cost area. I dont buy the mass media clock bait hysteria.
I will NEVER find a doctor who does not accept medicare because I am in am HMO but even PPO - 98% of doctors accept medicare payment in full. If you run into that 2% or even 4% I would go someplace else but it doesn't happen here. It is also why I could care less about HMO or PPO. Lowest MOOP wins within 20%. I do also looks at the plans.
Im not even sure if we are talking about the same thing. But others comment how they would never be in an HMO or any Advantage plan and that is ok, we all have a fear of something in life.

https://www.kff.org/medicare/how-many-physicians-have-opted-out-of-the-medicare-program/
"Participating providers agree to accept “assignment” on all Medicare claims for all of their Medicare patients, which means that they have signed a participation agreement with Medicare, agreeing to accept Medicare’s fee schedule amounts as payment-in-full for all Medicare covered services. Medicare beneficiaries seeing a participating provider can only be liable for the cost sharing required by Medicare. Providers have several incentives to be participating providers, such as being paid higher rates (5% higher) than the rates paid to non-participating providers. In 2022, the vast majority (98%) of physicians and practitioners billing Medicare were participating providers."

SO even with Plan A and B and no other. You're going to pay 20% of the low Medicare payment rate. AS I said before if I was going self insure like another posted in here "Rodger" I would of course verify 3 times over.

I think off the top of my head. when you talk about MA PPO plans your stating that a retail percentage can be applied instead of the Participating Provider rate. That I have no knowledge of because I never looked into or considered a MA PPO plan and most likely will not because of the higher MOOP.

Happy almost Thanksgiving. I Enjoy our conversations and I enjoy learning but I am all over the place and why I suggested we are clear not to lump MA plans together. PPO vs HMO mores with limited time. I still haven't read over Rogers long post and will be on the road 8 hours tomorrow, round trip to my son's house. Ha! You know I wouldn't be taking an EV if I owned one! 4 hour non stop drive, stop at the house for 4 hours, 4 hour non stop return trip. Only stops are interstate rest stops or if emergency run exit, run in and out of a station. (just a thought as we prepare to get some rest now. Dont want to change the thread

 

[fantastic]

I think I may understand what you are saying. Also keep in mind I am coming here short on time the next few days. I have zero experience with Medical Advantage PPO plans and if by choice I never will your leaving that out of many posts. So I dont know about PPO plans and never have looked at the specifics and at this point, I can't see a reason I ever will be in one. Important for anyone reading that they understand what you are saying pertains to MA PPO plans, not HMO plans. It caught me off guard at first.
Even your own history with MA plans, your not specifying HMO or PPO including when referencing me.

Ugh... to simplify. Any of my posts are Medicare Part A and B You pay 20% of the Part B rate that Medicare pays and they pay 80% when another was talking about Plan G high deductible.

I had 3 years of HMO Medical Advantage plans. One year of A,B,N,D,
IN the HMO plan I know my expenses because you stay in-network.
Here is an example of a low out of Pocket HMO (im open if you find something I am not seeing)
https://www.humana-medicare.com/BenefitSummary/2026PDFs/H1036335001SB26.pdf

Other Contenders would be the HMO's here from BCBSNC. I like the $40 a month one a lot however the free essential plus is nice too
https://shopper.bcbsnc.com/medicare-plan-finder/pdfs/2026-BlueMedicareHMOSummaryOfBenefits_508.pdf

There are many others, I like three of these HMO's
My Past HMO's were two years of UHC and one year of Aetna. AS stated this year is Original Part A & B plus Supplement N and D
Pretty much covers all medical for $150 a month extra.

Maybe I am headstrong but only because we do not live in a high cost area. I dont buy the mass media clock bait hysteria.
I will NEVER find a doctor who does not accept medicare because I am in am HMO but even PPO - 98% of doctors accept medicare payment in full. If you run into that 2% or even 4% I would go someplace else but it doesn't happen here. It is also why I could care less about HMO or PPO. Lowest MOOP wins within 20%. I do also looks at the plans.
Im not even sure if we are talking about the same thing. But others comment how they would never be in an HMO or any Advantage plan and that is ok, we all have a fear of something in life.

https://www.kff.org/medicare/how-many-physicians-have-opted-out-of-the-medicare-program/
"Participating providers agree to accept “assignment” on all Medicare claims for all of their Medicare patients, which means that they have signed a participation agreement with Medicare, agreeing to accept Medicare’s fee schedule amounts as payment-in-full for all Medicare covered services. Medicare beneficiaries seeing a participating provider can only be liable for the cost sharing required by Medicare. Providers have several incentives to be participating providers, such as being paid higher rates (5% higher) than the rates paid to non-participating providers. In 2022, the vast majority (98%) of physicians and practitioners billing Medicare were participating providers."

SO even with Plan A and B and no other. You're going to pay 20% of the low Medicare payment rate. AS I said before if I was going self insure like another posted in here "Rodger" I would of course verify 3 times over.

I think off the top of my head. when you talk about MA PPO plans your stating that a retail percentage can be applied instead of the Participating Provider rate. That I have no knowledge of because I never looked into or considered a MA PPO plan and most likely will not because of the higher MOOP.

Happy almost Thanksgiving. I Enjoy our conversations and I enjoy learning but I am all over the place and why I suggested we are clear not to lump MA plans together. PPO vs HMO mores with limited time. I still haven't read over Rogers long post and will be on the road 8 hours tomorrow, round trip to my son's house. Ha! You know I wouldn't be taking an EV if I owned one! 4 hour non stop drive, stop at the house for 4 hours, 4 hour non stop return trip. Only stops are interstate rest stops or if emergency run exit, run in and out of a station. (just a thought as we prepare to get some rest now. Dont want to change the thread

Sorry Yes, I was referring to PPO which I experience with. HMO's you don't have a choice to go out of network but they both PPO, HMO, equally offer in network discounted payment rates.

That Humana plan not requiring referrals is nice and if you select a "Plus Provider" you get an extra $100 vision benefit. Looks like a nice plan.

$150 maximum benefit coverage amount peryear for contact lenses or eyeglasses-lenses andframes, fitting for eyeglasses-lenses and frames.•
OR• $250 maximum benefit coverage amount peryear at PLUS Provider for contact lenses oreyeglasses-lenses and frames, fitting foreyeglasses-lenses and frames.

The BCBS plan seems to give Part B premium back but $25 specialist vs $5 & $400 less MOOP on the Humana may eat into the giveback? Looks like you have some choices.

 

[alarmguy]

Sorry Yes, I was referring to PPO which I experience with. HMO's you don't have a choice to go out of network but they both PPO, HMO, equally offer in network discounted payment rates.

That Humana plan not requiring referrals is nice and if you select a "Plus Provider" you get an extra $100 vision benefit. Looks like a nice plan.

$150 maximum benefit coverage amount peryear for contact lenses or eyeglasses-lenses andframes, fitting for eyeglasses-lenses and frames.•
OR• $250 maximum benefit coverage amount peryear at PLUS Provider for contact lenses oreyeglasses-lenses and frames, fitting foreyeglasses-lenses and frames.

The BCBS plan seems to give Part B premium back but $25 specialist vs $5 & $400 less MOOP on the Humana may eat into the giveback? Looks like you have some choices.

YEAH,
Lucky I like shopping. No real giveback given this year. $1
THe BCBSNC plan is higher in some places but drastically lower in others. The Co-pays for services, on the BCBS plan such as MRI's, Tests, Labs and almost all the others lower, Dental is about equal in my mind and vision superior in BSBSto the other. Its a wash in my head because the lower MOOP of the Humana vs the MOOP of the BCBS.

What is VERY attractive about the BVBSNC plan is they have a program (SO FAR) like no other in this state. It's called "Blue to Blue" what that is, is they offer their customers the ability to switch plans. Example, if your in a BCBS Advantage plan they will allow you to switch to a BCBS Medigap plan without UNDERWRITING. That is HUGE I have never seen anything like it, so in disbelief I printed it all out in case I end up in their Advantage plan. There is one thing about that HMO plan though. It's not showing a hospital near me, yet it shows some doctors and primary also cardiologists near by. If I was to go that route I would call. Im sure its a website oversize but need to confirm because their PPO plan show in -network. I love HMO Advantage plans but we know the plans are in upheaval right now. So it is a nice feature. Then again, if any plan cancelled your right to switch to Medigap is there anyway. So ... but .... anyway...
I saved this from the BCBSNC site

and this from a search below

Anyway, just explaining some differences. Who knows if this cant be cancelled some year. Honestly the HUMANA is a great deal. Medical services are more co-pay (except doctors) yet some areas benefits are better. Pretty much a draw but we know every year the MOOPs go higher SO I rather start lower. *LOL*
Also Humana is the NC state employees retirement medical plan. I have no idea what that means other than a strong presence in the state.

 

[fantastic]

That BCBS is very interesting with that Blue to Blue rule. I wonder what prompts them to do it.

 

[fantastic]

YEAH,
Lucky I like shopping. No real giveback given this year. $1
THe BCBSNC plan is higher in some places but drastically lower in others. The Co-pays for services, on the BCBS plan such as MRI's, Tests, Labs and almost all the others lower, Dental is about equal in my mind and vision superior in BSBSto the other. Its a wash in my head because the lower MOOP of the Humana vs the MOOP of the BCBS.

What is VERY attractive about the BVBSNC plan is they have a program (SO FAR) like no other in this state. It's called "Blue to Blue" what that is, is they offer their customers the ability to switch plans. Example, if your in a BCBS Advantage plan they will allow you to switch to a BCBS Medigap plan without UNDERWRITING. That is HUGE I have never seen anything like it, so in disbelief I printed it all out in case I end up in their Advantage plan. There is one thing about that HMO plan though. It's not showing a hospital near me, yet it shows some doctors and primary also cardiologists near by. If I was to go that route I would call. Im sure its a website oversize but need to confirm because their PPO plan show in -network. I love HMO Advantage plans but we know the plans are in upheaval right now. So it is a nice feature. Then again, if any plan cancelled your right to switch to Medigap is there anyway. So ... but .... anyway...
I saved this from the BCBSNC site
View attachment 312349
and this from a search below
View attachment 312350

Anyway, just explaining some differences. Who knows if this cant be cancelled some year. Honestly the HUMANA is a great deal. Medical services are more co-pay (except doctors) yet some areas benefits are better. Pretty much a draw but we know every year the MOOPs go higher SO I rather start lower. *LOL*
Also Humana is the NC state employees retirement medical plan. I have no idea what that means other than a strong presence in the state.

If you click on the plan directory below you can see that BCBS NC is "Non-Profit" which is not common among MA plans. I knew there had to be something going on w/Blue to Blue rule. I think that must be a benefit of not really reaching for maximizing profits. Now THIS looks like what we need more of. If MA's had more Non Profit options I think we could see some real advantages again. Perhaps not every state due to rules but still. I suppose you can guess which of the companies you mentioned were for profit in NC...(Humana). Interesting to ponder.

https://www.cms.gov/data-research/s...ontract-and-enrollment-data/ma-plan-directory

 

[alarmguy]

If you click on the plan directory below you can see that BCBS NC is "Non-Profit" which is not common among MA plans. I knew there had to be something going on w/Blue to Blue rule. I think that must be a benefit of not really reaching for maximizing profits. Now THIS looks like what we need more of. If MA's had more Non Profit options I think we could see some real advantages again. Perhaps not every state due to rules but still. I suppose you can guess which of the companies you mentioned were for profit in NC...(Humana). Interesting to ponder.

https://www.cms.gov/data-research/s...ontract-and-enrollment-data/ma-plan-directory

View attachment 312587

Fascinating to say the least. Are you in the health care industry? That was a great link.
Cool that we are one of a few here in NC that still has a non profit. Though I dont think enough to sway me, yet enough to consider. I think knew BCBSNC was non profit but never much thought about it until you posted this spreadsheet.

Im getting right down to the wire now. One week left to select a plan if I am going to leave Plan N and D.
GO back to Advantage. Still between Humana and BCBSNC. Possibly one other... have to look at them all again. Believe it or not there is a MA plan that will pay me $180 (not a misprint) a month to take their plan. Thing is the Moop is close to 10k and higher for out of network. As far as I am concerned if the MA plans get that high Id rather do a High Deductible G or some other solution. Ive had a fortunate healthy life up until I got prostate cancer diagnosis in late 2024. All good, it's treated and technically gone, we just hope it never comes back. *LOL* With that said I am still in the mist of an immune system (upset) after ending 6 month regimen of the anti cancer drug Orgovyx. Which ended 07/2025.

Technically known autoimmune urticaria and angioedema of unknown cause. However it will work itself out and I think has already started too. Happened to me once 6 years ago after a longer course of an antibiotic I took for something that I dont remember what it was. Since it happened six years ago and eventually went away after a few months of a daily antihistamine I suspect it will go away again, though right now a daily one isnt enough and I take two different kinds of over the counter antihistamines. Also was at an allergist/immunology center last week. follow up in 10 days, six vials of blood. I KNOW they are NOT going to find an outside source of an allergen but I am letting them do their routine. It's kind of rare but not unheard of but rare enough that this doctor is convinced the blood results will show something different. I even gave in the drug information that this is a rare but possible side effect. He discounted it and is sure he will find something. I cant wait to go back and him tell me all tests were negative for an allergic reaction

Ugh... anyway, the long post is about since I am in the middle of this I want to make sure every place I currently go to is in the plan. BCBSNC at first glance isnt as complete as Humana. The place I am going to is not on BCBSNC provider list. Humana has them all. The catch is, on the outside CHANCE of needing something other then an over the counter drug. a once a month injection until it clears runs over $15,000 a year without insurance. However I am almost positive I will not need it. So far no further reactions taking two over the counter antihistamines. I need to stress. My posts sound like I am sickly and I am not, well disregarding the cancer. Heck on Black Friday we payed 6 rounds of intense pickleball in temperatures of the low 40s. *LOL*

Time for shopping at the outlets! Great link! Sometime this week I will make the final decision. Strongly in Humana's favor but I want to review UHC and some others just to make sure.
If I ever want to go back to Medigap I suspect at some point the Humana MA HMO wont be offered with such a low MOOP and I can do it then OR I could simply switch to a BSBC MA plan if I think I want a Medigap in the future and then to Medigap from there. I would prefer BCBS if they had all the facilities I am currently in, Im even willing to pay the $40 a month because most all procedure co-pays are lower anyway.

Regarding an allergist, an allergy which is technically what I have, an allergy only, I am not allergic to anything outside my body but my immune system mistakes something inside as an enemy.

 

[fantastic]

Fascinating to say the least. Are you in the health care industry? That was a great link.
Cool that we are one of a few here in NC that still has a non profit. Though I dont think enough to sway me, yet enough to consider. I think knew BCBSNC was non profit but never much thought about it until you posted this spreadsheet.

No, I'm not in the healthcare & never have been. I don't have any special degree's but I'm a sponge... That's what my wife says...ha! I've often told her over the years that we're very low income but I refuse to be ignorant. 8th grade drop out w/lousy upbringing, I've had to sink or swim in life alarmguy. I choose to swim for as long as possible!

Im getting right down to the wire now. One week left to select a plan if I am going to leave Plan N and D.
GO back to Advantage. Still between Humana and BCBSNC. Possibly one other... have to look at them all again. Believe it or not there is a MA plan that will pay me $180 (not a misprint) a month to take their plan. Thing is the Moop is close to 10k and higher for out of network. As far as I am concerned if the MA plans get that high Id rather do a High Deductible G or some other solution. Ive had a fortunate healthy life up until I got prostate cancer diagnosis in late 2024. All good, it's treated and technically gone, we just hope it never comes back. *LOL* With that said I am still in the mist of an immune system (upset) after ending 6 month regimen of the anti cancer drug Orgovyx. Which ended 07/2025.

Technically known autoimmune urticaria and angioedema of unknown cause. However it will work itself out and I think has already started too. Happened to me once 6 years ago after a longer course of an antibiotic I took for something that I dont remember what it was. Since it happened six years ago and eventually went away after a few months of a daily antihistamine I suspect it will go away again, though right now a daily one isnt enough and I take two different kinds of over the counter antihistamines. Also was at an allergist/immunology center last week. follow up in 10 days, six vials of blood. I KNOW they are NOT going to find an outside source of an allergen but I am letting them do their routine. It's kind of rare but not unheard of but rare enough that this doctor is convinced the blood results will show something different. I even gave in the drug information that this is a rare but possible side effect. He discounted it and is sure he will find something. I cant wait to go back and him tell me all tests were negative for an allergic reaction

Ugh... anyway, the long post is about since I am in the middle of this I want to make sure every place I currently go to is in the plan. BCBSNC at first glance isnt as complete as Humana. The place I am going to is not on BCBSNC provider list. Humana has them all. The catch is, on the outside CHANCE of needing something other then an over the counter drug. a once a month injection until it clears runs over $15,000 a year without insurance. However I am almost positive I will not need it. So far no further reactions taking two over the counter antihistamines. I need to stress. My posts sound like I am sickly and I am not, well disregarding the cancer. Heck on Black Friday we payed 6 rounds of intense pickleball in temperatures of the low 40s. *LOL*

Yes, keep getting the care you need. You're not "Sick" but have had some health setbacks, just a reminder that we're all human. You're right Dec 7th is coming quick! I know you know but just a reminder that you can always change MA plan again during the Medicare Advantage Open Enrollment Period (MA OEP), January 1 to March 31. That is if you decide to go to an MA.

I've already selected & ready to go but I understand your using the time wisely by thinking & researching. I agree about that $180 plan, that wouldn't be great when or if you really need to use the plan for higher expenses. Don't do it...LOL! Doesn't sound like you would have any backup in that case.

I will say that I did enroll the wife into $9,250/$13k MOOP Humana plan BUT if she pays her $391 Medicaid Spend Down then State Medicaid turns on & will start paying so we can use it as sort of a "Medigap" but as you may know when you die Medicaid puts a claim on your estate for recouping cost.

I've planned her to be on this high MOOP Humana plan for a few years to ride out those "MA Benefits" but they have been dwindling every year. They've been reducing the healthy benefit card by $50 a month, that's $600 less benefits each year! Soon enough it will make no sense & I'll put her back into a lower MOOP plan. Yes, it's a bit of a gamble but she does have Medicaid for backup, for the time being, if things go south in the process. I really don't want to rely on Medicaid for $1,000's of dollars on a $9,250 MOOP instead of say a $3,500 MOOP MA Plan that would start paying much sooner. Remember, Medicaid comes back to us when we die. I'd rather limit that payback as much as possible. So much for those that claim it's "Welfare" (spoiler..it's not).

Time for shopping at the outlets! Great link! Sometime this week I will make the final decision. Strongly in Humana's favor but I want to review UHC and some others just to make sure.

Here's more gov't data if you want to browse.
https://www.cms.gov/data-research/s...-advantagepart-d-contract-and-enrollment-data

I'm currently diving into seeing how many people on are the plans I'm interested in. You can download by county/state.

I've been browsing some of this data that I find interesting. Here's a graph I ran into. Don't know all that it entails but appears to point to inpatient hospital as the highest cost, followed by physician, & hospice categories.

If I ever want to go back to Medigap I suspect at some point the Humana MA HMO wont be offered with such a low MOOP and I can do it then OR I could simply switch to a BSBC MA plan if I think I want a Medigap in the future and then to Medigap from there. I would prefer BCBS if they had all the facilities I am currently in, Im even willing to pay the $40 a month because most all procedure co-pays are lower anyway.

Regarding an allergist, an allergy which is technically what I have, an allergy only, I am not allergic to anything outside my body but my immune system mistakes something inside as an enemy.

I thought that you might be able to switch over to BCBS & use the Blue to Blue rule if you want to go back to Medigap? I'm sure you'll want to confirm on your end.

 

[alarmguy]

I think we can all agree that going with Original Medicare ONLY is the worst thing you can do. Getting a Medigap, any Medigap plan, is the right choice to work with OM. A low MOOP MA is a great way to go as well. The only thing about Medigap is like alarmguy & others have mentioned that you'll want to choose which Medigap plan to stay in since it's hard or impossible to swap around. Getting it right the first time is good.

Here's a comparison video to show that even a Medigap G HD is no comparison to Original Medicare alone in savings if you have some really high bills.

I watched this video. Im within days or hours of choosing next years plan.
I actually posted a question to them and they responded within minutes. It's such a basic question but when making what can be life changing financial decisions I need to see it in hard print form at least someone and I could not find it on the Medicare.gov site though I am sure it is there. I knew I saw someplace in print High G you are going to pay the first 20% of Medicare Part B approved cost. Not billed cost. The difference is HUGE as most know. However I wanted to see that in print someplace regarding Part B without a supplement plan and they answered the same. If no supplement plans you would be responsible for 20% of the approved cost of what Medicare pays. NOT the billed cost.