Medicare questions
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I have a $250 quarterly allowance for OTC items. Last year I used it to get a touch less thermometer, just got a finger pulse ox thingy. I have a $400 once yearly allowance towards glasses. Need to get my eyes checked!! That visit will be $0.00 copay. All of my meds are 0$ copay, including insulin and test strips. It’s true we don’t know what the future holds in what meds we may need and it may not even be cancer meds. DH is stage 4, bone Mets He was just dx COPD, a whole different type of meds Didn’t see that coming, so far all that is covered 100%
As for hospital, they are run by large corporations or religious groups, but all accept the many, many insurance plans around here.
The SHINE groups can really help figure out what is best for you, and what is available in your area. And explain the cost of each type, in person or over the phone.
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candy,
Yes, Kaiser is a different healthcare model than traditional health insurance. The last figures I read said that 1 in 4 Californians were Kaiser members.
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Thanks everyone !!!! You have been a great help, and I hope this Thread can help others too.
I mentioned that I have had COBRA insurance (continuation of the employer plan I had when working) for the last 18 months, since I stopped working. All this discussion began when I found myself having to find health insurance for when the COBRA expires and before Medicare kicks in----- July thru Dec. 2021. I think I have found an individual plan thru the Marketplace, aka Obamacare. I was told I will have to use Obamacare, no choice. Pre-existing condition situation, I guess. For the State of Illinois we only have 2 insurance companies to choose from in the Marketplace-- Blue Cross and Health Alliance. Then several plans within those companies with various price ranges. I have reviewed the premium costs, deductibles, max out of pocket costs, meds covered (current meds and plugged in some names of future meds that we discuss on BCO for possible next line therapy), and if my providers are in network. Cancer center (which is out of State) is still iffy, in my opinion. They say they are in network- contract with State of Illinois, but insurance company says not. I guess I trust the cancer center's word.
So, first hurdle is getting the individual plan to cover the last 6 months of this year.
Next, I will review this Thread, all your posts and links, and start research on next hurdle--- Medicare, Advantage Plans, Supplements, and Drug Plans. Open enrollment is in October, right? To start coverage in Jan. So I have some time to research and make calls. I want to have my ducks in a row for when I need to enroll.
Keep the posts coming if anyone has any more info. Good discussion.
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Similar to exbrnxgrl, I also receive care through Kaiser in California. However, my large Kaiser hospital did not have radiation oncology as a service line. There was a Rad One facility one mile from my Kaiser and that's where I went for my radiation. I didn't have to go through any hoops, pay a co-pay not did I ever receive a summary of charges and payments. I have also had to receive care in New England. I presented my Kaiser card and only paid my regular co-pay. As far as hospital facilities, if a patient presents to an ED for any type of care, no hospital can turn that patient away. Now, if that patient had to be admitted as an inpatient, the hospital will contact Kaiser to see if they want the patient back to a Kaiser facility or receive treatment at the original hospital. That determination is based upon distance, service lines, how busy each facility is, etc. So, sometimes non-Kaiser patients are indeed admitted, have surgery and whatever else is required.
I would agree, in my circumstance, Kaiser as a Medicare Advantage plan is seamless. To the question of how much money you should plan on for drugs - this can be a very, very expensive journey. Some chemotherapy is in the several thousands of dollars per treatment day. If you are new to treatment paths, expect to be astounded at the cost.
Jane
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jhl,
Thanks for affirming that my transition to Medicare will be easy. At stage IV, Kaiser has been my care provider since dx almost 10:years ago. I am generally not superstitious but I feel like I'd be tempting fate if I went outside the Kaiser system.Silly, I know but true!
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just a note, under Medicare, infusion drugs and “some" oral chemo drugs ( but not Ibrance, I think) are covered under Part B so with a supplement or Advantage I would expect you pay nothing for infusions?
If you only had traditional Part B, without supplement of course, you pay 20% with no maximum out of pocket, so 20% of EVERYTHING. Other oral medications that aren't considered “chemo" go under Part D drug plans so there are deductibles and co-pays.
Under a marketplace “Obamacare “ plan you have your deductible and your max out of pocket for the year. Looks like annual max out of pocket for 2021 is around 8500 for an individual.
https://www.healthcare.gov/glossary/out-of-pocket-maximum-limit/
Drug coverage differs by state and by plan, as far as I know
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Does anyone know if one must sign up for Medicare when one is eligible? I will be eligible for Medicare in 8 months because of being on SSI for two years. Right now I'm covered through my husband's insurance through his work and I’ like to continue on it because it's excellent.
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figtree- On page 1 of this Thread, JavaJava and illmae both mention we SSI recipients will receive notification/paper card from Medicare prior to time for us to enroll. I qualify in Jan 2022, so if I do not hear anything by Oct (open enrollment period, I think) then I will take the first step and ask. Actually, I will probably try to call someone (Medicare or Social Security) this summer to ask.
I do not know if you would rather keep your current insurance if that is acceptable. Can you turn down Medicare for a later time??? I don't know. Not my case unfortunately.
Hopefully some will post answers if they have them.
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Figtree - you can opt out of Part B but you also need to contact your spouse's insurance company to find out how they want you to handle things. This is because some companies will want you to sign up for Part B so they can just provide you a supplement. this is from the Medicare and You handbook on Medicare . gov
"Should I get Part B? This information can help you decide if you should get Part B based on the type of health coverage you may have. Employer or union coverage If you or your spouse (or family member if you have a disability) is still working and you have health coverage through that employer or union, contact your employer or union benefits administrator to find out how your coverage works with Medicare (see page 21). This includes federal or state employment and active-duty military service. It might be to your advantage to delay Part B enrollment. "
here is the link -
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Thank you, Candy and Olma, these info are helpful. Just took a look at the handbook. OMG, Medicare part D is a nightmare!
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Re part D, honestly, I don’t know why it has to be so complicated and the drug coverage so inadequate. My state (NJ) has a program for seniors and people on disability that supplements Part D drug coverage and the income guidelines are pretty generous, but that may not exist in every state. It is worth checking with your state Office on Aging.
Also, drugs in the pharmacy are sometimes cheaper to just buy cash with a coupon from GoodRx, rather put through insurance . But you can’t tell the pharmacy you have insurance.I was getting my blood pressure meds through Valisure.com for awhile because the meds were subject to a recall due to contamination. So not only does Valisure test each batch for contaminants they have low cash prices on a lot of drugs. My price there for Losartan was cheaper than all the chains except maybe Costco
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figtree,
You must sign up for Medicare Part B when you become eligible. If you don't, you will pay a penalty. Medicare will always be the primary insurance. Any subsequent insurance will be the secondary.
You should enroll in Part B when you're first eligible. If you don't enroll when you're first eligible, you may have to pay a Part B late enrollment penalty, and you may have a gap in coverage if you decide you want Part B later. Learn more about how to get Parts A and B.
As far as Part D, I find the rules very simple and actually inexpensive depending on the drugs you take. Medicare actually has a very easy interactive website that can help you find a plan that works for you: https://www.medicare.gov/blog/find-medicare-plans. You might need to balance your premiums (monthly cost) with your co-pays & the different tiers of medications.
Really, work with the Medicare.gov website to fine tune your own selections based on location & formulary. If you also qualify for Medicaid (MediCal in California) you may have some limitations. Some states have chosen not to participate in the Medicaid expansion may have plans that are very, very restrictive on drug options & possibly very very expensive.
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If a person is insured under a spouse's employer-based insurance, they may not have to pay a penalty for delaying Part B - the criteria is at this link:
Should I get Parts A & B? | Medicare
Again, you also have to check the employee benefit plan to coordinate.
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candy, have you considered requesting an extension of COBRA due to disability? It’s expensive (and yours is already very expensive) because the employer is allowed to charge you up to 150% of the actual premium cost but it can be a good way to cover the period of time between when standard COBRA coverage lapses (at18 months) and Medicare starting. The extension rules provide for up to 11 additional months of insurance coverage for a total of 29 months.
Also, as was mentioned previously, in my state there was only one option for medigap coverage for people under 65 and on Medicare due to disability so you may not have to do too much research about options
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MargaritaMS- I did file a request for an extension of COBRA but was denied. IDK, something about filing error. I am not going to fight them. I think I have chosen an individual plan for July- Dec. Then on to Medicare. And I need to start researching that.
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Candy, that’s strange that they denied your request but glad you found alternative insurance. It’s so stressful to worry about insurance coverage while fighting this crappy disease! Good luck with your research. You’re very wise to think about insurance well in advance. It’s easier to deal with when you’re not under time pressure to quickly sort it out
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I receive SSDI and I just received my letter notifying me that my Medicare coverage will start in Oct. I currently get my insurance through my husband's retirement from the state of IL. I called them and they only offer two advantage plan choices since we live out of state. I looked up coverage for some common oral cancer drugs (e.g. Ibrance, Xeloda) and the coverage is terrible, those would cost me about $13,000 a year under the plans available.
Do most of the pharmaceutical companies offer some type of assistance similar to pfizer for Ibrance?
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Simone- I hope the pharmaceutical companies offer some kind of assistance. I am changing from COBRA coverage (continuation of previous employers coverage) to an individual plan and I think that my copay would be 50% monthly for Ibrance ($6,500 a month). Then.... I am eligible for Medicare in Jan. I have not checked into supplements yet and how much my Ibrance (or whatever I am on by that time) would be. So I pray that there is financial aid out there. I hope you get some responses to your post as I will be in that situation too.
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Candy, it's scary. I thought my copay was bad yours is worse. I'm sure there has to be assistance out there.
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There is, at least for my ibrance. I have 0$$ copay on it. Check with your MO financial people.
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Simone80, my only recommendation at this time is the call the respective insurance companies to specifically ask about the meds. Insurance for retired state employees should definitely be better than that. I was really concerned when Medicare became my primary and my state of Texas retirement plan secondary but the advantage plan offered ended up being way better than I thought with most things covered by Medicare first. I actually pay $0 for scans, appointments, Herceptin infusions and Xeloda and in or out of network is capped at $1,000 annually. Before the change, I spent 2 months trying to find answers online and by phone, it was a nightmare.
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I am also due to start Medicare in October. My husband is going to be retiring at the end of the year, and we’ve reached 100% coverage, so I’m going to call Social Security and have them hold on Part B until January. That way I won’t get penalized for not starting it in October. I have a phone appointment with someone who was recommended to me today. This change is very scary, as I haven’t paid a penny for Ibrance for two years. Now it’s probably going to cost a lot. It doesn’t make any sense to me. We have private insurance and pay nothing and then get Medicare and have to pay a ton when we are done working. This system is so screwy.
We pay almost $500 a month in premiums right now and have to pay $8,000 out of pocket to get to 100%. Yep, I made it to $8,000 this month. I’m going to keep this insurance until my husband leaves. We’ve already spent a ton. I could go on Cobra after he leaves for the 18 months, but our premiums and copays to get to 100% would be about $24,000 a year. Is that ridiculous or what?
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KBL, that's ridiculous. I don't know how most people can afford to pay that.
I've been spoiled with my husband's health benefits. He's retired but still gets health insurance coverage from the state. We have Etna, ppo, and I'd love to stay on it. It pays for a lot of my expenses.
Pfizer has a copay assistance program and picks up the cost of my copay for ibrance. I'm hoping someone will chime in that gets assistance with their copays on some of the other oral meds. Maybe I'm just worrying about nothing.
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And it’s private insurance through his work. It used to be much better until they switched to an entirely high deductible health insurance. That’s why I’m waiting until January. Our income will be way down due to his retiring early. I believe I may be able to get copay assistance then. They got rid of their retiree benefit for insurance long ago. They don’t even offer a pension any longer. I can understand why companies have trouble finding employees.
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Mae, I’m getting closer to Medicare. A question about scans. Do you have to get preauthorization for any of them? I hate that part with my husband’s private insurance. Such a hassle. I will have Part A and B through December, which I won’t need to use and then sign up in open enrollment in October for the other supplements. No matter how much I read, I’m still not sure which way to go as far as our specialty meds are concerned. I have someone who will be guiding me in the plan I choose. If you have any advice, I will gladly take it.
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KBL, I am not stage IV, but have been on Medicare for a couple of years. The telephone call is overwhelming and I studied all the plans offered to me in my "zip code" prior to. I have a Medigap supplemental plan N, so that I can cross state lines to see any doctor/hosp I want to see. I can go anywhere without a referral. My brother has Aetna Medicare Advantage and where he lives that is working for him. With my Medigap plan I had to also get Medicare part D, drug plan. My Tamoxifen is free. No Medicare D plan can have a deductible greater than $445.00. Some don't have a deductible. You might want to ask what cancer meds are covered in which plan. My husbands' advantage plan includes Medicare part D, but limits which doctors he can see. For every scan he pays $300.00 and needs preauthorization. My deductible is $203.00 this year for part B. Write down your questions you need answers to. The phone call is about an hour long, if you can't meet in person. Medicare will get you a lower negotiated cost, but it is the supplemental plan that pays for the expensive 20% that isn't covered and Medicare part B pays for all outpatient services. For Medicare part A you have to be in the hospital for 3 nights/4-days before it kicks in. Best of luck.
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Thank you for the great info, flashlight. I know getting started on Medicare has to be hard for everyone. I will definitely have help to choose which plan. I know the Ibrance I’m on will be expensive, but I’m pretty sure I will be able to get help from Pfizer. The thing I think about is I’ve been on it for 25 cycles, and either Afinitor or Xeloda are next. I hope it’s not right when I’m starting so that I have to try and get different financial help
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I will be going on Medicare in September (turning 65). It will be an easy transition for me as my HMO, Kaiser Permanente, is a five star Medicare provider and I will be keeping all of my doctors so my care will be very consistent. What has been crazy is the amount of mail I get from various people and/or organizations that want to help or advise me about Medicare. They’re worse than all the campaign flyers I get before an election!
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So true! And once you’re on the next open enrollment starts all over again. I’m very happy with my Advantage plan, so I just toss it.
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anyone from Illinois who is getting or has gotten a medigap plan under age 65 due to being moved to Medicare from receiving SSDI for 2 years??)
I know that sentence is a mouth full.
I started SSDI in summer of 2020 so once I have received SSDI for 2 years, I will be moved to Medicare even though I won’t yet be 65.
Most medigap plans say you have to be 65 to sign up with a notation that states may offer a plan or two for those under 65 but at a higher premium. It seems from what I have read that Illinois does offer medigap to people under 65 but I can’t get an idea on cost. So looking here for information from those going through this ahead of me.
Thank
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