Medicare questions
This is pertaining to Medicare in the U.S.----
I will be eligible to start Medicare in January 2021--- 2 years after being approved for Social Security Disability. I do not know anything about Medicare as I am not close to regular Medicare age (I am 50 years old). I want to do some research now in preparation for applying for Medicare.
So my question for anyone recently going on Medicare----- are there multiple plans with Medicare? Or is it a one size fits all thing? Can I research the plans now? Are there different plans for deductibles, out of pocket expenses, doctors in network, etc. Like with health insurance plans.
The medications are a separate plan, right? Drug plan?
I was on COBRA the last 18 months and found out that it is expiring and I am having to find health insurance to cover the last 6 months until Medicare kicks in. Wow !!! The insurance plans are confusing. Various deductible levels, some are not in network for my established MO, etc. I am hoping that Medicare will be easier.
Advise needed. Thanks.
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Hi Candy,
Yes, you will need to do some research for your local area. Medicare Part A & B cover hospitalizations, doctor visits & some durable medical equipment and diabetic supplies - but not fully. You will need to research for a Medicare Supplement for your area. You will have a Medicare Premium deducted from your Social Security check. You will also have a Medicare Supplement monthly premium. You may or may not have a copay each time you visit your Dr, lab, radiology, etc. You may or may not have a deductible you will have to reach before they fully cover everything.
Drugs are covered under Medicare Part D which you will need to sign up for at the time you sign up for Medicare. If you delay, you will pay a penalty. There are lots of ins and outs to Medicare Part D. One thing that seems to always confuse people is the donut hole so its worth your time to investigate your various options and compare using the medications you are currently on. One thing to note is chemotherapy when given in an infusion center is billed differently than picking up medication at a pharmacy.
Here is a good place to start: https://www.medicare.gov
Best of luck,
Jane
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Thanks jhl. I know I will need a Medicare Supplement Plan. Medicare covers 80%, right? So I will need supplement to cover the rest-the 20% remaining.
I was wondering about within the 80% Medicare Plan. Are there levels of coverage? Gold, Silver, Elite, etc of Medicare? Or is Medicare just Medicare and it all pays the same for that 80%?
Then the Drug Plan---- I am sure that will be confusing. I am on Ibrance. Will the Drug Plan pay ___% of Ibrance as a covered med? Or are there levels of Drug Plans too? And one Plan might cover Ibrance at a better percentage than another Drug Plan?
I will check out the link you provided.
This is too confusing.
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Candy, you're smart to educate yourself now.
One of the first things I learned about Medicare was: since I am under age 65 on disability, I can only get a Medicare Advantage Plan. It is somewhat different from Medicare & Supplement Plan, which I believe is called Medigap. The eligibility is different for each state. I am in Ohio, I don't know about Illinois, so check into that since you are only 50. (Gosh, I didn't realize you are so young!) When I am 65, I can switch over to Medigap.
You can also check to see if there is a place in your area that offers these Medicare insurance plans. I went to one called “Health Markets" where I live. It cost me nothing, and the woman insurance rep explained everything in detail then gave me lots of literature to take home. And she got me all signed up the first year, then I go see her once a year to renew. (This past December was all done via phone). And, like I said, it costs nothing. I find word of mouth is the best way to find the best of this kind of service, so ask people you know in your area who are on Medicare if they have someone they recommend. A good insurance rep will be happy to answer any and all questions you have.
I still pay the monthly Medicare premium which I think is about $144. With the Advantage Plan, prescription coverage is included so there's no part D. So before you delve in to that, check to see what you're eligible for.
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candy, contact any good insurance rep. They can advise you what you need, and set you up
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Thanks for the advise.
I know an insurance broker (? is that what she is called--- she sells insurance plans) in my area that I contacted to help with the Individual Health Insurance Plan options to get me coverage after COBRA and before Medicare. I mentioned to her that this fall I will qualify for Medicare sign up--to begin in Jan. She said "Oh I don't do that. I will help you with a Supplement Plan, but you will need to contact Medicare to sign up with them for coverage". Medicare? What is the number? How do I contact them? So she was no help with my Medicare questions.
Divine- I did not know that about Advantage versus Medigap. I thought I heard gossip that Medicare Advantage Plans are not good, coverage wise. Not many providers take them and you should shy away from them. True?? Maybe not.
Most of my church friends are in their 70-80's so I don't know if they would know who they called when they first began with Medicare at age 65. How do I find out who in my area deals with this? Someone I can make an appt to go talk to?
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Candy, I was curious about this stuff too. After two years on SSDI, I was moved to Medicare with my retirement plan providing a Medicare advantage plan and it’s worked out well so far. Everything has been approved and outpatient chemo (Herceptin and Xeloda) has been covered 100%. It started in December and so far I’ve had multiple MRI’s, a CT and brain radiation. To date I’ve only paid a $112 copay for a specialty drug (Tukysa) for brain mets. My advantage plan is $0 copay in or out of network with a $1,000 max out of pocket annual. The advantage plan premium is completely covered by retirement but the Medicare itself is $144/mo. and is deducted from my SSDI payment. I’m 46, so only eligible due to SSDI but so far, so good.
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candy, do you have friends your age with older parents on Medicare? They might give you leads. You can also google “medicare insurance agents near ________ (your town or zip), Illinois" to get some direction. And is there anyone at church who's the know-it-all of things happening in your area? Or a neighbor like that or a friend of a relative? I know a person like that who I turn to because she's up on a lot of things and those kinds of people are always pleased to share their knowledge.
As for getting your providers: my insurance rep asked me who my providers were and found me a plan that accepted them. I go to a cancer center at a big Pittsburgh hospital and my plan covers them. The Advantage plan costs me nothing, but I have an out of pocket max of $3500 per year. Co-pays, like $10 for lab work, $30 office visits and $150 for CT do not count towards the deductible.
The only thing is some of the cancer meds are tricky. My plan only pays for a portion of the Xeloda since I get it in pill form. But the price I pay goes towards the plan's deductible. Illimae, I'm curious how it costs you nothing on your plan. Other meds in pill form haven’t cost me much at all. If you get treatment at the hospital, it’s covered.
With higher priced cancer drugs co-pays, there's often help from Pharm Companies to help pay if your income is below a certain level.
Candy, I also find that the understanding how it all works gets easier as you kind of dive in. Sure would love if it was simpler, tho.
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The part A Medicare @ $144 a month comes out to $1728 a year. Then if you end up paying all your deductible for that year, like in my case would be $3500, it adds up to $5228 total plus the additional fees of office visits and scans which isn't a whole lot more. Not sure how much you pay per year now, but I always thought Cobra was pricey unless your former employer pays for it.
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Divine, I don’t know exactly how it’s so inexpensive but assume it’s because I medically retired from my government job, my employer paid advantage plan is United Healthselect of Texas. Before Medicare, with my regular employer BCBS, I paid 3-6K annually out of pocket.
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illimae, since it’s a government-employer paid plan, that may have something to do with it. I'm glad you have such terrific coverage!
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I agree Divine and signing up for all available coverage options including long term disability was the best decision I ever made, thinking I’d never need it, of course. Little did I know.
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Great posts! I am not on disability but will be retiring at the end of this school year and turning 65 at the end of September. I will be retaining all of my health care providers as Kaiser Permanente, the all inclusive HMO that I have been with for years, offers Medicare plans. Now, to tackle all of the other pieces of health coverage as a retiree...
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That’s what happened to me. My school district had Humana, when I retired and turned 65, I was able to just switch into an Advantage plan. Prior to that, I was paying what they paid per employee monthly. Over $600 monthly just for me. That was 11 years ago.
So now I have $144 taken out of my SS check each month. I don’t have or need a supplement or medigap plan. The advantage plan covers ALL of my medical needs. It covers the whole alphabet of letters.At 0 cost to me in premiums. My specialist copay is $5. Other copays are very very low. Generic meds, $0.00. Both time with cancer, no hassles.
I live in an extremely populated county, I have a wide network of doctors I can see. That may not be the case in less densely populated areas so would be good to check into that.
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Oh my gosh. A lot of information here. Thank you all. Good discussion.
I had to take a nap this afternoon--- thanks to Ibrance fatigue. Now I am back online and reading your posts.
Divine- COBRA is expensive !!! I am paying $1,100 a month in premiums. And my out of pocket costs in 2020 (looking this up for tax preparer) was over $5,000. I am gathering my prescription out of pocket costs now so I do not have those numbers yet. So... I spent around $20,000 in 2020 on medical care. And I am on a fixed income and live alone with no other income coming in (spouse, etc). FYI... I am paying for all this out of my IRA/Pension. Thank God I had that. This Individual Plan I am looking into will have a $2,500 deductible. Unsure of premium cost at this time. Still looking at all plans.
Mae- You mentioned that you just transitioned to Medicare with your SSDI situation. Will I get some notification from Medicare/ SSDI that it is time to enroll? JavaJava mentioned this. Or do I just know that open enrollment is in October (I think) and I am responsible to contact them?
Divine- I will think about my friends/contacts and see if someone can help me locally. As far as the insurance broker I am using, she wanted me to do the legwork of calling my providers and asking what plans they accept. She gave me the name of the Plan and the Plan ID number and I was to check with my docs--- local PCP, MO I see (in a neighboring State to add to the confusion), etc.-- to see if they are in network. That was confusing. Got conflicting information. Some areas/people say that my MO is in network, some say she is not. I told that to my insurance broker and she didn't take the hint that I didn't know what I was to ask because I am not an insurance professional !!!
Wow, Looks like with Medicare I am going to be saving a ton of money.
I am trying to take notes with all this. And I hope it can help others too. Keep the posts coming.
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Candy,
Since your MO is at a large center, you could look at their website and see what it says regarding plans that are accepted. But yes -- the interstate stuff might prove difficult.
Also, at my large center there are financial consultants who can walk you through a lot of things like insurances that they take, etc. If you peruse their website maybe you can find a number to call. Failing that, you could call your MOs office and ask about financial consultants. Hopefully you won't have to do that -- my MO knows zippo about the financial aspects of cancer care.
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Looked at JavaJava's link she posted. Talks about disability and automatically get enrolled in Medicare and get card sent in mail to you. I need to read this more closely. Do I have a choice of Medicare Advantage Plan? What providers in network? My docs?
Wow, I need to read this when I can think better.
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Hey BevJen. I did think to message my MO nurse for help. No she did not know zip about the financial. But she gave me a number to call. I called the number and they lead me to the cancer center's website. Due to a lot of Southern Illinois residents going across the River to St. Louis, MO for medical care they have contracted with Illinois to take the Illinois plans that are in the "Marketplace". That is my stickler--- I have to shop the "Marketplace", aka Affordable Care Act, Obamacare. But before I knew that, I called one of the Insurance companies and they told me if I go out of State it would be out of network for their insurance. And the websites for the Insurance companies say my MO is out of network. The cancer center says the insurance company's websites are not up to date. Loopholes??? Who to trust?
But the cancer center did not offer any other help but directing me to their website that had the notice posted about taking the Illinois Marketplace plans.
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Candy, I got a paper Medicare card in the mail about two months before it was effective.
For my Medicare advantage plan, I had two options through my retirement plan, an advantage plan or a secondary plan. The advantage plan covered more, so I’m seeing how it goes, which has been great so far. I don’t know how this works for those using ACA or other personally paid plans.
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Candy, you have time to figure out how Medicare works, so that’s a plus. Is there a Medicare office in your area? If so, you can call them and ask if they can give you the name of an insurance agent who offers Medicare supplemental insurance, whether Advantage Plan or Medigap. I found the people at the Medicare office in my county to be professional and helpful. Believe me, they get asked all the questions you have on a regular basis, so they have a lot of the answers.
In the meantime, since you have time, keep your ears open. It’s funny how when you are focused on figuring things out, often the subject will pop up in random conversations. Don’t be afraid to bring the topic up in casual talk that you’re looking for an insurance agent to help you with the Medicare ins and outs. Because that sounds like way too much work for you to be calling around doctor offices to see what plans they take. A good insurance rep can pull that info up on a computer immediately.
Also, when you are eligible, Medicare plans are more flexible than a regular health insurance plan. I live in Ohio but doctor a lot in Pennsylvania with no problem in coverage.
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Candy, hi, insurance and Medicare can be so confusing to figure out! I can relate.
I remember somebody told me that each state has an office that helps people with information about getting on Medicare, most states call it the SHIP program.
You mentioned Illinois, so I looked up the SHIP website for IL . here is the link.
https://www2.illinois.gov/aging/ship/Pages/default.aspx
There's a phone no & email halfway down the page.
“To contact SHIP, please call (800) 252-8966 or email AGING.SHIP@illinois.gov."There are counselors who respond, it might be by appointment.
I am not on Medicare yet and I think I will be waiting til age 65 to get on it, since I am so close - I believe I have to contact Social Security about six months before I turn 65 to opt in to paying the Part B premium...not sure if that's right but that's what I think I was told.
it could be different when you are on SSDI ....maybe someone here can clarify that.
Also, the following link on Medicare.gov lets you put in your zip code and see which Medigap or Advantage plans
are available to you and the approximate cost. My state only offers one plan for under 65. That makes it easy to decide ...https://www.medicare.gov/medigap-supplemental-insurance-plans/#/m?lang=en&year=2021
Good luck getting this all taken care of
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hi Ladies, this is a very timely topic for me as well.
I will be 65 in June. A year ago I began regular Social Security. I will automatically be enrolled in Medicare as of June1. My card came in the mail the other day. I still need to choose a Part D plan and a supplemental plan. If I would rather, I can choose a Medigap policy which may or may not include a drug plan.
So there it is. Is a Medigap plan a good idea for me?. A year ago we asked an independent agent and he said generally with cancer you are better off staying on Original Medicare and buy additional coverage with part D and a supplemental plan. He did not elaborate as to why. DH would be fine with Medigap.
I've gotten a ton of junk mail re health ins. plans and I plan to call a few to see what I can learn. I'll be watching here too. Wish I could offer more.
I think it's criminal what the governmet did coming up with such confusing plans. The people that need it most ( the handicapped and retired) are least equipped to understand it. Talk about job security.
Doing well all things considered. Hope you are at least as good.
Gailmary
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Hi, Gailmary,
Yes, this is all very confusing. But one thing you've got to do is make sure you are using the correct terminology when looking at, and getting, coverage.
Medicare A & B is original Medicare. Medicare Part C is what is known as Medicare Advantage plans -- not Medigap, as you are referring to it. If you get a Medicare Advantage plan, Medicare Parts a and b and D (prescription plans) are generally rolled into one. You can find more information out at medicare.gov.
I have original Medicare (A &
plus a supplemental (aka Medigap) plan. Original Medicare pays 80% of reasonable and customary charges for hospital and doctor care. If something is covered under Medicare, then my supplemental (aka Medigap) plan (which I have through United Healthcare/AARP) will pick up the additional 20%. Drug coverage is something else. Again you can go onto Medicare.gov, enter your state, and enter all of your drugs. See if your drugs are in which Part D plan's "formulary" to help pick.You and your husband do not have to go on the same type of a plan. And, insofar as I see on these boards, in some states, Medicare advantage works just fine for folks. I have never had a managed care plan (like Kaiser) and I don't like the idea of having to get referrals for everything or having to go to only certain docs. So the Medicare Advantage plans just were not attractive to me. Everyone pays a set fee for Medicare A & B which is deducted from your SS check (last year it was $144) unless you make more than a certain amount of money, in which case the government charges you more. Supplemental plans charge different amounts. My husband and I pay about $340 a month for both of us for that. We are heavy medical users (he's a diabetic) and we've not had to pay anything for medical with this setup. On the other hand, the drug situation is something else especially when some of us are taking very expensive drugs. That requires a ton of reading.
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BevJen,
I did want to elaborate on something you said about Kaiser Permanente. I have been a Kaiser patient, on and off, for the better part of 30 years. In terms of referrals, if my medical issue is related to bc, I see my mo. If the problem is not cancer related she does indeed refer me to the appropriate specialist. This is never questioned or challenged and my mo, or whichever doc is sending me on to someone else, often makes the appointment right then and there! All records, including imaging and all tests, are online so whoever you are seeing has access to every aspect of your care under Kaiser in just a few clicks. There are also no insurance companies to go through for approval of anything! If your doc determines that you need a test, procedure or whatever they just order it and it’s done. I have never had to worry that something wouldn’t be approved. Although I can only use Kaiser docs and Kaiser facilities, the choices are enormous. I live in Silicon Valley and there are several very large Kaiser facilities (whole campuses with every medical service imaginable) as well as a multitude of satellites offices. I have, on occasion, changed docs and that was easy to do. The pool of practitioners is quite large and I have never felt hobbled by having to stay within the Kaiser system. Kaiser care providers are salaried so they don’t make money by ordering unneeded tests and procedures. Their pharmacies are great and, as much as possible, their prescription prices are very low. Their pharmacies also offer a large selection of OTC meds and health care supplies that are cheaper than a sale at Target! I also appreciate their emphasis on wellness as they offer a multitude of classes and services focused on staying healthy. On some campuses, they even have weekly farmer’s markets.
I know that like everything in this world, Kaiser might not be everyone’s cup of tea but their emphasis on wellness, not ever having to worry about insurance approval and the seamless integration of all my medical history/records between providers has made my stage IV life much easier and I don’t feel limited at all in my choice of providers since, literally, there are hundreds of choices in the greater SF Bay Area. Managed care doesn’t mean less care as the common misconception holds. Nothing that my docs have deemed necessary hasever been denied. My plan will change when I go on Medicare but my transition will be equally seamless as Kaiser has great options for seniors.
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Exbrngirl,
I didn't mean to disparage Kaiser, and in fact it was the only managed care place that I could think of. That was not my intent. I only meant to point out that some people like that, and some people don't. And, as you point out, it all depends upon where you live in the country as to what kind of plan is best for you. For me, it's just not something that I've ever done. That is a personal preference, as I clearly stated. But I'm glad that for some people, Medicare advantage plans work out very well.
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So Kaiser is an insurance company? Like Blue Cross/ Blue Shield is for my area?
So think of Medigap as filling the gap that original Medicare doesn't cover---the 20%? A supplement?
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yes Medigap and supplement are the same thing, they pick up the expenses that part B doesn't pay Added for accuracy: What I mean is...your supplement covers your deductible on expenses that ARE Medicare covered. It doesn’t cover things that Medicare will not cover
An advantage plan, on the other hand, replaces traditional Medicare but usually puts you in a network where you're limited to certain doctors and hospitals.
With traditional Medicare plus supplement you use any doctor that will accept Medicare.
as others said, some people really like their Advantage plans and others not so much and a lot depends on where you live and which plans are available in your area0 -
Wow. Thank you ladies for clarifying.
And to think one part of the equation is the complication of drug coverage as nobody knows what drugs they'll be on throughout the year. How do you weigh your options re drugs? Drs can't say what you'll need next. Pay more upfront or later as they are prescribed? Network or preferred pharmacy ? Ugh.
Gailmary
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candy,
Kaiser is not an insurance company. They are health care service providers with their own medical personnel, hospitals, labs, pharmacies and everything else that goes along with medical care. They offer a variety of health insurance plans, both individual and employer based (This is what I currently have and because I am a state employee my coverage is excellent because so many state employees opt for Kaiser). Patients are referred to as members. The best way I can explain it is that it’s like an all inclusive resort for medical care. Every service, test, prescription, treatment, etc. is delivered by a Kaiser employee at a Kaiser facility. All staff from doctors to housekeeping are Kaiser employees
Some people struggle with the idea that you must get all of your care at a Kaiser facility but they have such a big presence in CA that you can choose from hundreds of doctors and numerous facilities. There is no issue of in network or out of network. Conversely, if you are not a Kaiser member, then you cannot use any of their facilities or service providers. I think the ER might be an exception as ambulances probably just go to the closest hospital in case of emergency. BTW, if you need medical care when traveling and there are no Kaiser facilities in the area, Kaiser will cover your care wherever you are.
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Wow, exbrnxgrl we don't have that in my area. That I know of, at least. Glad you are happy with it.
Gailmary- So true. I am looking at an individual health insurance plan right now--- for 6 months July- Dec to get me thru to Medicare. I am checking if the meds I am on are covered by the plan, but I don't know of the next treatments (if I would have progression in those 6 months). But at least this is just 6 months. With my next move to Medicare and another Drug Plan then that will be for an extended time frame. Progression will happen at some point. So I guess we just pray that the next lines of therapy are covered under the Medicare Plan we chose, or we are screwed.
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Candy, make sure to find out if you are only eligible for an Advantage Plan before you spend time researching Medigap. There’s no reason to pour over a lot of Medigap info right now if you can’t use it.
My Advantage plan, which is from Aetna, has little perks. Tho I’m covered by dh’s vision and dental plan, I still get a $150 stipend for each from Advantage to cover extra costs. For example, I needed both glasses and contacts this year, the vision plan only pays for one of them, so the $150 can pay for the other. Also, every three months, I get a $165 stipend to go to an online site to purchase over the counter meds and other things like Tylenol, toothpaste; I even bought a blood pressure monitor.
The plan is accepted at my small, local hospital and local primary doctor in Ohio and also accepted at a large hospital in Pennsylvania along with my oncologist there, so I’ve had no problem seeing who I need to see.
Almost all my deductible has gone to pay for medicine. Since I get Zometa as an iv at the hospital, Advantage pays for it. I had an ER visit which ended up in an overnight stay at a hospital last year and paid nothing except $150 co-pay for a ct scan. Even so, the most out of pocket I would have per year is $3500. I’ve been at this paying-for-cancer-treatment for 10+ years; it’s the price I pay to stay alive. Worth it!
Yes, in comparison to Cobra, you should be saving money when you go on Medicare.
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