Topic: Waiting and worried about insurance in NYC

Forum: Waiting for Test Results — We know, waiting is VERY difficult but we're here for you.

Posted on: Dec 5, 2021 02:10AM

Posted on: Dec 5, 2021 02:10AM

Lucy711 wrote:

Hello everyone,

I just had a biopsy 2 days ago and am anxiously waiting for results. I currently live in NYC and have an aarp Medicare advantage plan. I have till December 7 to switch plans….2 more days😕 can anyone tell me how they fared with an advantage plan in terms of coverage for breast cancer in NYC?

I’m so worried that this plan won’t be adequate and am trying to decide if I should go on original Medicare, supplemental plan and part D drugs. Not knowing what type of care and drugs I would need is confusing.

Thanks, The anxiety of waiting for a diagnosis is stressful and I’ve been reading the boards for encouragement and grateful for the generosity of members.

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Dec 5, 2021 07:50AM threetree wrote:

Lucy711 - I am not on an Advantage plan and I'm not in NYC, but I have been doing most of this for myself with traditional Medicare, an AARP supplement, and now Part D. I had work insurance too until the end of this past November and that kicked in for the drugs and a few other things that Medicare did not cover.

When I began all of this at age 65, I only had my work insurance, so had a lot of out of pocket (close to $10,000?) and it was killing me. When radiation time came around I decided I wanted to do proton instead of the "regular" photon and almost all private insurance does not cover it (cost is about $65,000.00). I was told by a financial counselor that you are automatically assigned to when you look into proton radiation that Medicare would cover it, so I signed up for traditional Medicare and the AARP supplement after talking to her. I told her I didn't know whether to go with an Advantage plan or traditional. She told me that in her experience working with people at the proton center, the Advantage plans were far more likely to try and find a reason to not cover something, since they are private plans, rather than traditional Medicare. Traditional is still government sponsored and paid. Traditional Medicare covered the proton therapy and the supplement picked up the co-pay thank goodness, as that would have been around $7,000, I think.

When I had the work insurance, traditional Medicare, and the AARP supplement, I was literally paying nothing out of pocket, but now that I've lost the work insurance, I will have to pay for the one drug I take (Letrozole), and the AARP Part D premium and deductible will cost more than the drug, but that's the way it goes, I guess. I also expect that I will have some costs to pick up now because Medicare does not cover some stuff that the private insurance did, e.g. my lymphedema compression sleeves.

It's a hard thing to figure out. One insurance will cover something another one doesn't, but to get the big picture is really difficult. Have you checked online with "My SocialSecurity" and AARP? I found that one or both of them (can't remember now) have calculators where you can enter where you live, your insurance options, the drugs you take, etc. and get comparisons with the different options.

The financial counselor I spoke with said that most people preferred traditional Medicare and a supplement over the Advantage plans, at least in her realm. She also said that most of them would rather pay premiums every month than have to pay unexpected, ever changing, fluctuating, "surprise" out of pocket balances.

I know all of this isn't exactly what you were looking for, but maybe there is something in my experience that could help. Good luck for sure!

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Dec 5, 2021 08:43AM alicebastable wrote:

I'm not in New York, but I live in a different city and I have an Advantage Plan. My yearly co-pay is capped under $2500. I don't have a deductible, and no premiums except for the Part B which would be deducted from my SS for regular Medicare anyway. It also covers Part D with no premium. I'm happy with it because although it's a network, I still have a wide choice of local doctors and hospitals.

Ignore treatment info (below) which is a BCO glitch. Do not enter personal information on this site since they grossly mishandled a data breach. Surgery 7/10/2018 Lumpectomy; Lumpectomy (Left); Lymph node removal Surgery 8/7/2018 Radiation Therapy 10/28/2018 Whole breast: Breast, Lymph nodes
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Dec 5, 2021 08:50AM Lucy711 wrote:

three tree,
I can't thank you enough for taking the time to reply. It is confusing to me since fortunately the only medications I take are inhalers for asthma. Not knowing what the outcome of the biopsy is I can't compare drugs, treatments etc. The results that led to a biopsy was Bi rads 4B, persistent focal distortion in slightly lateral right breast. There is also a separate 0.5 x 0.5 cm circumscribed modular asymmetry which I will have to go back for another mammo in 6 months.I have been happy with my Advantage plan and so far don't mind the copays but am leaning toward switching to traditional Medicare/ supplemental since it seems to cost more but covers more.

Appreciate your input, it is helpful,Be well and many thanks

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Dec 5, 2021 08:59AM Lucy711 wrote:


Yes, the Advantage plan I have is an HMO and so far it has worked well for me. I have been very fortunate at age 72 to not have had to use it often! Your plan sounds good. The out of pocket limits in my plan keep changing yearly and is over $7;000 next year. That includes co payments for drugs. When I looked at Part D drug plans they seem similar and that makes me wonder if I should stay on an advantage plan for next year. If costs get out of hand I guess I could switch to tradional Medicare in 2023. I have learned that it is best to have my annual physical, mammograms etc mid year instead of later in the year. That way I would have more time to assess future medical costs🙁

Thanks for taking the time to reply and stay wel

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Dec 5, 2021 12:06PM minustwo wrote:

I may be incorrect, but I understood that once you drop "original" medicare with a supplement for a medicare advantage plan - going back to a standard plan may require a physical & can be denied. Good luck.

2/15/11 BMX-DCIS 2SNB clear-TEs; 9/15/11-410gummies; 3/20/13 recurrance-5.5cm,mets to lymphs, Stage IIIB IDC ER/PRneg,HER2+; TCH/Perjeta/Neulasta x6; ALND 9/24/13 1/18 nodes 4.5cm; AC chemo 10/30/13 x3; herceptin again; Rads Feb2014
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Dec 5, 2021 12:53PM threetree wrote:

I'm not certain about this, but with regard to what MinusTwo said above, I think it is the supplement that is so hard to get back if you drop it. I think we are all entitled to traditional Medicare itself, but the other components are private (Part D, supplements, Advantage plans), so it is the private companies that will drop you or require physicals, etc. I've heard that if you drop a supplement and then try to get back on later, it can be very difficult. It's just all so confusing way more complicated than it should be - especially when you think that some older people are in their 80's and 90's with failing cognition and they need to sort all of this out too. I really understand Lucy711's dilemma. It's really easy to wind up paying for more than you need, but in many cases there seems to be no choice.

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Dec 5, 2021 02:42PM Lucy711 wrote:

Thanks Minus two, that’s a good point that I will have to look into.

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Dec 5, 2021 02:50PM Lucy711 wrote:

Three tree, that’s what I thought also.  But I was told in NY you cannot be denied due to a preexisting condition.  But if true, that could always change as plans and rules change yearly😞it’s really terrible in the midst of a health problem insurance companies make it so hard to decipher benefits.  I’m trying to stay positive and hoping for a good outcome from the biopsy.  I should get results sometime next week🤞

Thanks all for your input.

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