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Posted 2/6/2020 3:18 AM (GMT 0)
Just trying to get an early start on "PC Financial Planning". Can anyone on Medicare with a BCBS or AARP/UH Supplemental Plan, and undergoing RT and ADT, give me a ballpark figure on what I might expect to have to cover. Guess i might have to start selling off some of my guitar collection. sad
Posted 2/6/2020 4:14 AM (GMT 0)
Assuming you have traditional Medigap, what is your plan? For example, F, G, etc? That dictates the specific coverage. That said, as long as your treatment is within Standard of Care--which is generally the case--your OOP is not likely nearly enough that you would need to sell your '58 Les Paul.
Posted 2/6/2020 1:17 PM (GMT 0)
manich, from my experience, only out of pocket is deductibles, so far. I've been through surgery, radiation and hormone therapy, nothing else out of pocket.
My coverage is traditional Medicare (not Medicare Advantage), and my supplement is a plan F medigap policy, which is a group policy (wife's retirement) with Emblem Health, it is called Senior Care. I believe that all plans F and G are the same, from company to company in terms of coverage. Plan F as i understand it is going away but the plan G's are very similar
Member JNF will likely chime in, he has been the resident expert on Medicare coverage.
Posted 2/6/2020 1:24 PM (GMT 0)
To expand and clarify, what exactly are you on? Traditional Medicare plus a supplement? Or did you opt out of traditional Medicare and enter the Medicare Advantage system?

As Michael pointed out, a traditional Medicare and supplement plan will limit your out of pocket expenses to the supplement plan deductible (part B) and could be $0 if it is an F plan. Plan G you pay the Part B deductible of $198.00 in 2020. Plans A, N and so on have larger deductibles as do the High Deductible versions of Plans G and F.

If you opted out of traditional Medicare and are using an advantage plan it will depend on the plan and your area as they differ by region. Generally the deductibles and co-pays in the Advantage plans can be a bit costly up to about $7,000 per year out of pocket maximum, but it depends on the plan.

You mention two different carriers, Blue Cross Blue Shield and United Health. Which company is it and what is it? Supplement or Advantage. You are not allowed to have two plans.

Decades ago laws were passed limiting you to one plan (with an initial 30 day exception). Having multiple plans means you would be paying premiums for coverage you could not use as you can not receive multiple reimbursements for the same claim. This was quite a racket particularly in retirement states like Florida in the 1980’s (I think) and was stopped by federal law. I remember a 60 Minutes report where an 80 something widow had about 20 plans and was going broke paying the premium only to find out that only one would pay a claim.

Your medical providers will not begin treatment until they have assessed your insurance and informed you of your financial responsibility. Talk to them and they will tell you precisely your costs. Your insurance company lists the coverage on their website and will tell you your coverage and responsibility if you will call them. They can answer your question with authority and accuracy, but we can not.
Posted 2/6/2020 1:39 PM (GMT 0)
Further, it depends on the type of ADT. While the radiation coverage is clearly out patient covered by Part B, the ADT depends.

If it is an injection like Lupron, Eligard, Firmagon, etc. it is covered under Part B. If it self administered (pill form) like Avodart, Casodex, Zytiga, Xtandi, etc. it will be Prescription Drug coverage Part D. The Part D coverage will have deductibles and co-pays based on your company’s formulary based on drug tiers and the Donut Hole and Catastrophic Coverage aspects may come into play. Again, call the experts at your company charging you premiums for the coverage.
Posted 2/6/2020 2:24 PM (GMT 0)
I have traditional Medicare and a AARP(United Health) Medicare Supplemental Plan N($180 deductible). My Plan D is a Humana Rx Value Plan for only $13 a month. That is the main one I have concerns about if it is involved in any of the treatment. Sounds like if I have ADT in my future, shots will keep me away from my Value drug plan.

Post Edited (manich) : 2/6/2020 7:33:26 AM (GMT-7)

Posted 2/6/2020 3:07 PM (GMT 0)
Thanks, very easy now.

Your radiation therapy is Medicare Part B expense. Medicare covers 80% of the covered charges and the UH Supplement plan covers the remaining 20% after you meet the deductible. Any injectable drugs, like Lupron, will be Part B expenses like the radiation therapy.

Any self-administered drugs (mainly pills) are subject to Medicare Part D (prescription drug coverage) and will be covered by your Humana Rx Value Plan. Simply visit their website and see what is covered and at what cost. They have a simple calculator where you enter the drug and pharmacy and they tell you the coverage and your out of pocket cost. This would apply to drugs like casodex that may be part of your treatment regimen.

Unless you have to take very expensive drugs like Xtandi and Zytiga, your out of pocket expenses will be very minimal and not financially threatening. Keep the Stratocaster and consider buying my 1964 Gibson Classic in showroom condition!!

A notable, but not relevant to you, exception to the Part B and Part D distinction regarding drugs is that several years ago as the newer very expensive monoclonal antibody class of drugs (name ends in MAB) became more mainstream, the CMS re-characterized many these drugs as Part D coverage even though they are administered in a clinical setting and not self administered. This was done to shift significant cost from the government to the commercial insurance companies providing prescription coverage and the consumer through deductibles and co-pays. It is unlikely you will be on any of these for PCa as none has yet proven effective for PCa and normally used. Rarely Keytruda might be used and a few others are still in clinical trials, but none are yet mainstream or applicable to your treatment at this time.
Posted 2/6/2020 3:32 PM (GMT 0)
Manich, I am covered by traditional Medicare with AARPUnited Heatlhcare as a supplemental coverage. I also have Walmart/Humana as my prescription drug plan. As you can see in my signature, I had brachytherapy, ADT and SBRT. The only out of pocket costs I incurred were some nominal ($8) prescription drug costs and none were related to ADT. Since the plans you have are almost what I have, the only difference may be the prescription coverages. Medicare and the supplemental plan have taken care of all treatment related expenses.
Posted 2/6/2020 3:38 PM (GMT 0)
This is actually very instructive for me. I'm still a few years (just turned 61) from Medicare, but thinking about what will be coming is useful to me. Of course, who knows what Medicare will look like 4 years from now?
Posted 2/6/2020 4:00 PM (GMT 0)
Thanks for all the informative responses. Looks like I will get to keep my 1964 Gibson Acoustic, but unfortunately sold, a while back(pre-eBay), my 1962 Fender Precision Bass, and got pennies on the dollar that I could get now-a-days. But I guess all us old guitar players have stories like that.smile
Posted 2/6/2020 4:05 PM (GMT 0)

Pratoman said...
Plan F as i understand it is going away but the plan G's are very similar


That is correct. As of this year the Type F is no longer available but those who have them, like myself, can keep them.

Also, the lettered plans all offer the same minimal coverage but there is nothing to stop an insurance company from adding extra features and coverage to each of those plans.

In my case, my RALP and AUS jobs were completely covered. The only out-of-pocket was $300 related to something in the second opinion I requested.

BTW, I am on an F through my previous employer. After retirement we wanted to keep on there insurance rather than search for new coverage due to my wife's previous conditions and ongoing therapies and the only way to do that after I went on Medicare was to buy my supplemental through them and they only one they offered was the Type F. In a few years when she goes on Medicare we will reevaluate our position.
Posted 2/6/2020 4:11 PM (GMT 0)
Nice thread
Though i am in a situation where might not need treatment.
Need to be prepared
Have medicare/medigap uh plan F with humana walmart value
Expensive up front(premium) but little out of pocket

Thanks all
Posted 2/6/2020 4:53 PM (GMT 0)
Vince, all the Medicare supplement plans have very clear coverage requirements and a G is a G no matter what company offers it. Good point about the F plans being suspended. This means that no new entrants can get a $0 deductible plan from this point forward. The only difference between Medicare Supplement Plans would be the premium and underwriting for qualification.

Medicare Advantage plans can and do have different coverages depending on the carrier and the the region where issued. Their basic requirement is that they must cover, at a minimum, what traditional Medicare covers. They can add on top of that and have a great amount of flexibility to do so. They can also have different deductible and co-pay formulas. They just can’t cover an occurrence for less reimbursement than traditional Medicare.

A large differential between Supplement and Advantage Plans has to do with provider networks. Supplement Plans are simple, just go to any provider anywhere that participates in Medicare. No geographic restrictions and usually no requirement for referrals to specialists. If I want to go to a doc in California, I am covered the same as I am in Georgia. Most , if not all, Advantage Plans have stated network providers. If the insured goes outside that network, generally co pays and deductibles are much higher. Many are also HMO based and require referrals to see a specialist and the list is usually limited. All this needs to be considered before choosing a plan.

Hal, little has changed with Medicare for decades. Last significant change was in 2006 when, for the first time, seniors could buy prescription drug coverage under Medicare Part D. Very unlikely anything will be different than it is now in the next four years or foreseeable future. There is no legislation even being hinted at that would have any meaningful changes. As for so-called “Medicare for All” on some candidates wish lists, the plans are totally different than what we have now. A change to these plans would be a far bigger change than getting the PPACA was.
Posted 2/6/2020 4:55 PM (GMT 0)
One thing to keep in mind if considering changing supplemental plans is....don't. There have been changes across the board on premium costs that allow the ins companies to start increasing them rapidly. If you already have a supplemental plan you are grandfathered in to only get the smaller premium increases each year.

My wife thought she could save some on her supplemental premium by switching from her $225/mo BCBS to what looked like a $169/mo AARP/UnitedHealth. When she signed up, UH then told her the premium would not be $169, but was going to be $350. This was allowed because of the new "rules". Luckily she had time to cancel before the UH plan was to start, and her old BCBS plan was still in effect.
Posted 2/6/2020 5:12 PM (GMT 0)
I recently completed SRT. I have traditional Medicare and the G Medicare supplement. The Uro visit for Calypso beacon insertions and the visits and 40 treatments at the RO clinic cost me zero OOP. However, the RO clinic had me sit down with their financial person and verify all my coverages PRIOR to anything being done. No complaints from me. Medicare with level G supplement is great.
Posted 2/6/2020 5:18 PM (GMT 0)
JNF - as a side note, one thing I figured out is that there are exceptions to generalized Medicare rules as MN and few other states have waivers from the federal requirements and offer different supplement plans and only some lettered plans. There are also different state laws that cover medigap policy eligibility such as in NY where I think you can get them at any time. Most states are standardized but I was surprised at some of the variations that occur across the country as I live in one of those states.
Posted 2/6/2020 5:27 PM (GMT 0)
Mumbo, good points about a few of the exceptions based on Some state laws.

Munich, some good advice regarding Supplement plans.

The basic reason a different company can charge more is the new company can consider health history and deny coverage or charge a higher premium. Generally people wanting to change have enough of a health history that the new company would see them at an increased risk and can thus either decline them or charge a higher premium. Current insureds are protected in that our own company can not increase my premium more than someone else due to my claims or health condition.

There are a few exceptions to this. First, if one permanently moves from one Medicare region to another, they get a fresh start regarding the Supplement Plan and do not go through underwriting. Also, if a person changes from a Supplement Plan to an Advantage Plan, they have one year to change back to the Supplement Plan without any penalties.

It is easy to change Advantage Plans each year and I suggest everyone on an Advantage Plan should re-shop each year as coverages, provider networks and premiums change each year. But, not so with Supplement plans. The key when you choose a Supplement Plan is the initial choice. That is where the real research and shopping has to occur before deciding. I advise that a person choose their Supplement plan as if there will never be a change to any other company, as that is the reality for most people. I have been fortunate that I have had little change in my Supplement Plan G premium over the last four years and pay $138.44 a month each for my wife and I. There is no way I can do better than that with a Supplement plan.
Posted 2/6/2020 9:33 PM (GMT 0)
I have an Advantage plan with an annual out-of-pocket max at about $1000 for medical treatment, not including drugs. $0 copay and deductibles for medical treatment. The cancer drugs can get quite expensive tho. The lupron type drugs would fall under "specialty drugs" and the member would pay about 33% of the insurance company's contracted rate. I have the VA as a backup, which is one of the primary reasons I chose an Advantage plan - which saves me over $200/mo in premiums (on top of the amount they take out of SS). Plus, I have good doctors in the network I belong to. And if I become dissatisfied with the network I can switch to another network in any given month (don't have to wait for open-season).

Everybody has different needs and we all live in different areas of the country where the Advantage plan benefits and charges differ widely. I always recommend that those approaching Medicare age to find a good qualified Medicare insurance agent to walk them through the maze of Medicare and Advantage plan rules and options - to find the optimal plan. It's complicated for sure.
Posted 2/6/2020 11:09 PM (GMT 0)
TJ, your suggestion that people find a qualified local agent is great advice. Many people think that having an agent will increase costs because the agent earns a commission for their work. All insurance is sold through an agent that earns a commission. This includes organizations like AARP that is an agent and earns a commission for each sale of insurance. The premium is the same whether you go through a local qualifier=ed agent or an online 1-800 organization.

I always advise people to find a local agent that knows their state’s particulars to assist with the purchase. It does not cost one red cent more and it means that you have someone you know personally to help you.
Posted 2/6/2020 11:28 PM (GMT 0)
Regarding Advantage plans -- My wife and I have been on BC/BS Advantage plan since I retired in 2011, but like TJ I also have the VA as a medical and pharmacy provider if I need it. The plus side of the Advantage plan for us has been the lower premiums than with a Medicare supplement plan - currently $86 per month per person. This compares to maybe $200-$250 a month each for Medicare supplement plans plus pharmacy plans if we had gone that route instead. So over the 9 years we've been on these plans we've saved maybe $25 - $30,000 in premiums. And because it is a PPO plan our coverage is essentially the same both in and out of network. Beyond premiums, our only costs have been just co-pays for doctor visits and $200 or so for a CT scan, and $200 for an emergency room visit a few of years ago for a broken rib. For the year I was on monthly Degarelix shots my out of pocket costs were about $90 per month - reasonable for a drug that has an actual cost of $2,000 or so per month to the insurer.

But the downside has got worse over the 9 years we've been on the plan. Maximum out-of-pocket has gone up from $3,000 to $5,000 per year. Neither of us has had to pay it, but one or two days admitted to a hospital would put us there for sure. And if both of us had to pay it, we could be on the hook for $10k in a year. Also, I am now looking at probably going on Zytiga, Xandi, or Apalutamide in addition to Degarelix when I resume ADT at Dana-Farber later this year - I've been on break from Degarelix since last May. These three drugs all fall into the top tier of my Advantage plan's drug coverage which means I would need to pay 25 percent until after the "donut hole" and then would pay 5 percent thereafter. At $10,000 to $12,000 per month for any of those drugs my share would put a sizeable dent in my wallet $6,000 or so over the first couple of months and then $500-$600 per month afterward if they fall under Part D.

Unlike most people I have the VA as backup as an Agent Orange veteran and should be able to get these drugs through the VA at no cost to me if they agree with my Dana-Farber oncologist. And because the VA re-rated my condition as permanent last year we've also been able to get the VA as my wife's secondary insurer, which means she has now dropped her Advantage plan and reverted to standard Medicare with the VA as her co-insurer and prescription plan. I know I'm exceptionally lucky (provided we overlook my government paid trip to Asia in 1968), to have this as fallback. I knew having the option of moving my care to the VA if I needed to reduced the financial risk of choosing to go the Advantage route.

So all that said, I think it is a better deal in the long run for most people to go with traditional Medicare plus a high-tier Medigap policy and pharmacy plan if they can afford the premiums unless maybe they happen to also fall under the VA's umbrella.
Jim
Posted 2/7/2020 4:04 AM (GMT 0)
Since 2012, I have Medicare plus a federal BCBS plan I pay for... They have paid for everything. $0 costs to me since 2012...

pasayten
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