Can We Talk Medicare

I went with traditional Medicare plus a supplement and Part D drug plan. If you go this route, look at Plan N as the Plan G premiums are starting to go up and will do so significantly as Plan F is no longer available. This will give you much better coverage than an Advantage plan, but comes with a larger premium. Another advantage is that you have no network limitations and do not need a referral to see a specialist. Go anywhere and see any provider/hospital. You will qualify for guaranteed issue if you elect this as you turn 65. Fail to elect properly and the insurance company will medically underwrite you and your PCa could prevent you from getting a supplement plan. With traditional Medicare you will also need a Plan D prescription plan and most cost from $5.00 a month to as much as $100 a month depending on the area and what you need.

If you opt out of Medicare and choose an Advantage Plan, you will pay little or no premium, but you will face significantly higher out of pocket expenses and deal with restrictive networks and likely need specific referrals to specialists and providers not in your network, potentially at a higher cost. Every state has different coverages. For instance, my mother-in-law is moving from Florida to Georgia. Florida has the best Advantage plans in the country. They are very popular. Her out of pocket is $3,400 per year. The best she can do in Georgia is $7,500 per year. With an Advantage plan, the prescription drugs coverage is included but with a wide variety of deductibles, copays and formularies that will vary by plan, company and area.

Also if you get an advantage plan there will only be a few times you can get into traditional Medicare with a Supplement without medically qualifying. First is within the first year you can change your mind. Otherwise, it is only when your insurance company stops selling the advantage plan you have or when you move to a different Medicare servicing region (there are 54 of them). In those two instances you can go back into traditional Medicare and get a supplement without medical underwriting. The guarantee issue plan is now Plan G, so you won’t have choices among the other plans like N.

So, if you are starting with an Advantage Plan, figure you will always be on an Advantage Plan as with your PCa and other conditions you now have or will develop with aging, the Supplement route will likely be unavailable. If however, you start with the traditional Medicare and a supplement, then you can change to an Advantage plan during the yearly election periods in the October-January time frame.

I strongly advise you to find a qualified insurance agent that specializes in Medicare coverage and get their service and advice. You will not pay more for doing so. All of the companies must provide their plans through licensed agents and organizations like AARP are licensed agents and receive the same commission as an individual does.

My initial thoughts followed that line of thought until my wife was quoted what appears to be a very good advantage plan in Ohio and I am tempted to go that route. It includes both Cleveland Clinic and Ohio State University Hospital, referrals not required. $35 specialists, $3400 annual output of pocket, 33% on high tier meds. My major concern is step treatments / medications or denials for imaging.

I just completed the medical underwriting to change from Medicare supplement plan G to N and was approved. In an extended session with the underwriter he questioned in detail my PCa history. He concluded that I was past any problems from the insurance perspective and that the long string of undetectable PSA tests and no treatments in the last two years qualified me for the change in plan that will significantly reduce my premium.

For others on Medicare supplement F or G plans, I strongly suggest you attempt to make a similar change. Due to the enactment of the MACRA legislation in 2020, Medicare insurance experts expect F and G plans to have disproportionately higher premium increases in the future. This has already been the experience in 2021.

I believe it is best to start with your current company and inquire as to a change. If they can’t accommodate the change then seek out an agent that is experienced with making such changes. These are medically underwritten and not everyone will qualify for a change. However, you are protected from any adverse changes in your current coverage if you don’t qualify for the change. No worries there, just don’t cancel anything until you have confirmation of the improved change.

JNF, thanks for the education and great information! I'll be 65 next January so I'll be deciding on something in as early as September. My biggest concern is the cost of drugs, should things turn bad.

Duck - It really depends on your attitude about medical insurance and what you can afford. Do you like finding network providers, paying co-pays, paying medical bills, reviewing explanation of benefits, and fighting with insurance companies? I don’t after a lifetime of doing that and can afford the “cover everything” Medicare supplement and a good Part D drug plan (25% on expensive drugs) and covers most pharmacies.

I had hernia surgery in December and have paid $0. Have not even looked at any paperwork. This is worth something to me and I don’t care if I have an emergency in another state as it is all the same to me.

On the other hand, it costs $300/month/person to have this coverage in MN in 2021. Many people have trouble with this type of expense level and get bombarded with TV commercials about free Medicare, etc. so you have to take a look at them. In most cases, you will find the annual financial exposure to be high and limited doctor networks. In the MN, most of the good Advantage plan include Mayo Clinic in their networks but they are not free and have co-pays and out of pocket maximums to contend with. I have reviewed them at length and their pricing can be really good for pretty decent networks, etc. as pricing has gotten more competitive.

Different strokes for different folks. I have a large deductible on my home insurance since that makes sense to me but medical has gotten more personal in recent years.

Steve n Dallas said, " With Joe Namath telling us to "Get what we DESERVE."
And, don't forget, you might be eligible for the "Give back benefit," says Joe.
My wife and I watch old Westerns on the INSP channel, and I'm so tired of hearing Joe Namath's voice that I thank God every day for the invention of the DVR.
But, it's not just Namath. It's also Chris Berman for CarShield and the lady saying, "It's like having a "s(l)uit" of armor for your car, or the guy saying, "A transmission AND a motor, who does that?"
Or, the insurance company with the famous "$9.95 plan."
Or, the walk-in tub.
Or, the "Up Walker."

The same four or five commercials, over and over, all aimed somewhat misleadingly at senior citizens.

** With Joe Namath telling us to "Get what we DESERVE.
It's also Chris Berman for CarShield. **

I sometimes wonder how these guys spent their money to the point that they are in these cheesy and embarrassing commercials, hawking dubious products. Maybe they were married and divorced too many times.

It's good to know that I'm not the only one watching old shows on INSP.

First and foremost, I suggest that you contact a good honest insurance agent who specializes in Medicare coverage so he or she can help you analyze the plan that is best suited to your needs.

I went with Medicare Advantage. Why? I have VA healthcare as a backup is one reason. Plus, I save about $3000 a year by not paying the extra premiums for the supplement and Part D - the drug plan - that would be needed.

More reasons? My Advantage plan is excellent. A large network of doctors. $0 premium. $0 co-pay for all routine services (doctors, labs, MRI's, podiatry, etc..) and hospitalization. ER coverage and hospitalization (if required) when traveling out of state or out of country. Dental plan. Eye exams and glasses. They throw in about $100 worth the OTC products for free every quarter.

Now, if I didn't have VA coverage and there was a decent chance my Pca could go into metastasis - I would probably go with the supplement - since the specialized drug treatments with the supplement (depending on which drug plan one selects) is generally much better than the formulary offered by the Advantage plans - which charge co-insurance (maybe 20%-30%) for specialized drugs. Not sure what the Medicare supplement drug plans charge for theirs.

But you are smart for inquiring about Medicare plans well in advance of your enrollment date so you can carefully research and analyze your best options. Insurance agents offer free advice. Use their expertise too.

Good luck.

Update, my wife was also able to get her plan updated to N and her new premium is $94 per month. Total out of pocket for a year will not exceed $1,400 for her. We are very happy about theses changes. This will reduce our monthly premiums by about $125 and hardly increase our exposure. Importantly it gets us out of the plan that is expected to have the greatest premium increases in the future.

Mel, as Mumbo stated, it is all about the plan you are in. If yours is through your former employer, it will likely have much better coverage than what you can by as an individual.

My message is to shop and understand plans, understand the true differences in plans, understand that traditional Medicare with a supplement will be the most comprehensive coverage and provide the insured the greatest control over their healthcare. Supplement plans are exactly the same coverage regardless of the state or company. The only difference will be premium. Understand that Advantage plans differ greatly by state and company and are usually far more complicated to understand and compare. Some can be great and some can really suck. Understand that what Broadway Joe is spouting is basically rubbish, but he is convincing to many people.

Advantage plans may have benefits like limited dental and vision that can add value, but also often have greater co-pays, deductibles and network limitations. For example, the best Advantage plan we can get for my 92 year old mother-in-law in Georgia will have a $6,400 out of pocket expense in network. Double that out of network. As an example of how some co-pays work, if she is admitted to the hospital she pays $290 per day of the first 7 days of a stay. So you can see our exposure if she has a few hospital admissions of just a few days each. Since she is moving she does have a guaranteed ability to return to Medicare and buy a supplement. But under the law she would have plan F and at the highest risk level making the premium over $500 per month. So for her we take the $0 premium Advantage plan and hope she stays out of the hospital. On the bright side she will get a Silver Sneakers membership at a fitness center. The only way that will get used is if I carry her ID and act a little different.

Things I noticed in this discussion --

1) Someone mentioned that once you get an Advantage Plan you have to stay on it. Untrue, you can change plans for a 6-8 week period every fall.

2) Some are saying if you get an Advantage Plan you "have to use their doctors". Advantage plans come in all flavors, including PPO so you can choose your Drs without any issues. Sometimes they will still talk about In-Network and Out-of-Network in the plan summaries, but if you look at the details you'll see the same coverage for both In and Out of Network services.

3) It's been mentioned that some plans vary by state or company -- I have experience with a Humana PPO and rates (not sure about coverage) changes from county to county here in Georgia.

4) Before I went with an Advantage Plan, I ran into multiple Drs who "don't take Medicare" -- so don't be fooled and think if you get Medicare you get a huge gamete of Drs to choose from -- there are numerous Drs who won't treat you!

Read the fine print, use the comparison tools on the SS or Medicare web pages, and have in mind what you expect your needs for services and medications will be in the next 2-3 years. Good luck!

compiler said...
JNF, et. al:

Your comments leave me confused. As a retired Michigan educator, I opted for our health plan that I've had for probably 15 years. It is a Medicare Advantage Plan via BCBSM. It is a PPO (not an HMO). I have been to Mayo and Prostate Oncology Associates and other out-of-state doctors, including Cleveland Clinic and UCLA. Coverage has always been great. I had a severe spinal injury in 2017. I was hospitalized at Scripps for weeks, much of it in intensive care, and then spent 7 weeks in rehab in L.A. before being well enough to fly home. My bills: 1 million bucks. My share was under $500. One very helpful feature is the annual OOP max. I have an $800 deductible and $1700 OOP annual max. That is a savior when major expenses hit. Oh, and they covered past PSMA scans (when it was still considered experimental). My RP was $64K and my SRT was also $64K. Again, my cost for both combined was minuscule.

Folks, what am I missing?

Mel

Mel, I f you check your retirement plan website your pension pays $168 a month and you pay $42.

Mine here in Ohio has opted on a retiree medical account to defer Medicare costs.

Post Edited (Duck2) : 4/22/2021 5:07:34 PM (GMT-6)

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