The Medicare transition?

I am about to make the transition from excellent Group Insurance over to Medicare. I would like to hear experience from other PC brothers on what to expect considering our circumstances.

When my wife turned 65, we converted her from my company paid health plan to a Medicare Advantage plan with our HMO. It was a lot less expensive than my company plan. The only real change has been slightly higher co-pays and more paper work being mailed to the house.

Otherwise, not much. The key is getting the advantage plan.

Andrew

I went on Medicare a year before my diagnosis. I was previously on my former employer's (school district) plan for which I was picking up the whole family premium since I retired 6 years ago. When I transitioned to Medicare the issue was that my wife had just gone through breast cancer and our insurance from the school district was VERY good and if I went off the district's plan, she would as well and with her pre-existing condition we were uncomfortable in today's climate to leave a good plan we couldn't go back to.

So, I simply bought my supplemental from the school district. The only offer a Type F plan with a pretty good Part D.

I have friends who bought into a Medicare Advantage plan but I was uncomfortable being limited to where I could go to seek treatment since I am in Montana and our choices are limited. That turned out to be a good decision on my part because when I was diagnosed last February and learned about my treatment options, I felt that no one here had sufficient experience that made me comfortable. In fact, one of my running partners is a doctor at our main hospital and when he was diagnosed a year or two ago he went out of state. So, I did the same. I chose Cleveland Clinic. It turned out that my local urologist, who is quite young, did her training there and gave me the name of the doctor she considered the best.

I didn't even check to see if my insurance allowed me to do it but I called Cleveland, set up a consult, had my slides sent, and went there for a visit. I was VERY impressed and went back a few weeks later for RALP. Everything went well. I did have to cover all the cost of travel and lodging but I made sure to go early and make a vacation out of it and take in the sites like the Rock and Roll Hall of Fame, Cleveland Art Museum, etc. Insurance has covered everything but for a few hundred bucks.

I've just done this in July. I started with an agent (Boomer Benefits). I made sure that they linked me with someone licensed in more than my home state. We started with the understanding that I could be looking for care in multiple states, and might have to move for family issues.

So I wanted a policy that I could move. Because of the Advantage structure in my state, they were all eliminated quickly. Many of the Advantage plans are so limited that you'd be always out of network.

I wanted something I could afford, but would cover me. This brought us back to Medigap plans. Each of those can be different, but they must, in the same plan type, cover the same minimum list of items. I found a good price and geographical coverage in a Plan G. Plan G leaves you paying the $183 (?) deductible, but covers the rest of Medicare approved expenses, plus a few "extras". Because I occasionally enjoy a cigar, I found a plan that did not rate against smokers. All that considered, the Plan F was always more expensive, more that the $183 over the year. So Plan G it is.
BTW - Plan F will go away in the next few years, so you need to get the company policy for how they will do a transition in writing. Most will promise, few will "write". Just go with the G.

And the Rx Plan D required another specialist who took a list of all the recent and potential meds, and ran the coverage / numbers. There are tools for that, and she spent days getting answers for me.

I started this process in February, then in April was assigned a Medicare number so we could start the process. Even up to the start date in July I still had incomplete to-do lists with the Medigap company. Got it all worked out, but the agents & I spent many hours chasing details.

What was broken?
- Medigap company got all of my payment account info, but it was an account that has my Mom's name so that she can write a check on it. They required a signed form from my "wife" (ain't got one) to use that account. I killed the chaos by using a different account, but only after the agent figured out the company couldn't understand my Mother being on the account.

- Medicare issued my a card with the old style number, but set my account up with the new style number. No card for that one, and docs all have software that wants the physical card. I'm still carrying around copies of a letter from Social Security to prove the number.

- Medigap company required a copy of the card, and couldn't understand that I could know the new number without one. Getting Medicare and Medigap hooked together was a challenge, but the agents did that for me.

- Medical facilities you work with constantly will find a way to continue to bill the old insurance, no matter how hard you try. You may suffer a few weeks of getting that all sorted out.

- Even when everything is hooked up, it takes 4-6 weeks to see a claim in Medicare's system, then another 3-4 to transit the pipe to the Medigap company. In that transit period, there is no way to see what is going on. You are blind. Medicare will tell you that is was sent, but the Medigap company may be as well. Nothing gets posted with progress notes. The first time you see it, it is all done. This is most perplexing to those of us who've lived for years with companies that have claims posted the day they arrive with updates as to handling progress.

- Check with each provider you expect to use, and be sure they "accept assignment". This means they accept what Medicare and your Medigap will pay as the total. One of my docs processes through, and accepts money from Medicare / Medigap, but then wants me to agree to pay the difference. That won't happen. That same group will not accept a new patient with Medicare, but I am grandfathered in IF I stay.

- I saw ED meds mentioned. No Plan D will pay for them without a fight. Been there. I have not won that one.

- Not all Plan Ds do mailorder or larger than 30 day quantities. Be very careful to look that up. Also, there is turmoil in the acquisitions area for pharmacies. If you have a critical one, be sure it will be expected to stay in the plan next year.

Did I say to look up Boomer Benefits? They have a 6 day email "school" that explains a lot of the basics.

And remember that the agent gets paid by the company. You don't pay them. But be sure you get an agent that really works with a lot of companies, not just one or a few.

Here are my observations on Advantage plans vs original Medicare plus a medigap plan.

It's not necessarily true that an advantage plan will limit your ability to use out of network doctors and hospitals. Plans vary a lot from state to state and also within insurance providers. My wife and I have been on a Blue Cross Medicare Advantage PPO plan in Massachusetts since I retired in 2011. Because it's a PPO, not an HMO we can go out of network with very minimal difference in cost to us -- e.g., our co-pay for a hospitilzation is the same whether in or out of network, primary care doctor co-pay is $20 both in and out of network, specialist co-pay is $40 both in and out of network. The plan costs us $89 each per month - it was around $49 per month when we started in 2011. There is a bizarre structure to the benefits and co-pays of the "Value" plan we are now on vs the Blue Cross "Plus" plan, which we were on for the first couple of years. The monthly fee for the Plus plan is much higher $262 vs the Value Plan ($89), but the Plus plan charges higher co-pays for out of network services. Go figure. Had we gone with traditional Medicare plus the Massachusetts equivalant of a Plan F (they call it something different in Massachusetts) plus a Plan D pharmacy plan we'd have also had to pay $250 or more each per month.

Our rationale for chosing the Advantage plan was the lower monthly cost (the certainty of paying n dollars per year) weighed against the risk of having to pay the annual out of pocket maximum, which has crept up from about $2,500 each to $4,900 each over the 7 years on this plan - not including co-pays for drugs. Until this year neither I nor my wife has had to pay more than a few hundred dollars total per year for co-pays or other out-of-pocket costs, so the money saved in monthly premiums amounts to $25,000 or so since I retired.

That's the plus side. Now here's the minus. I'm now enrolled in a clinical trial at Dana Farber. Because it's a recognized trial all of my costs are covered except my co-pays for imaging and co-pays for Degarelix, which is considered standard treatment. My Blue Cross plan refers all other trial costs directly to original Medicare and Medicare has paid Dana Farber about $19,000 so far. That's good. I've had to pay a few $40 specialist visit co-pays and so-far about $300 for imaging -- CT and bone scans. There's another $300 or so for another imaging session due to turn up sooner or later. No biggie. But as for the monthly Firmagon shots, I'm now paying 15 percent under my Blue Cross Advantage plan. This means my share of my first shot (a tripple dose) is $1,165, and for each subsuqunt monthly shot is $370 (covered under Part B, in-hospital administration). This still leaves me way ahead of what I'd have paid so far in added premiums for Medicare plus a Plan F, but you can see that at $5,000 per year in costs to me the worm is beginning to turn.

I have an option that isn't available to most, for which I'm grateful, that also influenced my decision to take the risk of added out-of pocket costs vs the certainty of high monthly premium payments over these past years. As a Vietnam Agent Orange veteran, I began getting greatly increased monthly VA disability payments when my PCa returned in late 2016. And because I am also enrolled with the Boston VA hospital I may be able to arrange for the VA to provide my Degarelix to Dana Farber at no cost to me. I'll discuss this with my MO and my case manager on my next visit. However, I will not do anything that risks the integrity of the trial. I will gladly pay the $5k per year if I need to. But if the Degarelix could be provided by the VA I'd also be very happy to apply the money to paying off the new roof we just had put on and the house painting that is still to be done.

Jim

142 said...

Back to Advantage plans, there is one highly advertised in my area as a wonderful deal. It "INCLUDES!!" 8 hospitals. But wait... Not 8 hospital groups, 8 physical sites in a huge metro area. There are other extraordinary limits on docs and labs. Any fool who signs up for that one is, well, a fool.

Different plans are professionally designed to be effective for different people in different life circumstances. There is no one-size-fits-all plan that is most effective for every person and every situation. Personally, I wouldn’t call people “fools” just because they have different life circumstances than mine, but maybe that’s just me. Pick YOUR plan by selecting the one that works best for YOUR unique, individual circumstances.

Almost a 10 said...
If you have expensive meds that you take you will need to research the prescription plan and what it pays.

And also research the the different costs to you depending on whether a med is covered under Part B (typically administered by doctor, such as Lupron, Firmagon, chemo, etc.) or Part D - all other prescription meds.

And yet one additional frustration. Even if you, as did I, have medicare part A and B, as well as a supplemental plan, you have to be very sure that your supplemental plan properly records itself as secondary to medicare. My first few months of claims were held up while medicare and BCBS fought with each other as to which should be primary. The insurance companies will not just assume that medicare is primary. They BOTH must show the same sequence of who first, who last.

I think mine is sorted out now, but time will tell.