Medicare Insurance Plans

Beware of the Medicare advantage plans. Many docs do not want to be in-network on those plans and therefore you will find providers limited. Most PC docs are happy with traditional Medicare with a supplement plan. Also the advantage plans make the docs jump through many hoops to get treatment plans approved, whereas with traditional Medicare, the docs that see older patients know exactly what will be covered.

One advantage that I have seen with traditional Medicare, is that if a service is not to be covered, they must put that on a form and have you sign it. So there are no nasty not-covered or out-of-network surprises. Its difficult to be blindsided with Medicare. Since PC is mostly an over 65 age disease, most PC treatment is Medicare friendly. There are some notable exceptions:
mayoclinic.org/patient-visitor-guide/minnesota/billing-insurance/faq/medicare-faq

Like they say when you sign up "Welcome to Medicare!"

I hope others will comment as my insurance will change on Sept. 1st. I am going from a "cadillac" plan back to the State of Michigan Teacher's retirement plan. For me it is Medicare A/B plus Medicare Advantage (BCBSM).

We also get dental and vision.

From what I have read, a MediCare Advantage Plan means traditional MediCare plus some things are better. I pay for Parts A and B and an additional amount for the Advantage plan. So, I'm confused when someone here posts that it's worse.

Also, I thought that with the BCBSM (the M means of Michigan), that there is a very WIDE assortment of medicos in the plan nationwide. I THOUGHT that, say, if a doctor was in BCBS of say Maryland, then that doctor would be in my Plan (ie: the Blues).

Can someone enlighten me?

I've read through a lot of materials, but it is still vague.

Mel

If you're in a big city with big-time cancer experts right there and in-network with a good Advantage plan, then you're okay. If not, then you will have to pay huge amounts to any experts you want to see who are out of network.

Here's our negative experience with a Medicare Advantage plan.

My husband switched to regular Medicare and a very good gap plan and drug plan after being in a Medicare Advantage plan for five years. (He was very healthy during that time.) Why did he switch? We had a horrendous time with our Medicare Advantage Plan, which was considered a very good one. We ran into some real headaches and expenses while we were traveling. An out-of-town physican told my husband to get a CT scan to determine the cause of increasing abdominal distress. Initially this was not an emergency, so we paid out of pocket at an imagining center plus paid two doctor visits out of pocket. Our Advantage plan said it would take two weeks to get approval for a CT. Well, the CT showed he had a ruptured appendix! He spent eight days in the hospital, and I spent eight days and much more fighting with the insurer over various things to make sure it fell under the "emergency" provision, which Advantage plans are supposed to pay. It's been a nightmare.

Fast forward. My husband was diagnosed in October, 2014 with Gleason 9 prostate cancer. We live in a university town in Massachusetts far away from Boston or New York. My husband's urologist said our options were limited to our area. He suggested to pay out of pocket for Dana Farber or Sloan Kettering for second opinions, or just get regular Medicare and a good gap plan and a good drug plan so we could go anywhere. Luckily, because we are in Massachusetts, my husband was able to change to regular Medicare+gap+drug without penalty. In most other states if you go from an Advantage plan to regular Medicare+gap+drug plan six months after you sign up for Medicare, rates the insurance company can charge for the gap plan are not regulated in the future. We had absolutely no problem getting our new insurance accepted at Dana Farber and Sloan Kettering for their consultations. At DF, the intake person told us the Advantage plan we'd had was horrible. (We had the "best" level.) Every doctor we've seen anywhere has accepted regular Medicare+gap+drug plans.

My suggestion, based on our experience, is that regular Medicare plus the best gap plan and drug plan you can afford will give you the most flexibility. Do find out if the doctors you see accept Medicare. Unlike Fairwind above, all the local and big cancer doctors we've visited prefer Medicare and a good gap/drug policy over the Advantage plans that give them a hard time. If you go the regular Medicare/gap/drug route at the get go, the gap plan will always be subject to some regulation in terms of premiums increases. But if you make the switch after the first six months after reaching Medicare age, your insurance company's gap plan premium may be higher basically for the whole time you have it depending on what state you're in. We've not had a single problem getting any of our docs to accept Medicare. As I said, Dana Farber prefers regular Medicare, plus gap, plus drug plan over Advantage plans. Your mileage may vary. Good luck with your treatments.

I found this NY Times article informative about the pros and cons of different Medicare options. In particular, read the comments section to see what patients' real-life experiences are.

http://www.nytimes.com/2014/10/04/your-money/beware-of-shifting-options-within-medicare-plans.

Maybe it depends on where you reside. I live in Florida and have had Medicare Advantage for years (AARP United). My experience mirrors that of Fairwind. It's a PPO but most doctors that I want to see are included as in network with a small deductible. If I choose an out-of-network doctor, the visit is covered but the deductible is slightly higher. The plan also includes drug coverage which supplemental plans do not. The plan has an out of pocket maximum for the year for either in network or out of network payments. So, in the event of a worst case scenario, e.g. major expenses out of network, I still know what my maximum out of pocket costs will be.

Last year I did a comparison of what my expenses would have been over the past several years with my Medicare Advantage Plan vs. a very good supplemental plan + a drug plan. My MA plans costs me nothing; I just pay the deductibles or minimums when I use it. Overall, despite some major medical use of my plan (e.g. wife's total knee replacement), I am MANY thousands of dollars better off for choosing my Medicare Advantage Plan vs. a supplemental plan.

I would recommend that you explore the doctors available with the MA plans you may be considering and see if they are satisfactory to you. Also, look at the annual out of pocket maximum. Then assess your health. Like most things there is a cost-benefit trade off. If you want a guaranteed annual cost that may be pricey but allows you total flexibility then go with supplemental plans. If you can afford to pay an annual max in a worst case situation, then a MA plan is likely to be a better financial choice.

Jim

Tud:

Your post is more encouraging.

Yes, I have already chosen the BCBSM Advantage Plan.

I did this because it was not limited to certain counties and it did have a maximum OOP.

Frankly, I have always felt that insurance should be designed to prevent financial catastrophes.

This does it, as far as I can tell.

Very uncertain as to what the reality will be.

All of my Michigan doctors (sadly, there are actually quite a few) seem to be in the Plan. Dr. Lam is not in network, but I don't anticipate huge costs there. The huge costs will occur as my PC worsens and I have to get on the more expensive nostrums. Hopefully, that won't be for awhile

Mel

Medical cost and scripts will fall into two different arenas for the most part.

January 1st of this year I was forced to make a change. I was already on Medicare and my AT&T policy before Medicare had become my secondary. It was wonderful and very cheap.

AT&T decided to drop that for retirees. A friend put me in touch with a guy that does this stuff for a living. We had a couple of very long conversations about where I am with Pca and the drugs I take and might have to take.

His recommendation to me was a Plan F policy. Yes the cost is a little higher ($199 a month through AARP/United Healthcare), but I have not paid anything out of pocket this year for anything at all other than scripts which is a different policy. The Plan F picks up everything that Medicare doesn't, including the Medicare co-pays. There is no deductible and there is no copays.

The script plan costs me $23 bucks a month and I have a $300 up front out of pocket. Just like every other script plan out there, if I go on some of the more costly and heavier drugs I will go into and out of the donut hole. That is sadly just the way it is for us old farts.

So far so good and this situation is working for me.

I can pick and choose my own docs anywhere in the country as long as they take Medicare. And when you are dealing with Cancer there are few if any of the bigger Medical Systems that won't accept Medicare.

Someone else mentioned that your medical facility or doc must inform you of anything they are planning to do and whether or not Medicare will cover it. On two different occasions this year I have had scans that were not approved and I had not been informed before hand. Before I even received a bill from the facility, I received a letter from Medicare stating that because they were not covered and I had not been informed, I owed nothing and the facility would be in violation of the law if they tried to collect. I have never received a bill for any of these things.

It is certainly a confusing jungle out there, so keep researching and asking questions before you decide on a course of action. Once you make a decision you are stuck with it until the next sign-up period.

Hope some of this helps,

Sonny

Like Sonny I chose the Medicare Supplement Plan "F" since it pays all copays and all deductibles in exhange for a fixed higher premium.

Your choice might vary depending if you are a Gleason 9 like me and only a matter of time before you incur the higher procedures or if you are a Gleason 6 or 7 already treated and not expecting any more treatments except during recurrence.

In latter instance Medicare Advantage which is sometimes free depending on your zip code may work fine for you as the sum of your deductibles and copays may be less than the higher Plan F premiums.

Regardless of which Medicare supplement you chose (Plan F and Plan N are the best) you will also need a Plan D Drug coverage.

As Mrs WorryWart alluded there is a veryhelpful website

www.medicare.gov/part-d/index.html

where you input your expected drug usage and your two favorite pharmacies and it answers with the best plan D coverage for you.

Though it is decreasing each year for the next several years until it is phased out, the so-called donut hole can be expensive if you are on pills like Zytiga or Xtandi until you reach a maximum out of pocket for that calendar year.

/www.medicare.gov/Pubs/pdf/11493.pdf

see chart on page 6 of link site. "Over the next several years, you pay less in the coverage gap until it’s closed by 2020.

By 2020, you’ll pay only 25% for covered brand-name and generic drugs during the
gap—the same percentage you pay from the time you meet the deductible (if your plan has one) until you reach the out-of-pocket spending limit (up to $4,700 in 2015)"

If you are retired with combined income less than $60K, there are foundations like Patient Access Foundation and Patient Access Network that pay the deductible that would have resulted in the donut hole situation.

But if you have a lot of rental income or income from trusts that donut hole can hurt for a couple of months until you reach the out of pocket maximum.

Anything doctor adminsitered or hospital rather than self administered or pill form is covered fully by the Medicare supplement Plan F under Medicare coverages A & B that have a low deductible, about $147 if I recall.

I figure that between Lupron since 3-28-13, Xgeva/Prolia since 8-1-13, Provenge, SBRT, Zytiga for 9 months. countless scans and PSA tests, that Meidcare and AARP have paid out about half a million in claim costs and like Sonny my only cost was the premium.

I did have to pay $2500 out of pocket for the C-11 Acetate test not covered by insurance and the only test ever denied was a bone density re-scan too soon after the prior one.

Post Edited (Nomar Schottzenkeister) : 6/18/2015 5:46:30 PM (GMT-6)

First lesson I learned, after being put on Medicare as my primary as the result of being fully disabled via Social Security. Seek out an insurance agency that only specializes in Medicare Supplement policies, as their only business. Wish someone had told me first. A good agent will look at your med list, your ailments, and fit you to the best provider in the state you live in.

I have been on Medicare now for over 3 years. I have had no problems. I see the doctors I want to see. I have never had any test or procedure denied me. In fact, I get treated better under Medicare than when I was under BC/BS in the past. BC was getting touchy with all my issues toward the end.

The first year, on my own, went with the BC/BS Medicare plan. Big mistake, they kept upping my more expensive meds, never knew from month to month what they would cost me, etc.

Second year, found out, that due to excessive customer complaints in SC, BC/BS could not renew any of their Medicare policies. So I was advised to via AARP/United Health Care. It's been a blessing every since. My drug costs are down to almost nothing. And I don't see a single doctor that asks for any kind of co-pay. Just this week, my new dermatologist took the Medicare as is, and said no co-pay was needed.

I am fortunate (strange use of the word) that I am also 100% VA disabled. The VA takes care of all my other medical expenses, including full dental and vision. I say "fortunate", because I have to live with this damaged body, so depends how one looks at it.

So between Medicare, the AARP plan, and the VA, I really don't have any concerns about health care.

For all the negatives one hears about Medicare, all I can say, I have never seen any of them. I am well treated by all my doctors and specialists. And they never talk about or hammer me for money, that's refreshing in itself.

I realize that on this subject, it really depends on where one lives for starters.

Well, just for the heck of it, I put in Zytigia and Xtandi (RE: that .gov site).

If I was taking both of those (hey, just a hypothetical), even with the BCBSM Advantage Plan, it would still cost me about $15900 per year. Pretty darn expensive. Also, there are restrictions in that one needs prior approval.

Can I assume that would be routinely obtained, assuming you are using it at the "proper" time, on-label?

Am I missing anything?

(I might add, almost all of the plans come out the same -- I think there might have been one or two MUCH less expensive. Do I have the opportunity to switch at some point?)

Mel

Donut holes are bad for PC patients

Mel

Jim:

That sounds much better. Am I doing something wrong? I went to that .gov site and entered in BOTH drugs. It then compares plans and BCBS had that high price.

How could this be?

Mel

I understand. I'm trying to figure out the disparity between those results and what I found on the .gov site.

I cannot access the BCBSM portal as I need my subscriber number. I'll be getting that in August, probably

Mel