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Politics and Political Issues Board / Re: ObamaCare is a complete FNG disaster
« Last post by Primemuscle on Today at 07:42:42 PM »What are your deductibles and co-pays.
Also what are your personal financial limits if you get a serious medical issue?
Are you covered if you go outside of your local area for treatment?
Does your plan require approval by the insurance carrier for procedures?
Medicare Advantage plays by the same rules as regular Medicare for the most part. If I could, I would provide you with a link to Regence's evidence of coverage pages but unfortunately, they are available only to people who have Regence Medicare Advantage. I have what is called the Classic plan. It has neither the lowest nor the greatest level of benefits in its array of plan options. So, I will cut and paste some of the information you asked about.
Medicare advantage Plans vary by location. Some are not available at all in rurual areas. Areas with the highest medical costs also have the highest premimums. co-pays, co-insurance, deductibles, and max out of pocket.
COPAYS
This is the flat amount you pay when visiting a provider or facility. Additional out-of-pocket costs may apply depending on your plan details and the type of services rendered. In some cases, copays apply only after satisfying your deductible.
Telehealth
You pay $0
Immunizations (preventive)
You pay $0
Primary care office visit
You pay $0
Specialist office visit
You pay $40
Urgent care visit
You pay $40
Emergency room visit
You pay $125 (waved if you are admitted to hospital)
Rehabilitative outpatient services
You pay $30
Outpatient substance use disorder treatment
You pay $25 (I believe there are some limitations)
Mental health office visit
You pay $25 (there is a limit on the number of visits)
COINSURANCE
This is the percentage of total costs you owe when your plan doesn’t cover 100% of services rendered. In some cases, coinsurance applies only after satisfying your deductible up to a maximum amount, this is called your out-of-pocket maximum.
Telehealth
You pay 0%
Immunizations (preventive)
You pay 0%
Primary care office visit
You pay 0%
Ambulatory surgery center (facility/professional)
You pay 20%
Hospital outpatient
You pay 20%
Some, but not all services require preauthorization. Note: I have yet to need a preauthorization to see a specialist.
You asked, “What are your personal financial limits if you get a serious medical issue?”
There is no lifetime benefit maximum for Medicare Advantage (part C). $14,000 is the most I pay out-of-pocket per year, for both in and out of network (out of area) coverage. After which Medicare pays 100%.
There is a maximum annual limit for my out-of-pocket costs.
Neither Medicare nor Medicare Advantage provide coverage when out of the country, with some exceptions.
You asked, “Are you covered if you go outside of your local area for treatment?”
You can go out of network for medical services, but the co-pays are higher. Neither Medicare nor Medicare Advantage provide coverage when out of the country, with some exceptions.
Vision, hearing and dental are each different in terms of what is or is not covered. For example, when I got new glasses this year the full price for them was $1,800 and I paid a little over $800. The co-pay for hearing aids is up to $1,000 per hearing aid through TruHearing. Otherwise, they are not covered. Annual hearing exams are covered. Preventative dental care, which includes cleaning and x-rays, is covered at 100%. Restorative work, such as fillings and crowns is covered at 50%.d
Prescription drugs are covered at several different tiers. Co-pays also vary depending on whether you get your prescription(s) filled at a preferred (in-network) pharmacy or out-of-network pharmacy. I use an in-network but non-preferred pharmacy. They usually come close to the same out of pocket I would pay at a preferred pharmacy. There is a deductible which must be met prior to just paying co-pays
This should give you a pretty good idea of what a Medicare Advantage plan covers. Like any health insurance coverage, it is imperative you read all the details of the plan, so you know in advance what is covered and at what rate. Whether you have private health insurance, employer provided health insurance, Medicare, Medicaid, or Tri-Care (Veterans), study your evidence of coverage and learn how to work within the system/plan (not work the system). It is better to be prepared for your costs and the level of coverage rather than to be surprised about it after the fact, only to find out you could have used a different option and saved yourself money and any hassle.

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