Medicare questions for the well informed

Well, here's the situation gang. I'm on S.S. disability and have pretty darn good insurance. I didn't want Medicare because of my insurance. However it seems the government, in its ultimate wisdom has decided to force Medicare on me. According to the literature that came, I have to take part A hospitalization but, I can opt out of part B.

Did anyone here opt out of part B because they had good insurance (K.P.) through work?
Did anyone get forced out of their private/spouses work coverage once Medicare was thrust upon thee?
Does it take anything special to keep your insurance and opt out of part B?

Or, if you kept part B, what kind of luck did you have with advantage plans? I looked today and most plans had estimate out of pocket from $6,000.00 for just prescription coverage all the way to 28,000.00 for prescription and medical.

Any help or words of wisdom would be greatly appreciated by Kristina and I.

Paul

Hey Palanon,

I am questing that when you go on Medicare your wife's policy will become a secondary payer (Medicare will be the primary payer).

When I went on Medicare, Tricare For Life became the secondary payer. Between Medicare and Tricafe For Life, I have paid nothing ... no co-pays, deductibles, etc. etc...... best coverage I have ever had.

I would recommend you check to see if your wife's coverage will become a secondary payer.

Good luck!

You are not being forced to do anything. You have now qualified for Medicare at a younger age than the normal age 65 due to your Social Security disability status. This has been the law for decades and can be to your advantage. With Medicare you have a variety of choices to make. You have to decide which combinations of coverage will serve you best. The Medicare website is very good at providing you the information to make a good decision. You can choose to stay on your wife's coverage if that is best for you, or you can use Medicare and a supplement. Check with your wife's HR department and they will assist you. You are not the first to experience this so they can help guide you with your options.

Also keep in mind that you need to sign up for part D-drug coverage. If you do not sign up for part D in the beginning, you will be fined monthly for life.

Let's clarify some items for you.

If you have qualifying insurance, usually employer sponsored, you can opt out of B and D. Then at a later date when appropriate you can elect B and D without penalty.

Medicare will not force you top give up employer sponsored insurance and force you into B. It is entirely up to you and what you qualify for.

Please do not confuse B and Medicare Advantage. They are separate and you do not combine the two. If you take B you will either use coverage from an employer sponsored plan or an individual Medicare Supplement plan. You will also need D if you use B and an individual supplement.

Medicare Advantage is Medicare part C. You can elect Medicare Advantage and then your coverage will be entirely under the private insurance company you choose. You will not be in Medicare A, B or D and they will not pay any benefits. The benefits will come from the insurance company. The government will pay the premium as you would not be claiming against Medicare. You will pay the Medicare B premium. Some plans have no premium and some have premiums as high as $100 per month. You can choose managed care or PPO and you will have a specified provider network, unlike Medicare. It will include rx coverage so you don't use D. As you point Medicare Advantage usually has a much higher participation rate as high as $6,000 or so in order to keep your premium very low.

This can all be very confusing so you have to keep the various coverage options clear and distinct.

Medicare Part D pays 80% of drug costs..The remaining 20% is your copay. With drugs like Zytiga and Xtandi, their outrageous cost means that even the co-pays can be staggering. Then there is the "Donut Hole" a period where you pay 100% before Medicare kicks in again..If you are of modest means, there are "foundations" (set up by the drug companies themselves) that will pay all your co-pays. The PAN foundation is one of them..

These deductibles are what's driving me to opt out of part B. The deductibles, at this point, would bankrupt us. Copays are $5.00 - $20.00. No prescription is more than $10.00. One of my treatment was contrary to established protocols and the chemo drug wasn't formulary. Both were changed fairly quickly in my favor. Just my bills for surgery and extended home care for basically a year or more came to over a million dollars. Only had to pay the hospital for addition since KP didn't own it. So everything cost $1,000.00 for several admitions. HP meds and Chemo cost 10 bucks. I wouldn't mind something that allowed me to pick another onco or specialist if I needed to. Just not at 20% copay and 10-50% copays on drugs.

just need to know what the best thing to do is with Medicare. Does anyone have really good coverage without huge copays. Any really good company's and plans that are really eliminating these copay issues? A majority of the plans I looked at on the Medicare site didn't even have Lupron on their formulary. Someone must have found the magic bullet for Medicare, or at least as close as you could guess I would think. Just confused and didn't expect this dumped in our lap with under two weeks to figure it out. That's why I'm thinking of opting out of plan B.

palanon said...
didn't even have Lupron on their formulary.

Lupron is an injection administered at the clinic so it will not show up in a part D formulary. That should be covered under part B. Am I correct?

Correct about Lupron being under B not D, as it is administered by the provider. The rx drugs like zytiga and xtandi would be under D.

As for using B and a supplement, with Plan G you only pay the B deductible of $166.00 per year and plan F covers the deductible, but at a higher premium.

But, again, understand that you can opt out of B with out a later penalty by continuing on qualifying employer sponsored coverage. This works when one is working (I did it), and I have client's whose spouses have done it. To confirm go on the Medicare website and call Medicare. I have generally had very good experiences getting good reliable information and the website is very good.

Fairwind and Fraustman,

Thanks for the insight. My copay for Zytiga already stings when I fill it monthly and unfortunately with my current insurance, I cannot get the reduced price through Jannsen. Now that I will be switching over to Medicare my big fear is that I will not be able to afford it.

My wife is on Medicare A + private insurance, and I am going on this shortly. The reason is reaching 65 and Medicare eligibility while still working. Our private insurance requires that we go on Medicare A, because they don't want to pay for what Medicare will cover. There are also consequences for not enrolling in Medicare when eligible. Our private insurance coverage for doctor and drug costs is better than Medicare parts B and D, so we are not enrolling for that. Unless your private insurance has poor coverage, I suspect that your situation may be similar to ours.