Medicare questions
Comments
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Lost this Thread for a bit. Found it again.
I got my Medicare Card in the mail. Starting Medicare Dec 1. Talked with my insurance broker and signed up for a Supplemental Plan. Going to cost me $250 a month in premium. But the Part D drug plan is awful !!!! I will pay over $2000 a month in drug costs??!!! Is what the insurance broker quoted.
I am going to reread this Thread and Dodgers I too am in Illinois. And under 65 with SSD for 2 years and now qualify for Medicare.
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Candy,
Two points: with a supplement plan, you pretty much get everything covered between that and Medicare, so long as it's Medicare eligible (which most things are). Make sure that your doctors accept Medicare in full for payment and you should be fine with that. As far as Part D goes, work with your MO to get into drug company plans that will give you drugs for free or reduced amounts. That 2k is not an automatic cost. You are still eligible for these free or reduced plans on Medicare. What you are not eligible for are the things you see advertised as $25 a month for commercial insurance holders. The Medicare ones look at your income in making their decisions. (We had a long discussion about this when you first raised this question about switching to Medicare.)
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BevJen- I am going to review this Thread's posts this upcoming weekend. I could not access this Thread for some reason and just got it to work again. Yeah the Medicare part sounds good. Yes, the premium cost of $250/mo but then no other costs--- I guess. Medicare at 80% and then the Supplemental policy picks up the rest with the 20%. It is the Part D that is awful. Sounds like it doesn't pay too well on the high end meds of the cancer meds-- Lynparza-- and my blood thinner--- Eliquis--- and my eye drops--- Restasis. And something about a high deductible I have on my plan too.
And the co-pay assistance with some drug companies--- i.e. Pfizer with Ibrance--- does not qualify for those on Medicare or Medicaid, only private insurance. So the co-pay assistance cards will go away.
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Ok so I wanted to post here as an update and maybe to help others. Also to ask for clarification on some things. I will put these in bold.
So, a few weeks ago I did indeed get my Medicare card in the mail--- I have Social Security Disability. Medicare effective Dec 1 (I was thinking would be Jan 1). I set it aside with so much going on-- sister's health and eventual passing. So this week I picked it back up. Tried to log into this Thread to review and could not--- hum, technical difficulty. I called my insurance person and was thinking we would talk about options and then apply closer to time. He did it all in 1 phone call.
He said we could do Medicare Advantage OR a supplement (Medigap). I told him of my cancer and lots of medical stuff. He said a Medigap plan would be better for me. He said there are 3 companies in my zip code area and named them and their premiums. Ranged from $250-$350 per month. I asked the differences and he said all the same plan coverage. HUM is this correct??? He said the most expensive option is due to the name of the company and that it is the most used. So I am spending more for the name??!! I chose the cheaper company. Is that ok?
He said my out of pocket would be my Part B deductible only--- $200 a year. Yes, I have the Medicare premium (comes out of Social Security check) and my Supplement premium. But otherwise no charges. Is this correct? Pay at 100% otherwise--- for CT's, MRI's, PET's, doc visits, labs, biopsies, procedures, etc??? Seems to good to be true.
Then we went to Part D--- drug coverage. This is where it gets confusing. He took the names of all my scripts and told me #1 I have a $500 deductible, then I would pay $2500 a month thereafter. That 3 of my meds are expensive--- of course the Lynparza, the blood thinner, and an eye drop.
So.... I get by with medical stuff cheap, but they stiff me with the meds?!
Is this how you guys see Medicare? Is this your experience with it?
Edited--- also, no prior auths with Medicare? No calling to ask if a CT is ok, or any x-ray ie a thyroid ultrasound?? Now we have to ask insurance before ANYTHING. Physical therapy, tests, meds, anything.
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candy— what medigap plan are you looking at? G?
Also, yes the coverage for each different medigap plan is the same except monthly cost.
Hubby is on Medicare and Medigap G. He pays monthly cost for Medicare and Medigap. Once the out of pocket is reached on Medicare, we haven’t had any other costs other than prescriptions.
Are you getting a Medicare Plan D for prescriptions? Is that whatyou are describing?
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DodgersGirl- Yes Medigap plan is Plan G. Insurance guy said all Plan G's among the 3 companies stated in my area is the same Plan G. So why the premium cost difference among them?
And Yes Medicare Plan D for prescriptions. Are there differences in those? The one he quoted me is the one I am enrolled in.
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Candy, I start Medicare October 1, but I will still have private insurance until the end of the year, so I can’t answer your questions, and please forgive me if you’ve already done this, but have you looked up AZ&me? You might be able to get financial help paying for Lynparza. I put in that there would be Part B and D, and it said, depending how much you bring in a year in income, you may qualify for financial help. I wonder if you can do that with the blood thinner and eye drops too.
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Candy- all Medigap plan Gs have to cover the same way by law BUT they don’t have to charge the same. Just as you were told. That is why it is suggested to shop around for which Medigap supplement you go with.
There is something in the language about Medicare/Medicaid that prevents you from being able to get private funding for things like Ibrance.
I didn’t realize Eliquis is going to be an expensive med with Medicare. Crap.
I will go on Medicare next summer due to being on SSDI for 2 years but won’t be 65 yet. I have to hope at least one company in my zip code sells Medigap plans to those under 65. I see your zip code did give you choices!! I noticed the cost is a bit higher than my hubby’s Plan G. That is because he was 65. Sigh. More weird roads we have to ford.
What Plan D did you end up getting with. Hubby took WellCare.
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I'm no expert, but I've selected plans for both DH & myself. Here's my experience & advice.
Friends who have been on Medicare advantage plans like them (low cost) until they get sick and then they have trouble finding Dr in the speciality they need. Finding Dr who takes medicare supplemental plans (medigap) is more wide spread. Plans are designated by letters A-N. https://www.medicarefaq.com/medicare-supplements/medigap-plans/ so decide what works for you. Getting cost info online is not easy, mostly you get sent to sales person. If you can find an insurance agency specializing in Medicare, I'd highly recommend. They will know plans offered in your locale and can summarize your options. They get paid by ins co, so no additional cost to you. Cost go up each year and by your age bracket also, so don't think 1st year cost is going to last forever. Get a reputable company and plan to stick with them. When 1st eligible and for 4-6 months afterward), there is no qualification, but later if you change plans, you must qualify medically and can be denied by the new carrier.
I picked my DH's and it's been painless. a few years later it was my turn....I didn't go w/company I picked for my DH to save "pennies". Before plan was effective I discovered they did everything via snail mail & paper, no electronic EOBs etc. (Agency I used was shocked and didn't know about this). Cancelled before it was effective. Picked another and after 2 months, they couldn't get me setup online and hadn't processed any claims. I was in the window that I could change & went with co I put my DH in. No problems. Another mistake, my MO appt was on 1st of month medicare was effective. Caused all sorts of problems. So try not to have Dr appts the day your medicare starts.
Drug plans are easy to pick online on medicare site. And you can change each year. Put in drugs you take and your preferred pharmacy and get $$.
Difference in private ins and medicare - Rx with private ins falls into the OOP, so you hit a point with MBC that virtually all (except maybe copays) are covered fully. With medicare, there is not max on Rx costs. So infusions will be covered after you hit deductible, but Rx never stops. Target therapy is moving toward Rx from infusions and is very pricey. I hit catastrophic level of drug coverage with 1st Rx of Afinitor in January ($2500) then each month it is $620/mo. Overall, going onto medicare didn't cost less in my situation.
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KBL- AZ and me??? You mean Astra Zeneca, the drug company for Lynparza? No I have not. That is something to do next. Look up if they have assistance with cost of the drug for someone on Medicare Part D drug plans. Then I need to see what drug companies are Eliquis and Restasis and ask them for assistance. Problem with financial help is the forms you have to fill out. They look at assets--- I have an IRA and my pension from my career. Right there I usually do not qualify for the income guidelines being single and only one in household.
Dodgers- My insurance agent took my zip code and said I had 3 companies to choose from for Plan G Medigap coverage. Guess that is how it works? Only so many in ones area that you can choose from. Yeah, the insurance agent said that the closer I got to 65 the less the premium. I am 50. I told him "Not to be too blunt, but I have Stage 4 cancer. I will not get to 65 (15 more years)." My Plan D is Atnea Silver Scripts Smart RX. The lowest premium and the highest deductible. ???? I am going to call agent Monday and tell him I want to change to something else. I got on medicare.gov and put in my drug list and there are more choices than that one that seems wwwaaayy better. But what do I know.
I asked insurance agent about dental and vision coverage. He directed me away from them. Said premium too high for basic dental checks and basic dental work. And yearly eye check and glasses as needed didn't make sense to pay the monthly premium. I had dental and vision with my employers insurance and hoped to have it now again. Guess not.
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Candy, yes, it’s Astra Zeneca.
Are you sure they look at assets? I think when I looked at Ibrance help, they take income and not assets. I may be wrong.
To see if you qualify, it seems it asks for income. Here is the site.
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KBL- this does look like income only. I will check it out further. Will I even be on Lynparza in Dec when I will need this? IDK. I have my insurance Sept, Oct, and Nov. See if I stay on Lynparza after that. Don't know when we are scanning again and I have only been on the med for a week so far.
I did look into the LIS (low income subsidy) for Medicare Part D and that does look at ALL assets.
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Candy, I hope it can help. If you have to switch, most of the meds have some kind of help. I have the paperwork for Ibrance, but I’m going to be possibly changing to Xeloda. I hope the Lynparza calms down for you. I know it’s been a little rough.
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Dodgers Girl stated:" There is something in the language about Medicare/Medicaid that prevents you from being able to get private funding for things like Ibrance." This makes it sound like you can get no relief from the drug companies on these very expensive drugs. That is simply not true. I am getting assistance on neratinib based on income. Previously, I got the same thing for Ibrance. My doctor's office arranged it all through the hospital's patient program.
I think what you might mean, Dodgers Girl, is that Medicare law doesn't allow the government to negotiate on prices with the drug companies.
There is more information on all of this through medicare.gov, although it's pretty dense to read through.
Candy, good luck with this.
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Nopink, you said "Friends who have been on Medicare advantage plans like them (low cost) until they get sick and then they have trouble finding Dr in the speciality they nneed"
I'm on an Advantage plan and that is true if you live in a small town in a rural area. I live in a city, and I have a large selection of doctors in various specialties that I've used. What I really like is that there's no premium payments for the drug plan, so the years I didn't have prescriptions, I didn't have to pay a cent. My premium for the plan is just my regular Part B amount, my out-of-pocket limit is $2500 a year, and I don't have a deductible.
I just wanted to let people know that any claim of "trouble finding a doctor" depends very much on where you live.
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I just went on Medicare on 9/1 as I will be 65 at the end of the month. For the past year, I have been bombarded by so much info, offers of help, buy plan XYZ, etc.that my head was spinning. I have been a Kaiser Permanente patient for many years and wanted to keep all of my current health providers . They have an excellent Medicare plan and at stage IV I wanted to keep my coverage consistent and yes, I do need prescription drug coverage. It was relatively easy for me but if I had wanted to leave Kaiser my head would have been spinning!
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BevJen- I was thinking she meant that you cannot qualify for co-pay cards from these drug companies when you are on Medicare/ Medicaid. I got a co-pay card from Pfizer for Ibrance and they asked if I was on Medicare or Medicaid. Because I was on private insurance I got the assistance. But if I was on Medicare then the co-pay card wouldn't apply to me. Maybe other financial assistance that the drug companies offer. Didn't Jaycee used to talk about Foundations and Grant monies??
Alice- Good points. But I do live in a small town in a rural area. And I travel, across State lines, to my cancer center. And also, as a Stage 4 cancer patient as this Thread addresses, there will not be times when I/we have NO prescriptions.
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BevJen- https://www.verywellhealth.com/when-to-use-drug-coupons-4174705
“The Anti-Kickback Statute
It's illegal for pharmaceutical companies to offer discounts for medications that you purchase through Medicare due to the Social Security Amendments of 1972. Included in those amendments is the Anti-Kickback Statute (AKS).
The AKS prohibits anyone—drug manufacturers included—from giving a customer anything of value that could result in referrals for items or services that are paid for by a federal healthcare program.”
I have no personal experience on this Just going by previous posts and what I read about Medicare online. I read that Pfizer is suing the federal government to end this limitation on one of their new and highly expensive heart failure meds.
Since I am on Verzenio currently, will be reading here for sure for updated info regarding Medicare as I am worried about affording my meds once I have to leave my current work insurance where Verzenio is $25 a month
Candy- yes, that is what I meant, “co-pay” cards when on Medicare Yes, Jaycee49 used to talk about this a lot
This is why these forums are so important. I sure hope I am just not reading the Medicare site correctly
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Dodgers,
Thanks for posting your information.
There is a difference between those coupons that the drug companies offer and the other types of programs that drug companies use -- yes, the ones that Jaycee used to talk about (foundation assistance) as well as those programs offered by the drug companies themselves. As I said, I've gotten assistance from both Pfizer and Puma for drugs (actually have gotten drugs for free) based upon income (I am retired.) My doc's office facilitated it.
Also, the AntiKickback Statute is much more complicated than the description given in VeryWell -- which is not a bad site, it is just watered down and doesn't examine the AKS in full.
I'm just reporting on my own situation and I'm sure it applies to a lot of people. No sense giving up on getting drug assistance or drugs for free without further investigation. Not trying to argue with you, just reporting on my own situation as facilitated by my cancer center.
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I do plan on asking my MO office for assistance with getting Lynparza, or whatever is next for my treatment plan. When I got the Pfizer co-pay card for Ibrance I just called Pfizer and did it myself. But, as I said, I was not on Medicare and it was easy peasy. This may now be harder with being on Medicare and I may need some "inside" help with someone that has done it before. Surely the cancer center can guide me. I will not give up. I am on a fixed income with SSD, though I do have some "assets" that makes me ineligible for some programs. And I cannot afford to pay for my cancer meds each month with an astronomical patient co-pay.
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BevJen— no worries. I did not read it as an argument. I honestly read your post with intrigue. Hoping there will be something available when I have to switch to Medicare as my current employer health insurance is quite good and hate to lose the prescriptions portion.
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Alice - yes, I live in small town so my information about Medicare advantage plans is from that perspective. I'd check with the preferred facility about which plans they honor. This is another thing that my insurance advisor was helpful with fro my area.
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I have been trying to sift through everything said here as I just found this thread, and my head is spinning. Here is my take to add to the confusion...
I am on Medicare and have been for three years now (I am 68.) Previous to that I was on SSDI but that only works for two years. The next two years I was on a private arrangement between Kaiser and Medicare since I was previously with Kaiser through my employee and it was wonderful and cost me nothing. That has ended and I am now on solely Medicare Kaiser. It is my understanding everyone pays basic Medicare to start (about $145.00) then it goes up if you are over a certain amount in income (don't know if that is Kaiser specific.) We pay $16 extra per mo for vision/dental/hearing which we have already received back because of perks and bonuses with vision coupons. We don't use the dental because it is Delta Dental and they have a poor reputation of doing more work than is needed in our area. I am a wimp with Dental and love my current dentist office, so I cash pay. The part D (pharmacy) for us is included with Kaiser so we pay nothing extra although I want to check on that with all the discussion from previous posts, but my DH insists we don't pay extra. Our Rx copays are very reasonable (usually about $10) but I just fell into the donut hole and paid $2500 for my Everolimus. That should end after one more copay as I will hit the deductable. Here is a website discussion on Medicare coverage stages https://www.rxmedicareplans.com/Learn/Stages This is an excellent explanation and worth the quick read.
exbrngrl, I also am happy with Kaiser services. When I was transported by ambulance after a syncopy incident I had two options of two different Kaiser hospitals. I live in San Diego and there are many additional good hospitals around and not too far apart, but the ambulance was willing to accept my preference understanding insurance issues. I don't know if that would have changed had the timing been critical. I have no problems with referrals as it is all in-house. I am currently traversing through setting up appointments, etc., to have cataract surgery, but so far everyone has been responsive even so far as my optomitrist called me personally to discuss the next steps. He made the referral and it happened.
Hope this helps.
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Questions for the group---
With Medicare you don't do prior authorizations for anything?? Say my routine scans. Now, with health insurance, my MO office has to submit a PA before doing my 3 month scanning--CT and MRI. If approved by insurance, then we schedule. Really with any testing--- thyroid ultrasound with PCP, physical therapy for my back (PCP), etc etc. With Medicare no PA's??!! Your doc just says "you need ___" and they schedule it ??!!! With my insurance I was approved for 8 PT sessions. With Medicare unendless sessions?
Also, some on here has mentioned only 3 PET's in a lifetime with Medicare. Is that true? Where is that documented? Is there a Medicare Guidebook?
I just do not understand.
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candy,
I just went on Medicare on 9/1. I am sorry that I really can’t answer any of your questions. I have belonged and continue to belong to an all inclusive HMO that allows me to skip pre-approvals/authorization. However I do understand that there will be some limitations on certain things. I haven’t run up against them yet, but I’m sure I will. My biggest question is why is Medicare so darn complicated
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Yeah exbrngrl you are on Kaiser, right? I was wondering about regular Medicare. Seems so different from the insurance I am used to--- first employee group plan and now an individual plan.
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Candy,
The best place to start with anything about Medicare is medicare.gov. There is a lot of info on that website. Medicare also publishes a booklet that gets sent out to all Medicare participants each year that has summaries of info about different things -- it's simply called "Medicare 2021" or whatever year it is. I've never asked for it -- it just shows up. But you may be able to request it through medicare.gov if you want a print source.
I've not had to have a scan okayed since I've been on Medicare so far as I know. However, I always go to providers who "accept" Medicare -- that is something that you want to look into and that you want to research. If a provider does not accept Medicare as payment in full, you could end up having to pay additional fees.
As for PET scans, I think that there is some sort of a glitch with Medicare with this. With my previous provider, I had no trouble with getting a PET scan. When I switched docs, they said that it's more difficult to get it okayed, but I never pushed it. But I've had no problems with CT or MRI scans. As for physical therapy, there used to be a limit on how many sessions you could have in a year. I believe that Medicare now allows whatever is medically necessary as deemed by your physical therapist. I think the physical therapist has to communicate with Medicare about that, but I don't think it's any kind of a problem.
The only thing I've really had an issue with while on Medicare is an internal exam with my gynecologist. Medicare only covers these every two years unless you are "high risk." They have a very specific definition for "high risk" and it's not having breast cancer. Wait -- I take that back. After my hospitalization this past spring, I had to be transferred to a rehab site. Hospitalization was in Baltimore; rehab site was about 26 miles away, closer to where I live. I got a mileage charge tacked onto my transport bill. So Medicare "paid" for my transfer, but my excess mileage fee was over $1,000. That was a weird one. After I complained, I got the bill cut for that, but that's something that's buried in the Medicare information and I would never have known it.
You can also call Medicare and ask specific questions about coverage. However, my experience with this has not been good. The "specialists" don't seem to be that specialized and it's difficult to get info. So my advice is to bookmark the online source; get the booklet; ask your doctor or health care provider if you have questions.
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The cancer center I go to always submits the scan orders to my Medicare plan. The first time it was to be billed to the Medicare plan, the center knew it would take up to 10 days for approval. so they just scheduled the scans for three weeks out. Now the center has changed, its much less personable, and I have to call to schedule the scans myself and it is a royal pain in the ass. But Medicare seems to approve within a day or two now.
My center always makes sure any medical procedure is preapproved. The nurse told me one time someone was in the infusion room about to get an iv inserted for zometa and an office person ran in and said, hold up, it hasn’t been approved, or it was denied or something. I remember asking because I didn’t want to get stuck with paying some astronomical bill for something not covered.
As for pt, your plan might specify a set number of times per year that they will pay for. You’ll need to check with them on that.
Just a side comment, last December I took dh to the ER and he ended up needing immediate surgery for a ruptured appendix. When we got the bill weeks later, we find the surgeon on call that Sunday was not on dh’s medical plan (from his employer ) so we are paying monthly on the $6,000 bill. Sure, well worth it as dh had no complications and a ruptured appendix can lead to sepsis and even death. So the surgeon did an excellent job. But still, it is frustrating to go to a hospital and get a doctor in an emergency situation who does not accept the same medical insurance that the hospital does.
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Hi All,
I have heard how great Kaiser is for Medicare supplement. Unfortunately, I just learned for people with SS disability under 65, Alabama has no supplement other than advantage plans. AND none of those work out of state for regular care (emergencies yes, treatment no) I want to be able to go any major cancer center that offers the right treatment to keep me alive. And I can, but will pay 20% of everything through part B.
My hubby has extremely good insurance through work and could retire to Medicare next summer. I also qualify next year through disability, BUT we did the math and paying 20% is really going to eat up our savings. He is thinking about working until 66.5 to get the best SS and then reevaluate what is available for my Medicare at that time
Cancer sucks! Pushing off his retirement just to cover my expenses sucks. Let's be real. I am stable disease on a trial now and have survived 2.5 years of MBC but the odds are not in my favor.
Feeling a bit cranky from the treatment SE. 🥴
Dee
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Candy, I think it depends on what type of supplement you have to Medicare. I have a Medicare advantage plan called UnitedHealth Medicare Advantage. My doctor does have to request pre-authorization for pet CT scans. A recent pet scan was denied twice but eventually they approved it. I’ve never had this happen with other health plans. So I am guessing there’s a lot of variability in the Medicare supplement or advantage plans. I would not recommend UnitedHealth.
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