Northern Ohio Medicare question - Advanced Prostate...

Advanced Prostate Cancer

14,595 members17,865 posts

Northern Ohio Medicare question

3putt profile image

Happy TGIF my friends. Well, the day has finally come that my wonderful wife is contemplating retirement. Her insurance has been incredible but now I must begin the long awaited process of shopping for Medicare Part B & D and any other letter that helps keep costs of treating this disease to a minimum. Like many, I’m on the Zytiga, prednisone and lupron train. Just curious if there are others from my neck of the woods that have navigated this path recently? Thank you all in advance for your consideration!

44 Replies

I'm not local, but have suggestions. You might check with the staff in your (and your wife's) doctors offices. The staff who handle insurance billing, pre-approvals, etc. should have some wisdom to share. Also, in my area there are a few non-profits which claim to offer free service to help evaluating the many plans during the annual open-enrollment period.

3putt profile image
3putt in reply to BerkshireBear

Thank you!

I'm not from Ohio but you should register at the MyMedicare.gov. You put in your zip code and answer some questions. It will give you options for medicare. One suggestion, don't choose an advantage plan.

LearnAll profile image
LearnAll in reply to Magnus1964

Magnus is right is saying "do not choose any medicare advantage plan" These plans look cheaper but there are restricted doctor networks and high copays and deductibles..so in the end they cost you more.By end of 2022, i will have to pick medicare plan. I am aiming to choose Medicare plus Plan G (medigap/supplemental plan) And we all need to buy Medicare Part D (for drugs)

This combo has higher monthly rate (approx. 600 to 1000 dollars a month) but has no restrictions on choosing doctors or hospitals. You can use this plan in any corner of USA. Besides it also covers 80% of medical expenses if incurred during international travel or while in a foreign country.

Alturia profile image
Alturia in reply to LearnAll

Original Medicare and Medicare Supplement plans don't usually cover you when traveling internationally. The text below is directly from the Medicare web site. medicare.gov/Pubs/pdf/11037...

But I agree that Original Medicare and a supplement plan is better than Medicare advantage for the reasons you note.

Medicare coverage outside the United States is limited. In most situations, Medicare won’t pay for health care or supplies you get outside the U.S. The term “outside the U.S.” means anywhere other than the 50 states of the U.S., the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands. This fact sheet explains some of the exceptions that would allow you to get coverage outside the U.S. under Medicare Part A (Hospital Insurance) and/or Part B (Medical Insurance). When does Medicare cover health care services in a foreign hospital? T here are 3 situations when Medicare may pay for certain types of health care services you get in a foreign hospital (a hospital outside the U.S.): 1. You’re in the U.S. when you have a medical emergency, and the foreign hospital is closer than the nearest U.S. hospital that can treat your illness or injury. 2. You’re traveling through Canada without unreasonable delay by the most direct route between Alaska and another state when a medical emergency occurs, and the Canadian hospital is closer than the nearest U.S. hospital that can treat your illness or injury. Medicare determines what qualifies as “without unreasonable delay” on a case-by-case basis. 3. You live in the U.S. and the foreign hospital is closer to your home than the nearest U.S. hospital that can treat your medical condition, regardless of whether it’s an emergency. Remember, in these situations, Medicare will pay only for the Medicarecovered services you get in a foreign hospital.

Medicare plus part G is just under $500 month for me. Drug plan is about $35

I second the “no advantage plan” advice. With this disease you will want freedom to choose the best Dr that you decide to work with.

In all cases, Foreign travel coverage is limited, read the plan details carefully before you book a trip

VCinTx profile image
VCinTx in reply to LearnAll

You will be UNABLE to choose Medicare G if you have PC.

Shorter profile image
Shorter in reply to VCinTx

I had a recurrence of prostate cancer and was able to get Blue Cross Medipack G before starting radiation. They paid everything. My monthly bill is less than what I paid at my last job. Part D seems to be the achilles heel, depending on your prescriptions.

Alturia profile image
Alturia in reply to VCinTx

If you choose a Medicare supement plan - including plan G - when first enrolling in Medicare then you cannot be turned down because of pre-existing conditions, including prostate cancer. Pre-existing conditions only come into play of you are applying for a supplement t plan after you have enrolled in Medicare.

dsadams profile image
dsadams in reply to VCinTx

We live in Northern Ohio. My husband had prostate cancer when he applied for Medicare. He has a Plan G with Aetna. He was stable for 5 years and now it has shown it's ugly face again. He is on the same regimen that you are. He has had many scan and MRI's as well as 3 radiation treatments. His Aetna has covered all the scans, MRI's and radiation costs as well as Dr. visits. His medication (even though he had drug coverage) is covered by a medical grant and costs us nothing. If a grant is not available for you Johnson and Johnson also provides help with drug costs. His premium costs him around $140 per month. Good luck

ImaSurvivor1 profile image
ImaSurvivor1 in reply to VCinTx

I don't think that's true. Pre-existing conditions only come into play of you are applying for a supplement t plan after you have enrolled in Medicare.

Ernbud profile image
Ernbud in reply to Magnus1964

I keep seeing so many on this site saying do not choose any Medicare Advantage Plan. I guess that I apparently have been very fortunate with my advantage plan and also luckily picked Drs. that my plan allows. My plan costs me nothing but the cost for Medicare part b. I get my prescriptions through VA but if I got them through the plan it would only add $70 to my cost. In addition to my treatment for PCa I’ve had both knees totally replaced ,at a cost of $300 per knee,cataract surgery at about the same cost, and a trip to the ER for Norovirus. I have no copay for my primary care Dr and only$35 for specialists. I don’t have to get a referral to see a specialist or to have most imaging done. My max out of pocket is $6000. I saw that someone said their supplemental insurance costs $500 per month. That would be equal to my max out of pocket. Any time I call my carrier a human answers the phone and directs me to the one I need to speak to. I’ve been with them for 7 years and wouldn’t go anywhere else if it continues to be like it has so far.

maley2711 profile image
maley2711 in reply to Ernbud

Is your company a top secret? I do understand that after 7 years and pre-existing conditions, changing to anotheradvantage plan with another company, or changing to a standard supplement, would be difficult if not impossible> others might provide more insight on that aspect?

Ernbud profile image
Ernbud in reply to maley2711

The plan I’m on is Pacific Source

Yank66 profile image
Yank66 in reply to maley2711

We are also on a Medicare advantage plan (United Health care) through my husband’s former employer -at no cost to us except the Medicare premium. We’ve had no problem getting anything approved including Provenge, Xtandi, Lynparza, surgeries. We have a copay of $10 for PCP and $15 for specialists. Our out of pocket is $1200/ year. This covers us when we travel including out of the country (as if—with Covid). Really blessed to have this provided for us.

3putt profile image
3putt in reply to Ernbud

Which plan became your plan of choice?

Ernbud profile image
Ernbud in reply to 3putt

Pacific Source was the one I picked

Alturia profile image
Alturia in reply to Ernbud

It's hard to compare insurance because each person's situation and priorities are often so different. But for me Original Medicare offers 2 benefits over the Medicare Advantage plans I have investigated. The first is that most health care providers in the US take Original Medicare and there is no need to stay within a network or get approval for procedures. The second is financial. I have the High Deductible Plan F (not sold anymore - the equivalent today is High Deductible Plan G) and in 2021 my premium for the YEAR was $617. Now that means I must pay the 20% copay until the costs reach (for 2021) $2350 - in 2022 that increases to $2470. Once I reach the deductible then 100% is covered. In the 7 years I have had this plan I never came close to reaching the deductible until I was diagnosed with PC.

Magnus1964 profile image
Magnus1964 in reply to Ernbud

I don't mean to say that all advantage plans are bad. There are some hospitals that have there own advantage plans, I think BC/BS even has one. But there are a lot of"fly by night" companies that advertise on TV with really bad policies.

Advantage plans were started during the GW Bush administration as a way for these companies to rip off medicare. They are paid differently than other plans and essentially the government has no control over them. They can adjust costs and cut where they please.

There are decent advantage plans. Just be very careful which company you select.

maley2711 profile image
maley2711 in reply to Magnus1964

Correct me if I'm wrong. My understanding is that Advantage plan must cover stuff that is covered by original Medicare.....that makes sense, or otherwise the "fly by nites" you mention could have a field day. Advantage can limit choice of Docs, unfortunately..that seems to be the biggest gripe . Contrary to badmouthers, kaiser Advantage actually has millions of mostly satisfied customers.....no, they are not perfect......but neither are other coverage systems!!

Magnus1964 profile image
Magnus1964 in reply to maley2711

Advantage plans do cover everything that other plans do but with co-pays and as I understand with network restrictions, etc.

swwags profile image
swwags in reply to Magnus1964

Spot on Magnus. The term used in the industry is "Narrow Networks". This partly defines the value of the product overall for the member/patient.

If you live in a densely populated area (big City) you are likely to have facilities and services that we stage 4 cancer patients need. Of course this doesn't mean you have quality providers but you will have them available to you.

If you are in a rural environment, the network in a Medicare Advantage plan may not include any facilities that have sophisticated scanning equipment or even qualified surgeons who specialize in specific diseases.

That's the nature of the beast and is a replica of the private/employer insurance model.

This is the primary reason why you have some say one is better than the other (Medicare+ Medi-gap vs Medicare Advantage.)

Some States offer Medicare advocate services at no cost and if you are overwhelmed, see if you can find one. Medicare.gov is a great resource but Medicare is confusing to many.

maley2711 profile image
maley2711 in reply to swwags

Yes, it is a fact that patients in USA receive better/worse care based solely on zip code and personal piggy bank

Mayley2711, I'm glad Kaiser Medicare Advantage is working well for you. What you call "badmouthers", however, are probably just people who have had a different experience than you. Millions ??? of "mostly satisfied customers" are not like most of the people on this forum. The typical Kaiser patient is not an older person with advanced prostate cancer, which is what this forum is about. Kaiser was great for us, too, when we weren't sick. But, if you get to the point where you feel you need treatment (or even a second opinion) from renowned doctors at "centers of excellence", Kaiser coverage will do nothing for you. There's no denying the simple fact that Medicare pays any Medicare Advantage provider the same amount of money per month, per patient, regardless of how expensive your care is, and they are businesses, not charities. If you've been healthy and you have a heart attack or stroke or break a leg, you'll promptly get great care, but they're going to find a way to minimize your cost to them if you require on-going expensive care.

Kaiser or not, most folks don't get care from renowned Docs at COEs. Most of the costs for advanced PCa drugs.....are you sure that Kaiser won't cover them? In any event, I of course understand your points, and am considering them for that approaching day when I 'll need to make a Medicare decision.Friends nurse practitioner and husband sone of 2 Docs have been in both types of insurance systems, and NP treated for breast cancer at Kaiser....they decided on Kaiser here for Medicare. When someone in a non-Kaiser system has a gripe about care, hey blame individual Doc at whatever clinic ...if someone at Kaiser is dissatisfied, the whole kaiser system, is blamed....provider and insurer. Kaiser referred me to med school for requested fusion biopsy...cost Kaiser extra bucks.

Most appreciated!

I’m in NE Ohio and have supplemental plan G from Anthem. So far so good. It does cost ~$120 more per month than an advantage plan. Less for my wife but she’s eight years younger. Two years in but didn’t start until my wife retired. It has covered PSMA scans, multiple second opinions, in office ADT, and knee work, no additional cost. Cleveland Clinic and UH. I have family ex-pating in Europe and it should cover getting us back to the states if either of us need care while visiting grandchildren. Plan D has been a joke. I use the .gov site to see what drug costs would be with different plan D’s and no plan covers all the drugs I require so I get the cheapest plan I can buy and instead use GoodRX, OptumPercs, Canadian Pharmacy, and InHouse Pharmacy in Vanuatu. Whichever is cheapest. My physicians staffs aren’t happy that my scrips go to different pharmacies, e.g. Giant Eagle, Drug Mart, Walmart, but they call/fax them in as told or provide paper scrips for out of country. I think my 90 day supplies cost me around $30 out of pocket. A few have been less than $10.

maley2711 profile image
maley2711 in reply to kreg001

My understanding is that Medicare supplement plans are mostly standardized, other than deductible, etc, and that all these plans must cover anything that Medicare A or B covers...nor are these supplements required to cover anything that Medicare does not cover?

Magnus1964 profile image
Magnus1964 in reply to maley2711

You are correct, if Medicare does not pay - the supplement does not pay.

maley2711 profile image
maley2711 in reply to Magnus1964

So, other than supplement premium, is there generally much difference between , for example, the G supplement from different companies...my understanding is NO? Or is it mainly that different insurers allow different networks for that G plan? or other factors. In general, underwriting is required if want to switch supplements after 1st 12 mo of supplement coverage.....also if you want to switch from advantage to supplement, or visa versa, after 1st 12 mo....or switch from one advantage to another advantage after 1st 12 months?

I think these questions cover most of the important points when making the initial choice? or did I miss something BIG?

Magnus1964 profile image
Magnus1964 in reply to maley2711

I have been hearing rumbles about getting rid of Medicare and this might be one of the first steps. I just went on the Medicare.gov site and found this:

As of January 1, 2020, Medigap plans sold to people new to Medicare can no longer cover the Part B deductible. Because of this, Plans C and F are no longer available to people new to Medicare on or after January 1, 2020. If you already have either of these 2 plans (or the high deductible version of Plan F) or are covered by one of these plans before January 1, 2020, you can keep your plan. If you were eligible for Medicare before January 1, 2020, but not yet enrolled, you may be able to buy one of these plans (Plan C or F).

Your question may be moot.

maley2711 profile image
maley2711 in reply to Magnus1964

and what would replace it...good luck to pols who support that!!

Magnus1964 profile image
Magnus1964 in reply to maley2711

Part G does not pay for the deductibles. The government is just going to keep chipping away at Medicare until it isn't worth anything.

Pops78 profile image
Pops78 in reply to kreg001

Is Anthem a part of BCBS? Do you have to have prescription plan D to have a supplement? I agree plan D is a joke and wonder why you have it unless the supplement requires it?

kreg001 profile image
kreg001 in reply to Pops78

A Plan D is required with a supplement plan to Part B. I think mine is $7/month. I pay a year at a time.

kreg001 profile image
kreg001 in reply to Pops78

Yes. Anthem is BCBS.

You don’t need to buy a Part D plan in order to buy a Part B supplement. However, if you buy a Medicare Advantage Plan, I believe these are lumped together.

Medicare.gov is very helpful.

You need to choose between a Medicare advantage plan or traditional Medicare and buying a Part B supplement and a Part D plan for drugs you take at home. If you find a broker who sells both, they can help you choose among the plans in your area. Remember brokers are paid by the plans, however

Part d is easy to change each year. The Part B supplements are medically underwritten so they become much harder to switch.

Spend time on this. BTW, we have gone outside our Part D plan and used GoodRx at times.

When you study Part D , look at annual costs ( the plan premium plus your annual drug costs).

How do advantage plans compare to D re drug costs ?

These plans vary by state and even county. You’d need to go to Medicare.gov, input your drugs, then look at Part D plans. Then, also look at MA plans. Then compare your results to see the difference. See the comment about SHIP help.

Brokers can help but just be aware they make their fee from the companies so you want to know what they sell because that is all they will compare logically.

See boomerbenefits.com they are the best agents for supplement plans and I believe Plan G is the best and please avoid Medicare advantage plans.

We are all just poor paYtients..............

Good Luck, Good Health and Good Humor.

j-o-h-n Sunday 01/09/2022 5:13 PM EST

I was shitting bricks, sooooo confused! Then the flyers were doing just that, flying out of my mailbox daily!!! You think Joe Naymouth is a pain....? Then I learned about my States’ SHIP, State Health Insurance Assistance Program, they come to you with answers to questions that you didn’t even know you had!!! Plan options, different companies comparisons, fills out all you paperwork, and is there from then on with any more answers needed!Turned a nightmare into a wet dream!

Good luck!

Jc

Thank you everyone. Great advice and suggestions.

You may also like...