Is Medicare Coverage Any Good? - Advanced Prostate...

Advanced Prostate Cancer

14,594 members17,864 posts

Is Medicare Coverage Any Good?

jfoesq profile image

Hi-I am 63 years old and fortunately have very good medical insurance through my wife's employment. However- she is planning to retire in a few years and I was wondering how well those of you on Medicare felt about the coverage provided and whether the various optional plans (Plan B and whatever else there is) are needed/recommended for treatment of met/PC. Any comments you provide will be appreciated and, if you can, kindly let me know how well Medicare covers "new" developments in treatment, such as PSMA, LU 177.....

Thank you all!

127 Replies

So many options. I would not worry about it now. PC drugs are covered. The drug portion will have a deductible and co-insurance and if you take expensive prescriptions you might have high bills in January and then the rest of the year the drugs will be covered. As soon as the FDA approves LU-177 it will also be covered. When you go to the pharmacy, ask how much the drugs cost without insurance so you are not surprised. Be informed!

Thank you for your response. Do you know if adding to Medicare with their various optional plans that I believe they offer is helpful to those with MetPC?

Purchase a Medicare Supplement policy. This will cover the part A deductible and other little things. Medicare Supplement policies typically allow you to travel and go to any provider that accepts Medicare. Just ask about providers when you sign up.

Thx!

Saydeebugz profile image
Saydeebugz in reply to jfoesq

Be SURE you go with a GOOD "Supplement plan" NOT 🚫 an "Advantage plan"!! An advantage plan will be cheaper BUT you will have a MUCH higher out of pocket (especially w/PC treatments). My husband was on a Plan F Supplement and we had ZERO out of pocket thru PC treatments, a major surgery and 2 hospital stays.

jfoesq profile image
jfoesq in reply to Saydeebugz

That's the way it should be for all of us, without thus nonsense of having to do research... Happy for you.

Shorter profile image
Shorter in reply to jfoesq

I was on employer insurance when I had Robotic surgery. I had to pay quite a bit. Thankfully I chose to buy a supplemental insurance policy about 3 years before my diagnosis. Two years later on Medicare I had 39 radiation treatments along with ADT. I had to pay NOTHING other than the annual deductable and premiums. I actually came out ahead because of the supplemental I had purchased 5 years earlier. I have Medicare with part G. As for prescription plans for part D, they are all over the place, some good, some not.

jfoesq profile image
jfoesq in reply to Shorter

Thx!

Coupe31 profile image
Coupe31 in reply to jfoesq

Try watching YouTube videos from Boomerbenefits. They offer many excellent videos which explain in detail original Medicare (Part A, PartB , Part D and MediGap Plans)as well as Medicare Advantage Plans. Their services offered are free as well as services from other companies.

jfoesq profile image
jfoesq in reply to Coupe31

Thx. That's great advice.

tsim profile image
tsim in reply to jfoesq

Agree with Coupe31, call Boomer Benefits, they deal only with these plans everyday and are a wealth of information. You have plenty of time so make a list of all the questions you have and they will have the answers.

It is absolutely incorrect to say that Medicare will cover a procedure or drug once the FDA approves it. They may or may not.

tsim profile image
tsim in reply to swwags

That is correct and unfortunately, most private insurers follow their lead.

Medicare is a good insurance if you have part A, part B and part D plus a supplemental plan that is not an advantage plan (managed Medicare).

One of the best supplemental plans are the PPO plans which will pay a large part of the Medicare deductibles and allow you to keep using your Medicare anywhere where Medicare is accepted.

Managed plans such as advantage plans may have restrictions in relation to network and out of network providers and they may be not accepted by places which accept the regular Medicare insurance.

Check what kind of supplemental plans are available in the County where you live.

medicare.gov/plan-compare/#...

jfoesq profile image
jfoesq in reply to tango65

Thx, Tango. Roughly speaking, what are the costs for all of those plans?

tango65 profile image
tango65 in reply to jfoesq

It depends on where you live. The AARP have many plans perhaps it may help

aarp.org/health/medicare-qa...

jfoesq profile image
jfoesq in reply to tango65

Thx again

Depends on which state you are in. Medicare is different state to state. I do not recommend an advantage plan no matter which state you are in. I have a Medigap Plan F from AARP United Healthcare. Plan F is more expensive but I have not paid a medical bill with it.

Part D is different. You have to go on the MyMedicare website and enter all the drugs you are on and search for the best plan.

jfoesq profile image
jfoesq in reply to Magnus1964

Thx, Magnus. I live in NY.Can you provide me an approximate cost for the Part F and any other costs you have?

Magnus1964 profile image
Magnus1964 in reply to jfoesq

I live in Pennsylvania, I pay about $248.00 per month each for my wife and myself. That does not include Part D. That is another $38.00 each per month.

jfoesq profile image
jfoesq in reply to Magnus1964

WOW! That's MUCH less than we pay for medical insurance now.

Magnus1964 profile image
Magnus1964 in reply to jfoesq

Medicare is a very good government program. Each year they cut a little here and little there. Someday it will disappear.

leebeth profile image
leebeth in reply to jfoesq

Remember, that is in addition to the Part B premium which is $170ish this year for most, but is higher if you have to pay an additional IRMAA premium if your joint income is greater than $182,000. This is based on your modified adjusted gross income from 2 years prior, and you could pay an additional amount per person up to a total of $578 per person. Premiums are deductible above the line if you have self employed earned income, up to your profits. So a small business could help decrease your income for IRMAA. This is only true if you are not eligible to be covered under an employer group plan, but you could deduct both your premium and your spouse’s.

The real cost of part D is drug costs! My husbands Xtandi costs us $8000 a year!

Try getting his xtandi from India. It's the same brand you get here in the US at fraction of the cost.

OT - reach out to PAtient assistance network or The Assistance Fund for help with covering the co-pays for Xtandi. So far my out of pocket has been $0

Many of these assistance programs specifically exclude people with Medicare Part-D coverage.

Don. They have been helping me for quite awhile. I have Part D coverage.

Ive heard there are co pay assistance programs for this. My neighbor got his Xtandi paid in full by the program.

swwags profile image
swwags in reply to jfoesq

Medicare Part F is no longer available to people who are eligible after 1/1/20

Fightinghard profile image
Fightinghard in reply to swwags

Part G is basically the same coverages as F, but has a small annual deductible. Monthly rate for G is slightly lower than F so it is almost a wash if you compare total annual costs

jfoesq profile image
jfoesq in reply to Magnus1964

Thx, Magnus. I live in NY. Can you approximate for me what you pay for your Part F plan and any other costs you have for treatment?

Magnus1964 profile image
Magnus1964 in reply to jfoesq

I pay $248.00 per month for part F and $42 for Part D. You can go on the MyMedicare website and answer some questions, they will list plans available in your zip code with prices.

WSOPeddie profile image
WSOPeddie in reply to Magnus1964

I have the same plan and I am happy with it. Not restricted to a network so you can see any specialist who accepts Medicare.

Pops78 profile image
Pops78 in reply to Magnus1964

Does your AARP UHC supplement increase every year with age? I see where some do, like BCBS and Mutual of Omaha. The UHC site says it increases with cost of living instead but that may be an open door? Helps to have first hand info.

Magnus1964 profile image
Magnus1964 in reply to Pops78

Yes it does increase. When I signed up I got a discount for being an AARP member. Then the premium increases every year. It's still a good policy for a good price.

Costs for Medicare Part A (free), B ($170), D (~ $20+/-), and Supplemental (~ $200) total about $400/mo depending on many factors. Compare that with your wife’s plan. You have 8 months to sign up for Medicare after leaving PI, and you need to chose wisely which company to go with, because pre-existing conditions rules don’t apply in Medicare if you try to switch plans after initial enrollment. Get the Medicare booklet and study your options. Get familiar with the formulary for Part D drugs you might need.

jfoesq profile image
jfoesq in reply to timotur

Thx, Timotur. Those costs are much less than what we pay for our present plan, so that's great news. Having said that, I am very surprised to learn that not allof the plans you mentioned provide for pre-existing conditions. What acrazy healthcare system we have in this country.

timotur profile image
timotur in reply to jfoesq

Sure, please be aware that underwriting of pre-existing conditions only applies to when you try to switch plans after your initial enrollment…. So make the best possible choice of Plan and Company based on your foreseeable needs going into Medicare. Preexisting condition rules are not the same as under the Obamacare act, Medicare was excluded after the initial enrollment. Good luck.

jfoesq profile image
jfoesq in reply to timotur

Interesting and strange. I wonder why they did that since it's a Govt program. Any way- I appreciate you clarifying that for me.

timotur profile image
timotur in reply to jfoesq

It was probably pushback from the Insurance companies to avoid taking new high-risk individuals after they've paid premiums to another company for an untold period. That's the price of having a choice, but you have to choose wisely first time.

Atlpapa profile image
Atlpapa in reply to jfoesq

the pre-existing condition thing only applies to the supplemental plan. if you get a supplemental plan when you first get medicare part B there is no underwriting so not a problem, if you wait past a certain number of months after signing up for medicare part b, pre-existing conditions will be taken into account and you can be denied but more likely pay a much higher premium. part of the rational is the insurance company doesn't want people to wait until they are really sick and then get a supplemental plan.

jfoesq profile image
jfoesq in reply to Atlpapa

Thx for the info.

OTPrincess profile image
OTPrincess in reply to jfoesq

Please remember drug D plan will charge you for each Medicare. My husbands Xtandi costs $8000 a year

jfoesq profile image
jfoesq in reply to OTPrincess

$8000- OUCH. Does your husband have Part C or Parts B and D ? Thx

OTPrincess profile image
OTPrincess in reply to jfoesq

We have A, B, G and D. We stayed away from advantage plans because of the limitations it has regarding treatment.

jfoesq profile image
jfoesq in reply to OTPrincess

Thx. really incredible that they are permitted to call it ADVANTAGE when from what I am reading, it appears to be a disadvantage.

OTPrincess profile image
OTPrincess in reply to jfoesq

Those advantage plans sound too good to be true and what I have learned over the years, “ if something is too good to be true, it is!”

Atlpapa profile image
Atlpapa in reply to jfoesq

also be aware the the estimated 400/month is for each of you, so total approx 800/month for both you and your wife.

jfoesq profile image
jfoesq in reply to Atlpapa

Thx. Still much less than we pay now, though.

Lulu- sorry, but I am a bit confused. First of all, I am only 63, so I believe I have to wait about 18 months before I can get Medicare. Secondly- what's the rush about the first 2 years? Don't I simply apply when I reach or approach age 65?

I gave up my company sponsored PPO plan (I think it was United Healthcare) and got on Medicare + AARP United Healthcare Medicare Supplement + a drug plan. I've paid virtually nothing out of pocket after premiums except some drugs. My PCa treatments since going on Medicare included Taxotere, radiation of lymph nodes (37 sessions), Lupron, and all the other drugs and scans that go along with those treatments.

I know a lot of guys with advanced prostate cancer who are on Medicare + a supplement like AARP, and I've never heard a single complaint about Medicare. My Medicare payments are higher than other guys my age because I'm still working full time with a good income, but I'm very happy knowing the only thing that comes out of my pocket are premiums. I've tried three different drug plans, and they all have crummy customer support and crummy web sites - so I revisit that choice each year and just try to minimize total costs of drugs.

Medicare often covers new treatments before and/or better than private insurance plans do.

Generally part D covers drugs administered in hospital or doctors offices but not prescriptions you take at home. Pills like Xtandi can cost you $8000 a year.

I think you meant to type B. D is what you buy as a type of supplement to cover drugs you take at home.

We have A B G and D. Both G and D are medigap/supplements. There are premiums for these and I was just shocked that cancer drugs that are not administered in doctors office or hospital , but are taken at home are very expensive. However, we are glad that they pay something towards Xtandi …. So while $8000 a year is a lot it’s way cheaper than not having part D.

Yes. My mistake. I meant B. D is for home drugs. Thank you for pointing that out.

jfoesq profile image
jfoesq in reply to ron_bucher

Great news-thx. Although, someone else indicated they pay about $8000 annually for Xtandi.

I feel the need to throw in a plug for Medicare Advantage plans, because not only replies to this post but also other posts have often dissed these plans. Just as with any private insurance that you buy, Medicare Advantage plans run from horrible, to mediocre, to OK, to very good. It all depends on what you buy, and how carefully you read the fine print. In my case, I had excellent health care through my employer, through Kaiser Permanente. When I retired, I chose to continue my excellent coverage through Medicare Advantage. I pay zero monthly premiums, I pay nothing for CT scans and bone scans and infusions and just about anything else. I have unlimited access to specialists; my oncologist is a leader in the field nationally. My hospital is rated among the top 10 in CA. I'm not saying that Medicare Advantage plans are good for everyone; it fits for me, and I'm lucky that my retirement plan provides a high level of coverage, that I know isn't available to others. I just didn't want everyone here to think that ALL Medicare Advantage plans are a bad thing.

Agree totally. Kaiser has been great for me too. No regrets at all with Medicare Advantage through Kaiser.

dixiedad profile image
dixiedad in reply to LifeQuality

We also have Medicare Advantage and it saves us thousands of dollars a year.

Prostta profile image
Prostta in reply to LifeQuality

As someone In healthcare taking care of cancer patients, Medicare advantage is a death warrant for cancer patients. They delay treatments and deny tests. There are some who falsely promote these . You get to save fir your coffin with these plans.

jfoesq profile image
jfoesq in reply to LifeQuality

Thx for this info. Very good to know.

TeleGuy profile image
TeleGuy in reply to jfoesq

The way I think about it is that with Medicare Advantage they get your average cost of treatment from Medicare and the way the insurance company makes money is to deny coverage. On the supplement plan, you basically have one chance to get it right because with a cancer Dx nobody else will want to cover you if you want to switch later. They HAVE to take you at initial enrollment time. As for the drug plans, you can play around with the Part D enrollment tool at medicare.gov. You can plug in the drugs you might need to take and see what they cost from different Part D plans and from different pharmacies. You can do all of this without actually trying to enroll. Realize that your shots (Lupron, denosumab, etc.) are part of the hospital benefit as they are administered by a doctor, so don't try to add them to your Part D estimates.

jfoesq profile image
jfoesq in reply to LifeQuality

That's great. But- is your plan available to everyone. or only to x-Kaiser employees?

LifeQuality profile image
LifeQuality in reply to jfoesq

Actually, I'm not an ex-Kaiser employee, which I think is a good thing since my sister retired from Kaiser and her coverage is not as good as mine! I'm an ex-State of CA employee. The key here is: read the coverage IN DETAIL. Yes, it happens that as a State retiree, I get a really good plan with almost no co-pays or limits for ANYTHING. But there are a bizillion other policies offered by Kaiser (or by every other health plan) depending on what you qualify for, whether you are part of a group or signing up as an individual, etc. Kaiser is non-profit, but every private insurance company has similar extreme versions of coverage. To start, read the book put out by Medicare that describes in detail all your options. It's quite well written, I think. It's online, or you can find a copy at any public library. There are a lot of choices out there, and many depend on your own circumstances, including where you live, whether you travel a lot vs. live in an area covered by a Medicare Advantage provider that has a good reputation, etc. And remember, you can always change your coverage once a year during open enrollment, if you aren't satisfied with the choice you made.

jfoesq profile image
jfoesq in reply to LifeQuality

Thx for the info!

What if you go out of state or the country?

As with everything else you've read here, it all depends on the "fine print" of the particular plan you choose, whether that's a Medicare Advantage plan, or "original Medicare" with supplemental insurance. In my case, my Medicare Advantage plan covers you out of their service area when you are traveling. For example, I was traveling out of town and got sick. I emailed my doctor, she sent a Rx to a local pharmacy of my choice, and when I got home I submitted the bill to the Plan, which paid me back 100% within 1 week.

jfoesq profile image
jfoesq in reply to LifeQuality

FYI I just finished an introductory Medicare group zoom question and the expert is on Medicare. He is on an ADVANTAGE plan because that's what suits his needs beat. He doesn't push nor recommend any particular plan (and gets paid by the plan for his services, not by the patient) and says everyone is an individual with different financial concerns, health situations/needs and .... and thus what's good for the goose may not be good for the gander. In addition some States are more restrictive in switching plans than others and apparently NY (where I am from) doesn't have underwriting for its ADVANTAGE plans. I will have a personal consult with him in a few days and keep you informed of what I learn.Lastly- in case some of you are under a misconception and IFFFF I understood him correctly, a doctors office or hospital that accepts Medicare MUST accept whatever Medicare plan you have. It doesn't matter if a particular doctor doesn't list your particular plan on his website of insurances accepted- as long a she/she accepts Medicare, he must accept the Medicare plan you have.

What is you move out of state?

I think Medicare Advantage plans could have a place for certain people. If you don’t travel much and feel no need to go out of network. If you feel you are receiving excellent care. MA plans can have some tempting bells and whistles like dental coverage, etc.

You hit the nail on the head. My mother had a knee replacement with a MA plan. She thought she could recover in a local place....OH NO... the MA plan required her to go to another city to recover so guess who had to care for her. ME!!!!!!!!!!!!!! My screen name should be GrumpysDaughter.

Always check Goodrx before you pay for prescription sometimes cheaper.

I have been well covered by Medicare and my BCBS supplement. I have not needed any extraordinary evaluations. And of course there are always copays.

Why read the fine print when Medicare covers you. I live in Georgia, treated at Duke, MD Anderson, UCLA, and UT Southwestern, always covered. I once changed to a United Health Care Advantage Plan...their top plan...MD Anderson had no contracts with any advantage plans when United told me they would cover. Medicare allowed me to reup outside the enrollment period. During the proton treatment I got a denial letter from United. I had already got back with Medicare. So why sweat it unless you want to save a few dollars. Blue Skies

I’ve found Medicare insurance coverage to be excellent. I have a supplemental and a drug plan along with A and B and it’s been great. Haven’t had any issues with coverage for drugs or treatment. My PCa MO Dr. Sartor said he hasn’t seen any issues with Medicare covering PSMA scan although you might be limited to getting one once or twice a year depending on your medical circumstance. I was told to avoid Medicare advantage plans if you are a cancer patient, that they can deny coverage of treatments or drugs as they choose. Even some of the professional consumer financial advisors like Clark Howard advise against them.

Ed

jfoesq profile image
jfoesq in reply to EdBar

Interesting. Thx for the info

jfoesq profile image
jfoesq in reply to EdBar

Thx for the info, Ed.

My impression is that private plans don’t pay for new treatments until Medicare does. I think they tend to safely follow Medicare guidelines. Is this correct?

Medicare and supplements are good for MO and testing. Prescriptions are another area. Some supported very well others as with Zytiga not so good. Try GoodRx as a shopping tool. Helped me lots!

jfoesq profile image
jfoesq in reply to katartizo61

Thx for the info. Which Medicare Plan(s) do you have/ Advantage?

katartizo61 profile image
katartizo61 in reply to jfoesq

A, B, F and AetnaI have a prescription program that simply did not help with Zytiga costs. I got that down to 250/month still a bit much, however worth it

jfoesq profile image
jfoesq in reply to katartizo61

Thx!

I joined Medicare this past June, and took a Plan G supplement and a Part D Rx drug plan. My agent advised strongly against Medicare Advantage plans, which can have limited networks.

On the Rx drug plan side, you may have to switch plans each year based upon the mix of drugs you expect to use during the coming year. I had to switch from the plan I had from June-December because I may have to start generic Zytiga and my new plan has it for about $110 per month, the cheapest I have seen.

Injectibles like Lupron are covered on in full by Part B, whereas pills like Orgovyx might be quite expensive under any pharmacy plan.

So you have to study all aspects of Medicare coverage, put it all together, and re-evaluate every single year.

jfoesq profile image
jfoesq in reply to dhccpa

Thx for the info. You don't seem to be alone in believing Advantage Plan is NOT the choice to make.

Thx for clarifying. I have been treated now for 9+ years, so I don’t think the 2 year period you mentioned concerns me.

But on Medicare B dont you pay 20 percent of all bills? I have 10's of thousands of dollars of things done at Mayo and that 20 percent would add up quick. ?

TeleGuy profile image
TeleGuy in reply to Survivor1965

Your Medicare supplement plan pays the remaining 20 percent after your deductible.

Medicare is really the only game in town if she can get Medicare and not go on an Advantage plan all the better. Then there is party drugs.My Zitiga List for $15K/mo. With Part D,

Cost is $10K/yr.

Best luck.

LifeQuality profile image
LifeQuality in reply to carbide

My Zytiga is $20 a month through my Medicare Advantage plan. Prednisone is $5

jfoesq profile image
jfoesq in reply to LifeQuality

Good to know. Which Advantage Plan do you have?

Just a word of caution wrt Plan F supplements:

I started out with a Plan F supplement, and it was awesome. No out of pocket costs at all. Then the premiums started going up rather dramatically...and it was my understanding that this trend was to continue until Plan F is no longer offered, due to not enough demand since folks are getting priced out.

I had an opportunity during a SEP in my home state to make a switch and jumped on it -- now I have Plan G, which is *almost* as good benefits-wise and *much* better premium-wise ... and the premiums are relatively stable ...for now, anyway.

There is also, IIRC, a high-deductible Plan F but I did not look into that; can't say much about it.

Love my Medicare coverage combined with Supplemental Plan F or G (the most deluxe and fullest coverage. Do not go for all of the heavily advertised “Advantage” plans! They take you out of Medicare and put you on a private managed care type plan. Very profitable for them because of restrictive loopholes which is why they are promoted so aggressively.With supplemental F or G everything FDA approved will be fully covered including Lu177 and any other treatment given in healthcare facilities, dr offices and hospitals. Only prescriptions you take at home which require a separate policy (Part D). You have to shop these when the time comes. No worries.

jfoesq profile image
jfoesq in reply to MateoBeach

Thx. It's amazing how many people have responded and provided info about their own experiences with Medicare. Unfortunately- many of the responses seem in conflict with each other so it remains difficult to understand. I can't believe how complicated this is.

A friend who is a professional medicare advisor counseled me to avoid the Advantage plans. I went with a Humana part G. The premium for me with limited income is $148/month. The most I will ever pay for hospitalization is about $3000.00. I believe in my state (New Mexico), I had 4 months after my 65th birthday to choose a supplemental plan without being subject to possible underwriting, which because of the pre-existing Pca could have increased my premium by hundreds of dollars a month. Yes, crazy system!

My mom had an Advantage plan. While there were no monthly premiums, when she had a 5 day hospital stay after a fall, Medicare would have automatically paid for 4 weeks of re-hab, with the possibility of being there longer if necessary. With the Advantage plan there was an administrator that required the doctor and re-hab facility to justify her stay after each 5 day period. A lot of work for the both doctor and facility and they only agreed to pay for 2 weeks, we had to pick up the $500/day for the last 2, even though all of the professionals involved said that she needed to be there.

As with every decision around Pca, take your time!

jfoesq profile image
jfoesq in reply to FRTHBST

Thx for the info. I can't believe you had to pay for the last 2 weeks of rehab on the plan she had but wouldn't have had to do so had she been on a different plan. CRAZY!

I am on medicare and AARP's supplemental....all alphabet soup which I never like...same with all these goverment run plans....private was bad too but this is worse...I am in NY too...so many can and cannot do...recommend you talk to a broker who can help guide you the best options....even giving personal information a 1000 times maybe then they can get that right...Good Luck Brother...Pray for God's direction always he never fails!!!..

jfoesq profile image
jfoesq in reply to SPEEDYX

Thank you!

Medicare Advantage are private insurance plans and they vary in quality. Note that they are ALL narrow networks, meaning they have a narrow range of network providers in small areas given your geographic location.

If you live in Rochester, MN, and you pick let's say a UnitedHealthcare Advantage plan, terrific, the Mayo is in your network.

Now if you live in Minneapolis, a mere 90 minute drive away, the Mayo would be out of network. So you have to look at the cost of care out of network.

The point is you need to understand which facilities and providers are in your network vs. out so a Medicare Advantage Plan may or may not be right for you.

Medicare Plans (True Medicare) are government plans and every provider who accepts Medicare in in network no matter where you are in the country - however, there are no limits to your out of pocket in some circumstances. That's why you read about people who go broke on Medicare. Example: if you need to stay in the hospital for more than 90 days with the same illness or injury, Medicare will not cover and you are left with the bill. Some treatments are only covered by Medicare @ 80%. The remaining 20% is owed by you. Now if those treatments run in the hundreds of thousands, you bank account dries up quickly. That's where Medigap comes in.

To address that, you purchase a Medicare Supplement aka Medi-gap plan, which makes up the difference. These Gap plans are also private insurance so read the fine print. Medigap plans have a minimal defined set of coverage standards across the country but are worth the money because they typically takeover when Medicare stops. Those standard are a bit different if you live in Massachusetts, Wisconsin or Minnesota. Medigap also covers the coinsurance, copays etc.

Then there is Medicare Part D, drug coverage. You have a limited window to enroll for Part D and if you miss it, you pay a penalty. The Penalty is a lifetime one, so buy it and don't procrastinate when the enrollment window is open.

Lastly, I said it previously but it bears repeating, Medicare does not automatically cover FDA approved treatments. They go through a process to determine whether alternative and currently approved treatments provide the same or better efficacy. That doesn't mean it won't be covered once approved by the FDA but they have a process.

jfoesq profile image
jfoesq in reply to swwags

Thx!!!

Let me add another example as we here on HU love our scans (borrowed from Healthline, emphasis in bold is from me):

"The cost for your CT scan will depend on several factors, including where you have the scan and which part of Medicare is covering it.

Here are a few examples of what a CT might cost in different situations:

STANDARD MEDICARE : When you have a CT scan in the hospital. In this situation, the cost of a CT scan will go toward your Part A deductible. In 2021, the Part A deducible is $1,484 for each benefit period. Once you’ve met this deductible, Part A will cover all tests and procedures during your stay, with no coinsurance costs during the first 60 days of hospitalization.

STANDARD MEDICARE: When you have an outpatient CT scan. After you meet your Part B deductible — $203 in 2021 — Medicare will pay 80 percent of the Medicare-approved cost of your CT scan. You’ll be responsible for the other 20 percent.

MEDICARE ADVANTAGE: If you have a Medicare Advantage plan. Your Medicare Advantage plan will have its own costs. The deductible and any copayment or coinsurance amount will depend on your plan. Contact your plan ahead of time, if possible, to get an estimate of how much this test will cost.

The exact cost of your CT scan will also depend on individual factors like your location and the exact type of CT scan you need."

So to the average Joe, this is confusing. I worked in insurance for 30+ years. Time to educate yourself on how to protect yourself both physically and financially. You can see the many and varied valuable opinions above based on where each responder lives and their age.

Medicare.gov is a good site. And call any insurer in your area of residence and they will send you boatloads of info on Medigap and Medicare Advantage plans.

jfoesq profile image
jfoesq in reply to swwags

Thx. It's amazing how much research one has to do to find the best plan.

blms profile image
blms in reply to jfoesq

Isn't that the truth

Medicare is great for doctors, hospitalization and infused drugs. I have the top of all the medicare plans and AARP supplemental and took top of that. Currently I have NO payments I ever have to make. With that said, I am grandfathered in a Medicare plan they no longer have available which covers more. AND the drug programs ALL suck. So, check your meds on a program and see what they cover. Good luck. This is wrong!!!

jfoesq profile image
jfoesq in reply to blms

Thx

Medicare has been great. I also have a good secondary insurance that pays the 20% that Medicare doesn't pay. So, I have almost no medical expenses except the co-pay for medications that my secondary insurance pays most of. A couple of caveats. If you intend to do a lot of traveling in retirement, Medicare does not cover medical treatment outside of the U.S. So, make sure your secondary coverage does. As others have said don't get one of the heavily advertised Medicare Advantage programs. They may be a little cheaper, and they may include prescriptions, so you don't have to buy separate prescription coverage. And they may allow you to get all your doctor visits, tests, treatments, and hospital visits in one location. They may throw in a gym program, and maybe even vision and dental coverage. And they may be very good programs if you're young and don't get sick. BUT, you can't get away from the fact that Medicare pays the plan a certain number of dollars every month, whether they provide any care for you or not. So, if you have any kind of serious, chronic illness, you'll probably see them cutting corners, denying certain tests or treatments, etc. I was in a so-called 5 star Medicare Advantage plan for 10 years after going on Medicare, and I got progressively more frustrated as I got more and more "No"s from my doctors when I wanted a referral to a specialist or a test, etc. Now, on traditional Medicare I can go to any almost doctor, almost anywhere at no cost (with my good secondary insurance.) If I have a complicated or serious issue, I find one of the "centers of excellence" for that condition, and get treated by the best. You asked about new radiotracer cancer scans. I just got the new Ga68 PSMA-11 scan. The hospital billed just over $35,000. I paid nothing. Good luck.

jfoesq profile image
jfoesq in reply to ImaSurvivor1

That's great! Thx for the info.

Pops78 profile image
Pops78 in reply to ImaSurvivor1

Any problems getting a supplement to take you after being on a MA for 10 years? What ins. company do you have for your supplement? Were you already diagnosed?

ImaSurvivor1 profile image
ImaSurvivor1 in reply to Pops78

Pops, My secondary coverage is Tricare, which I realize is not available to most people. It is available to retired military people. I don't know if there would have been a problem getting another supplement after leaving a Medicare Advantage program.

Pops78 profile image
Pops78 in reply to ImaSurvivor1

Thanks

When you switched from advantage to regular Medicare, did you have to go through underwriting? If you have a serious illness they can deny you coverage or charge a lot of money to switch as I understand it.

No. There's no qualifying for traditional Medicare. Some Medicare supplements may not accept you if yu apply other than at the time you originally apply for Medicare, but, Medicare, itself, doesn't require any underwriting.

Yes. Original sign up has no underwriting but if you want to later switch in the coming years, many plans have an underwriting clause.

You asked about switching from a Medicare Advantage plan to traditional Medicare. There are no "many plans" in plain ol', regular, traditional Medicare. There is no qualifying for Medicare. There may be specialists who won't take you without a referral, and there may be doctors or medical groups who are not taking new patients, but you won't have to be underwritten to use Medicare.

cnbc.com/amp/2018/11/15/use...

See you asked the right question...

As far as Medicare is concerned....... it's ok if we still have a United States in 6 years......... so save your confederate money cause the ____________________ will rise again......

Good Luck, Good Health and Good Humor.

j-o-h-n Wednesday 01/05/2022 5:58 PM EST

There is some serious misinformation in some of the replies on this thread. Since retirement eight years ago, I have been on a Medicare Advantage plan through United Healthcare and it is through my former employer. I had the option of signing up for the HMO plan or the PPO plan and I chose the PPO plan. It costs me approx. $70 a month more than the HMO would have cost. I can go to any Doctor in the U.S. who accepts Medicare. I do not need referrals, ever. I just make my appointment and go to any specialist who accepts Medicare anywhere in the country. Co-pay is $25. Subsequent to having my present insurance I was diagnosed with PCa. I had my 3TmpMri, three other scans, targeted biopsy, and RARP with the Doctors and hospital of my choosing. My total out of pocket cost was $160. More recently, I've had several more more scans and four treatments with anesthesia (mostly Lithotripsies) for a couple of kidney stones. My total out of pocket, $120. I've had a couple of colonoscopies and other procedures and I've only had to pay my minimal co-pays.

Certainly, all Medicare Advantage plans are not equal. There is no question, health insurance is really complicated. I have friends who have Medicare with a quality supplement and are very happy. I think everything about our healthcare system is, unfortunately, very complicated.

jfoesq profile image
jfoesq in reply to allie2020

Glad for you. Thx for the info.

Pops78 profile image
Pops78 in reply to allie2020

Would your plan possibly be with Shell? Sounds very similar. We're looking at one now and not sure about it. It has in-network and out of network but says it pays the same so why have it at all? And has a $3000 out of pocket maximum.

allie2020 profile image
allie2020 in reply to Pops78

Hi Pops,No, I am part of a very large, state retirement system. It includes retired govt. workers, police, teachers, fire dept., etc. They deal with billions of dollars, hence, can negotiate good healthcare options for members. BTW, I initially signed up for UNH Medicare Advantage HMO but switched to the PPO plan after a couple of years which costs me about $1000 more per year. With the HMO I had to stay in network and needed a referral to see a specialist.

I wish you all the best in finding the best healthcare option for you. Too bad it's so tricky. I take nothing for granted with mine. In the months following my RARP, when I'd open my explanation of benefits, I'd say a quick prayer, take a few deep breaths, and my heart would probably skip a few beats. Thank goodness they paid!

Pops78 profile image
Pops78 in reply to allie2020

I'd say "lucky duck" except for the fact that your on this forum. Thanks for answering.

OTPrincess profile image
OTPrincess in reply to allie2020

You got that right. Wat too complicated and too many lifelong penalties if you miss the last sign on date.

There’s been a lot of good information shared here on this subject. Does anyone know if there are counselors who are trained to take a look at someone’s unique financial circumstances and make suggestions? I’m good at a lot of things, but understanding insurance (and TV remotes lol) isn’t one of my strong suites. Thanks to everyone. Jim

Anyone on here who has commented about the wonderful plans offered through their former employment that have this and that benefit needs to understand they are fortunate. I am one of the lucky ones with former employment coverage but try to temper my comments here as I know that others may not have that access. I have learned this from my neighbors in our senior community.

Another thing I have run into is that drug companies have copay assistance plans that often don't help those who receive Medicare or are disqualified if of Medicare age-65. It's a crazy, patchwork system.

My coverage has been excellent and for that I am very grateful. My only reason for posting is to illustrate how patently false some of the information is on this thread. For example:

Medicare Advantage are private insurance plans and they vary in quality. Note that they are ALL narrow networks, meaning they have a narrow range of network providers in small areas given your geographic location.

Other posters on this thread and previous threads have said similar things. Few things in life are always or never.

Hope you took good notes to be able to throw away later. As any lawyer will tell you: everything is subject to change in 2 years when you actually need this info.

I’m sorry. I read it all wrong .

You may also like...