Seeking Medicare/Medigap advice for my situation

I am new to this Medicare Ins. and will need to make some decisions this open enrollment period. I am scheduling an appointment with a SHIP adviser (Called HICAP in TX) in the near future and wanted to ask for some insights.

Bottom line, I had an undetectable PSA after RP until July 2014. It is now detectable at .034, although very low. So, SRT and/or HT may have to happen in 2015. I also should have some dental work done that I have been neglecting.

I just want to be somewhat prepared for my meeting with the adviser and would like to ask if anyone has any advice as to what I should plan for 2015 as far what covers what, treatment wise that I may need to plan on? I don't have any idea how to figure out what drug coverage I may need. It is my understanding that if the drug is administered in the DR.s office, it may be covered as a Dr.s visit. But again, I have no idea what drugs I may need along with these treatments and their cost.

Thanks, all input/experience would be appreciated.

Startech,

Here's the best place to compare plans available for any local area within U.S.

/www.medicare.gov/find-a-plan/questions/home.aspx

Plan availability and costs can vary widely from one state to another. You'll need to look at both Medicare Supplement plans ("Medigap") which fill the financial hole not covered by standard Medicare (e.g., 20% co-pays) and also look at Medicare Advantage plans, which are offered by private insurers who are subsidized by Medicare. Most Medigap plans do not provide drug coverage, which means you would also need to buy a separate Medicare pharmacy plan. You may find Medicare Advantage plans that are less expensive and more inclusive (e.g., include pharmacy coverage) than typical Medigap plans. In my case I'm on a Medicare Advantage plan that has a monthly fee of $49 and maximum annual out-of-pocket of $3,400.

Be sure to compare closely the costs for copays and, especially, maximum out-of-pocket costs to you per year. You will probably see some Medicare Advantage plans listed that show a $0 monthly premium. These plans will almost certainly have much higher copays and much higher out-of-pocket maximums than Medicare Advantage or Medicare Supplement plans that have a higher monthly premium. The medicare site I've listed above attempts to average out what each plan would cost a typical person after factoring in monthly premium, copays, hospital costs, medications, etc.

Also be sure to check if a plan is accepted by your doctors before signing up. I know that some of the "free" Medicare Advantage plans offered in my area are not accepted by any of my doctors -- not by Primary Care, Uro, R.O., Dermatologist.

Also check if a plan offers out-of-network coverage and if so, is there a different (higher) out-of-pocket maximum cost to you for out-of-network treatment. This is especially important if you want to go to a specialist (e.g., radiation oncologist, medical oncologist) who you believe has skills that may not be available in your local medical network.

At the time I had my SRT, I was still employed and was covered by the best plan my employer offered. The plan had a maximum annual out-of-pocket limit of about $3,500 and I knew I was heading into SRT in the coming January (2010). Because I was still working I was able to set aside the $3,500 as a tax free withholding from the coming year's paychecks, which took out a bit of the sting.

Other than that out-of-pocket payment requirement, virtually everything else was covered in full other than co-pays for doctor visits ($20 or so each). My R.O. put me on Casodex for 3 months during treatment, which was covered (the generic version) by my insurance for a nominal co-pay -- maybe $10 or so.

Now that I'm retired and having just reviewed my own medicare insurance options for the coming year, I can see that my Blue Cross Medicare Advantage plan would give me pretty much the same coverage I had under my employer's plan -- I'd have to pay the maximum out-of-pocket of $3,400 and everything else would be covered other than co-pays for doctor visits.

FWIW, when I had my SRT in 2010 the hospital billed my insurer $2,256 for each of the (36?) treatments and settled for a payment of $1,714 per treatment from the insurer. So after the first two treatments, I'd hit my insurer's maximum annual out-of-pocket and they covered the rest with no problem.

Jim

I wasn't on Lupron, so maybe someone else can chime on on how that is covered under their medicare plan.

super max said...

I think you want to maintain maximum flexibility regarding what doctors you can see and which treatments you can pursue. That argues for traditional Medicare and against any Advantage (HMO) program in my opinion. Supplement Plan F seems to be the most comprehensive.

I absolutely agree about avoiding a Medicare Advantage HMO plan.

But in some areas there are also Medicare Advantage PPO plans that offer out-of-network coverage. In my case my Medicare Advantage PPO plan allows use of out-of-network doctors and facilities with the same out-of-pocket maximum for either in- or out-of-network services.

However some plans will charge a higher out-of-pocket maximum for out-of-network -- so be sure to read the fine print. And don't assume that more expensive is necessarily better across all aspects of coverage. For example I'm on a "value" plan. The same insurer's more expensive "plus" plan (at three times the monthly premium) would leave me responsible for paying a higher out-of-pocket maximum if I used out-of-network services. Go figure!

In my case, my Medicare Advantage PPO plan is $49 per month vs. a couple of hundred per month if I chose traditional Medicare, plus a Plan F, plus a Medicare Pharmacy plan. And I can multiply this by 2 when I add in my wife's coverage.

My advice would be to get the most comprehensive coverage through original medicare and a supplement Plan F. The potential issue with medicare advantage is that you have to stay in the network (with the exception of plans that allow out of network coverage at a higher co-pay.). Many doctors do not participate in Medicare Advantage plans and some Medicare Advantage plans are being discontinued. The other issue is that although you may be in network with a doctor or a surgeon, the doctor may send your lab work to a lab that is out of network and a hospital may use an anesthetist that is out of network. You have no control in those two examples. That being said, there are many people who are happy with their medicare advantage plans. If you are considering one, check with your doctors before enrolling to make sure they accept medicare advantage and to get their comments.

For a drug plan the best thing to do is to input your drugs that you think you will be on into medicare.gov and see which plans provide you the most coverage at the least annual cost. Some plans have deductibles of $320, some don't, some pay something while you are in the donut hole and some don't. There is also a wide range of premiums, and co-pays can vary depending on preferred pharmacies, mail-order, generic or brand name.

Drug plans can be easily changed every year. Supplement plans require a health questionnaire if you want to change during open enrollment, and acceptance by the new plan is not guaranteed.

I think you need to seek out a good independent Medicare Supplement insurance agent, one that only does this for a living. This is what I have done the past 3 years. She knows all my medical circumstances, and all my meds, etc., and she runs it through a computer systems, and it comes up with the best available plans based on all of the providers out there.

I just did that today. I was on Medicare Blue, and was happy with it, but Medicare canceled every single person on it in SC (not sure if it was other or all states), because of poor customer service the past 3 years running. So Medicare cut them off. And I had to have a new plan.

I got it all signed and settled today. Better plan, for less money, and all my drugs are still covered cheaply at the same CVS I have been using for nearly 18 years. My wife does all her meds at Wal-Mart, and I have seen first hand how many times they have screwed up things, so I don't trust them for myself.

But a good agent, can take all the work out of what can be a complicated decision process. Just my take. And it didn't cost me anything for the service.

David