Every year during the AEP, I run into a few folks who decide keeping straight Medicare as their only medical coverage is their best option. They will keep their Part A and B and then pick up a standalone prescription drug plan to meet their Part D requirements. It must be working for them as they clearly have not felt enough "pain" to make a move into an alternative form of coverage like Med Supplement or MAPD.
This photo really got my dander up because it is beyond misleading and I know a few of my seniors saw prompting phone calls and explanations. So let's go into this and demonstrate why it is false and misleading.
Medicare Part A has a deductible of $1,632 for 2024 and an 80/20 coinsurance with no maximum out of pocket limit (MOOP)
Medicare Part B has a monthly premium of $174.70, a deductible of $240 and an 80/20 coinsurance with no maximum out of pocket limit.
Medicare Part D has a premium dependent on the plan you choose which can be as low as $0 up to $100. For calculation of establishing the Part D Late Enrollment Penalty, the national average for a Part D plan is $34.
Now that we have some parameters, let's run a scenario to show costs and expenses.
Patient A wakes up in the morning and isn't feeling well and decides to go to the doctor. Since it is the first visit of the year, Patient A is responsible for the first $240 in costs for that visit but the visit only cost $100. The doctor sees that Patient A isn't doing well and sends them to a specialist where the specialist will eat up the rest of the deductible that the primary didn't hit. The bill for the specialist was $160 based on the remaining deductible and 20% due. The specialist decides that Patient A needs to be hospitalized for tests and observation. Patient A is now responsible for the first $1,632 of inpatient charges and then 20% of costs thereafter with no MOOP providing a stopgap. The bill at the end of the 3 day inpatient stay was $100,000. So after deductible and coinsurance are added up, it is $19,673. So let's add it all up to see the exposure.
Part B Premium - $174.70
Part B Deductible - $240
Specialist Coinsurance - $160
Hospital Coinsurance and Deductible - $19,673
Total Amount Due - $20,247.70
So now, let's run that same scenario but factor in the Medicare Advantage Prescription Drug Plan.
Patient A has a PPO MAPD with a zero monthly premium from We Don't Suck Insurance Company.
The plan has a $0 copay for PCP, $30 for the Specialist and a $355 per day for the first 5 days hospital copayment. Because it is a MAPD plan, the prescription drug plan comes as part of the $0 premium plan.
Lets run the numbers
Patient A wakes up in the morning and isn't feeling well and decides to go to the doctor. Since it is the first visit of the year, Patient A is responsible for $0. The doctor sees that Patient A isn't doing well and sends them to a specialist where the specialist will eat up the rest of the deductible that the primary didn't hit. The bill for the specialist was $30. The specialist decides that Patient A needs to be hospitalized for tests and observation. Patient A is now responsible for $355 a day for the first 5 days of admission. The bill at the end of the 3 day inpatient stay was $100,000. So after deductible and coinsurance are added up, it is $19,673. So let's add it all up to see the exposure.
Part B Premium - $174.70
Part B Deductible - $0
Primary Care Physician Copay - $0
Specialist Copay - $30
Hospital Coinsurance and Deductible - $1065
Total Amount Due - $1,269.70
That is a huge difference. Now, the folks on straight Medicare will talk about how they can see whoever they want whenever they want. That is true, no doubt.
The problem with that thinking is the MAPD member with a PPO plan can see whoever they want, whenever they want with no referrals. Now of course there are limits to that primarily that the provider has to accept Medicare assignment but that would be true for the straight Medicare consumer as well.
The meme that caused this blogpost is old thinking. Yes, 20 years ago when MAPD just had HMO and maybe a POS (Point of Service) plan there may have been network and accessibility issues but companies like Aetna and Braven have figured these issues out and now issue quality plans that provide a rich schedule of benefits with large provider networks and robust formularies for their PDP plans.
Going straight Medicare when your service area has a quality MAPD plan may not be your best play. If you are in New Jersey or Virginia, drop me a message and let me show you how you may be able to keep money in your pocket while not sacrificing coverage benefits.
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