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Phil's Blog

The Good, The Bad & The Ugly

29 December 2021

How to survive buying a Medicare Advantage Plan as my primary plan.

I am going to give you several important points that are essential to you to make your plan work.

           1.    If you have any prescription drugs, make sure that all are going to be covered by the plan you are considering and that you know the deductible and co-pay totals for o the entire year. You need to know what your meds are going to cost you.

              2.    Check to make sure that the clinic where your Dr. practices and the hospital that you would use are both “in network".

If you sign up for an HMO make plans to stay close to your home so that if you need a Dr. or need to go to the hospital and are admitted, you will know that you are going to be treated by an “in network" Dr. and hospital.  You never want to go to a hospital that is “out of network”.  I am seeing a 40% co-pay that will push you to your out of network maximum very quickly.

You are going to see me keep repeating “in network”.  You must be very careful to always be treated by a network provider.

We are seeing too many individuals that are not able to pay the stack of accumulated bills or having to find an attorney to file Bankruptcy for them.  Yes, I have had individuals tell me that exact thing happened to them.  I feel sorry for them because all they heard “its free”.    Yes, some of the benefits in the plan are free but what can get you in trouble is the “out of network” charges.  If you are treated by a local ”in network” hospital then transported to a more advanced hospital for treatment that may save your life you do not have a say in the destination.  They do not pay any attention as to the classification, network or not, of that hospital.

All of the above is for PPO plans.  If you chose an HMO you had better live in a metro location where there are several hospitals and Doctors “in-network”.  I describe HMO plan as a close collection of providers that will give you excellent care, but you do not want to go outside of their network.  You probably will not have coverage if you can even get treated.

All of the above is your responsibility.  Most of the time the individual you interacted with to set up your plan is not available for a review.  They are gone trying to sell someone else a plan.  We pride ourselves on the service after you become a client. 

Now that we have gone over some of the rules for your use of a Medicare Advantage Plan we need to discuss how to set yourself up to financially to survive the plan.

First, take a look at your plan and determine the maximum out of pocket that you are responsible for in a “bad” year.  Take that sum and deposit it in a separate account from which you can pay all co-pays, deductibles, and noncovered charges for Dr and hospital.  Do not pay any drug charges from this account.  That deposit will range from $7500 to $11,500 Yes, yes that is a lot of money,

Now, when it comes to October 15 of the following year you have to start over, check your current drugs and medical providers.  It is up to you to do the look ups because the person that signed you up is not around.  Do not pay any attention to “its free” because that will get you in trouble.  Again, take a look at the “out of network” maximum and be ready to bring your cash account up to that maximum by January 1 when your new plan will began.

Are you sure that an Advantage Plan is right for you?


Phil Mattox, CSA
Certified Senior Advisor