Medicare questions
Comments
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Candy,
And here's why this is all so confusing. My Medicare supplement plan (I am not on Medicare advantage) is through United Healthcare -- it's the AARP plan through United. I think they have been excellent.
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Thanks guys. I will definitely read medicare.gov and hopefully will get the Medicare booklet in the mail so I can review it. Some of this might get clearer as I go along and start using it. I start Medicare Dec 1. I got my card in the mail, but nothing else from Medicare. I chose a Supplement-- with the help of an insurance broker. He said I could do a Medicare Advantage Plan or a Supplement (Medigap). I chose the Supplement. He said that is Plan G. And that Plan G is Plan G no matter who you go with--- I chose Mutual of Omaha.
Just so much to learn. Seems much simpler but yet more complicated than regular health insurance. I guess because I am used to the hoops with insurance. Prior auths, etc. And I wonder if Medicare will have the hoops too--- auths for everything like insurance does. Definitely more expensive than insurance--- in premiums anyhow. Medicare $150/month, Supplement $270/month Part D prescription $80/month--- so premiums of $500/month. But maybe less in co-pays with doc visits or scans or labs. Meds are a different story altogether !!!! I am looking into help with med costs--- with pharmacy companies.
I want that Medicare booklet to read. And maybe call Medicare--- but don't want to be on hold forever and then get someone that doesn't know anything.
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Kaiser has been a godsend for me. They are both the service provider and the insurance provider! Because every Kaiser service provider works for Kaiser, all of your records from appointments to tests are in one data base, For instance, when I saw an endocrinologist recently, he was able to pull up my latest PET and other tests. Everything is there with just a few clicks and the doctors communicate easily through their internal system. Their way of doing things makes it really easy on the patient. Kaiser has such a large presence in CA that 1 in every 4 CA residents is a Kaiser patient . Are they perfect? No, nothing is but I have had excellent care without administrative hassles or hoops to jump through
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this just came. You will probably get a copy. Lots of info in it.
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Candy, my Medicare starts this Friday. I am paying the Part B of $148.50, but I don’t have any other premiums. I have Humana Medicare Advantage. I just started Xeloda today. I have learned it will be covered under Part B.
As far as scans go, I’m not sure whether I will need preapproval, but all of my doctors are on it, and it’s a PPO.
We will have to compare notes after we’ve been on it for a while. I won’t technically have to use it until November 1st because my husband has insurance through his work until October 31st. I’ve been a little overwhelmed trying to understand it myself
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The way my insurance broker explained it is that with a Medicare Advantage plan the premiums are lower, but when you go to the doc you pay the front desk a set co-pay. And then you have a percentage of cost of the scans, etc till you reach a maximum out of pocket for the year. With the Supplement I chose I have a larger premium, but no co-pays at the doc and 100% covered for stuff. So I guess I am paying up front with the premiums whereas with the Advantage Plans I would pay a little here and there for co-pays. Which ever way I wanted to look at it.
That is the way I understood it. May be not correct.
Plan D prescription coverage is another beast altogether.
Interesting that Xeloda is covered under Part B--- like chemo, but yet it is given at home in pill form. Wonder about the other pills we use--- Ibrance, Lynparza, etc. I am on Lynparza. Will have to check into that. Part B would be covered 100% whereas Part D drugs are tiered and big co-pays.
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I have Humana Gold Plus Advantage plan. 0 monthly premium. 0 copay to PCP. $5.00 for specialist. MRI 10.00 copay. Nuclear bone scan $10.00 copay. Generic meds, 0.00. I’m very pleased with this.
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Spookiesmom- That sounds wonderful !!! You do have the Medicare premium of appx $150/month (I think $148 this year) taken out of your Social Security check, right? If you get Social Security. I thought everyone had that. Since it is taken out, and we don't have to think about paying it each month, it kind of gets hidden I think.
I wonder if an Advantage Plan would have been better. When I told my insurance broker that I was a cancer patient, he said I should go with the Supplement. And he said that with the Advantage Plans there are networks and you have to make sure your MO, or any other doctor, is in-network. I go out of State to my cancer center--- I am in Illinois and go to St. Louis Missouri-- so we wanted to know that I would not have an issue with networks.
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Candy,
re xeloda issue -- the way the drug stuff is structured, if it's a drug that could be given in a hospital (I think this means as an infusion) then it's covered under Part B and not under the drug plan (Part D).
The other drugs you mentioned are covered under Part D.
You can go onto Medicare.gov, and use their prescription tool to see which Part D plan would be the best for you in any particular state. Sometimes the Part D premium is very high, but it doesn't really bring the cost of your drugs down. So that's a good check for you. Your Part D plan sounded pretty high to me -- I pay around $25 a month and so does my husband, who is on a good number of drugs.
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I logged onto medicare.gov. They have the Medicare booklet for 2022 online. I skimmed it. Not very helpful. For instance, DME products - walkers, wheelchairs - the booklet says are covered. Not. My mom got a wheelchair, but could not get a walker on Medicare. And you can only purchase 1 item, ie 1 wheelchair, in a lifetime with Medicare. So the booklet says Yes Covered, but not the whole story. And my sister that just passed needed a wheelchair for going to the doc (from car to building for instance) but not covered under Medicare unless she said that she would use the wheelchair around the house going from room to room so we had to pay cash for her wheelchair.
The booklet says scans-- radiology images- covered, but no mention of 3 PET's in a lifetime or having to have prior auth before the scans.
BevJen- KBL says her Xeloda is covered under Part B, but it is not an infusion. And my Part D I chose has $0 deductible, whereas some had lower premium but maybe a $500 or $1000 deductible before the plan kicked in. Yet again, pay more in premium, but less?? later versus less premium but more later. Maybe. I don't know how much my co-pays are going to be yet for my routine meds. So unsure yet how much I will pay each month with my meds-- BP meds, blood thinner, etc, etc.
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Yes, the Medicare amount taken out every month. No additional premium taken for Humana. Yes, it is HMO. Must stay in network, never been a problem.
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Candy,
I am on xeloda. I know it's not an infusion. But if it's a drug that could be infused (that's how I understand it) then it's covered under Part B and not Part D.
The prescription drug "planner" is a different part of medicare.gov than what you are looking at. It's set up state by state, because not all plans are available in all states.
Not saying it's not confusing, but there is a lot of info there.
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Candy, Xeloda is considered a chemotherapy, which is why it’s covered under Part B. I am on a PPO with Humana. I think your advisor gave you good advice if you’re able to go out of state. Mine told me they get paid the same no matter what plan, so I’m sure he took your situation into mind and told you what would be best for you.
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I hope you don't mind me adding this question. It's about Medicare, but a different circumstance.
Medicare and Tricare under 65 - anyone? I'm not eligible for another year, but I'd like to wrap my mind around this. I'm thinking Tricare picks up as a second (like when you have OHI) and acts as a supplement, yes? Any issues with referrals etc.?
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About a month ago I posted my experience re:Advantage plans. AliceBastable corrected my comments to say that my experience was true for small rural areas, but not for large metropolitan areas. She was correct. Today I got this from my ins advisor.
"A consumer can always switch from Original Medicare with a Medicare Supplement Plan to a Medicare Advantage Plan. However, if a consumer wants to switch from a Medicare Advantage Plan back to Original Medicare with a Supplement, they may not be able to get the Supplement if they have medical conditions. (A consumer can always go back to Original Medicare; getting the Supplement may be an issue)."
One thing I would add about getting an advantage plan, be certain that you are not going to need to move to a smaller place, or even another large city in the future when you need/want to be near family who will help take care of you. For instance, a great Advantage plan in LA may not have any participating Drs in Chicago.
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just want to share this WSJ article I came across. Interesting info about Medicare Advantage- if you move out of your Advantage plan's coverage area, you get a second chance to choose a supplement plan if you want it, without having pre-existing conditions held against you.
“8 Things to Know When Choosing a Medicare Plan
The choices can be confusing, and the fine print is important. But it's crucial to choose wisely, because it may be hard to change your mind.
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I am going to read this more thoroughly tomorrow, Olma61. Thank you for posting
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YW - Im gonna add the article title to my post too, there is more info there than just that one item about MA
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I was so busy today, I didn’t get a chance. I’m definitely going to read this tomorrow.
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How do you all find out if something needs a Prior Authorization Form filled out from your doctor to Medicare??? I just started Medicare and am getting Lupron injections at a medical clinic. My MO says I need a prior auth, but Medicare says MOST things don't . So does Lupron? Does anyone out there know? I called Medicare---- no help.
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I had some things that needed to be authorized, and my onc’s office got them covered. I just started using Medicare in the beginning of November. I needed Faslodex and Zometa. They got them both approved before I went. I would think it's the doc's office's job to do that
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Candy- I would think the doc could request authorization, and if it's not required Medicare will let you know. It's the doc that thinks the auth is required, right? So, no argument there.
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I’m not on Medicare yet but my pet scans and BP meds need pre authorization. The doctors office handles it when they set up my scan. With the Rx meds, the pharmacy notifies the doctor that the insurance wants the pre auth when they prepare to fill the prescription.
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Sorry for my question. My situation is different. I travel 2 hours one way to my cancer center. So when I moved to this cancer center, I asked my PCP locally if I could stay local for my monthly Lupron shots. He said yes. I have been doing this for a year. Now, I am on Medicare and switching my insurance info around. I told my PCP I needed a new auth and paperwork for the Lupron and he refused. Said he is not the onc and we are giving this for the cancer. So I was going to have to go to the cancer center monthly just for the shot. I was trying to see if Medicare even required a prior auth for this med. I heard that injectables given in a medical setting is covered under Part B, not Part D. So I didn't know if an auth was needed.
Come to find out, after multiple calls and portal messaging, that Medicare DOES NOT require an auth for Lupron. Good grief.
All this could have been avoided if when I called Medicare they just looked it up and said No not needed. But Government insurance. Had to not give a clear answer to me over the phone. And the Medicare Handbook was no help either. With my previous commercial insurance I could call and ask about a med and they looked it up and said Yes or No if an auth was needed.
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So sorry for all that grief, Candy. I’m glad you don’t need an authorization. My Xeloda is also covered under Part B, but the agent I went through to get the insurance didn’t know that. He was really great, though, and did the research to make sure I was right
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Hi All. I have looked around here but was wondering whether anyone lives in Colorado Springs and has a recommendation on an oncology center. Looks like I may be moving.
Thanks Chris
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SSDI and Medicare question.
I am not 65 but when I was approved for SSDI, I was told that after 2 years of SSDI, you are then put on Medicare. I have been aware of this SSA “rule” but wasn’t even sure I would be alive in 2 years. (And still realize that marker is not guaranteed).
My 2 year mark will be summer 2022. So questions are flowing to my head and thought I would throw them out here.
From what I have read at SSA.gov, the Medicare coverage is still automatic after 2 years of SSDI and nothing needs to be done or filled out, it just happens.
Question 1: is that how this actually works? I don’t have to go online at the 3 month mark and submit a request?
Question 2: how do I sign up for Medigap? Will I get notified before the 2 year mark of SSDI so I know to buy medigap at that time ( still not 65)
How did you you all handle this situation?
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Dodgersgirl, hey friend!
1. When I was eligible after 2 yrs of SSDI (not 65 either), I received a letter about when it would take effect and later received a paper Medicare card and welcome packet in the mail. I did nothing but notify my doctors and give them the new info.
2. I don’t know about medigap plans. I medically retired early and had to choose my new employer/retiree insurance, options were a Medicare advantage plan or a secondary plan. I picked the advantage plan, which had almost zero costs and handled all billing for Medicare’s portion. It’s been great so far.
I did find the Medicare website helpful, nothing clearly stated what to expect and I found it all pretty frustrating. Good luck!
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Illimae: thanks for the info!
Currently I have insurance from my employer that I took as a retired employee a few years ago. Not expecting Medicare until mid summer which gives me time to try to understand what's next,
Reference your Advantage plan, how has dealing with prescription coverage for cancer meds been?
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Dodgersgirl, prescriptions are mostly covered by the advantage plan. I’m on low dose cardio meds for protection, they’re $4, levothyroxine for thyroid is $3.70, Xeloda is $0 and a specialty HER2 oral is $60. The hospital infusion and injections are $0. Amazingly, the total out of pocket cost that I owed MD Anderson for all of 2021 was $8.53, instead of the 3-5K I was previously paying annually.
As a retirement benefit, I’d think you would keep your employer insurance to use in combination with Medicare. You might also reach out to any former retired coworkers to see how their situation is since benefits can vary so much by employer plan options and retirement rules.
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