Still Giving in Our Golden Years

[body2body]

Your Medicare Advantage plan covers prescriptions? Which one do you have?

I have Kaiser-Permanente Advantage Plus. My co-pay on most of my scrips is $5. I have one that is a schedule 3 that has a co-pay of $15. If I use the mail order pharmacy I get a three months supply for the price of two. I have friends who say they would not be happy with Kaiser because it is " like socialized medicine", everything is done within their system. They own and operate their own hospitals, labs, re-hab facilities, and pharmacies.If my Doctor orders tests and X rays or other imaging, he enters it into the computer and I go downstairs to the lab or imaging and get it done the same day. I have had health insurance through them for over 20 years ( pre-Medicare), and have been happy with the quality of care I have received. They operate in California extensively, and I believe in a few other states. They are not National like Cigna or United Health.

[Epigonos]

If I were willing to go with an HMO instead of a PPO the one I would have would most definitely be Kaiser. The problem for me is that after seriously looking into Kaiser their agent agreed with me that it would cost me just about as much as my current PPO.

 

I have a number of friends who have Advantage Plus plans with different insurance companies and are extremely happy with them. They do, however, have one MAJOR concern and that is that these plans may be severely curtailed or possibly discontinued in the not too distant future. The ONE health care issue that both the Democrats and Republicans in Congress and the White House agree on is that the cost of the Advantage programs is out of control. An early part of Obamacare was the total abandonment of the Advantage programs but it was dropped in order to obtain the number of votes necessary to pass the two houses of congress. After the election and the opening of the new Congress this issue will likely be seriously discussed. If Hilary is elected I would guess that we can look forward to a major increase in the cost of these plans to the insurer. If Trump is elected I would guess that these plans might be abandoned all together.

 

P.S. Frankly, I think, the best chance for the survival of the Advantage programs is if Hilary is elected and Congress remains in the hands of the Republicans. Thus when it comes to making adjustments to Obamacare it will be a stalemate and nothing will be changed including the Advantage programs.

[+ Charlie]

If this thread demonstrates anything, it is that no two people are in the same situation, so you really have to know where you stand and what your personal options are. My spouse and I, for instance, are both retired and on SS and Medicare, but beyond that there is no similarity in our positions. SS deducts the same Medicare premium from our monthly payments, although our SS payments are very different. He buys his own supplemental PPO policy from Anthem and pays a stiff rate, because he has had some serious medical problems in the past. A condition of my retirement was that I would continue to be included in my employer's group insurance policy, under a retiree provision in the policy, so I do not have to choose a supplemental carrier, but I do pay the premium that my employer would have paid if I were still an employee (it is much less than I would pay with my own individual policy). It is a PPO policy, so I choose the doctors whom I see (no doctor has ever refused it), and I hardly ever pay anything beyond my annual Medicare deductible. My spouse, on the other hand, pays $2200/yr to be part of a concierge practice, because he really likes his g.p. Although he has had some expensive surgeries in addition to treatment by many specialists, he has never had to pay more than minor sums on the major charges. He takes multiple medications, but has Medicare Part D, which covers all but the co-pays and the annual deductible. My group insurance covers prescriptions, but the $5 co-pay is negligible, since I take no routine medications. My group insurance also covers $2400/yr worth of dental work, which I manage to use up or exceed every year; my spouse has no dental insurance, and pays everything out of pocket.

 

None of these things are set in stone till we die. My employer could find it necessary to stop carrying me on the group policy, and I would have to purchase my own supplemental insurance. My spouse's g.p. might retire, and he might decide not to pay to be with another physician's concierge practice. Insurance companies change their policies and raise their rates. Congress might decide to radically alter Medicare and/or SS. It's important not to take anything for granted, or to assume that the set-up you have this year will still be the right one for you next year. Welcome to your Golden Years!

[+ WilliamM]

@Charlie, Thanks. Each Medicare supplemental insurance plan is different. So anyone relatively close to age 65 must have a headache by now. I do and I have been in Medicare since my 65th birthday, eight years ago.

[jjkrkwood]

If this thread demonstrates anything, it is that no two people are in the same situation, so you really have to know where you stand and what your personal options are. My spouse and I, for instance, are both retired and on SS and Medicare, but beyond that there is no similarity in our positions. SS deducts the same Medicare premium from our monthly payments, although our SS payments are very different. He buys his own supplemental PPO policy from Anthem and pays a stiff rate, because he has had some serious medical problems in the past. A condition of my retirement was that I would continue to be included in my employer's group insurance policy, under a retiree provision in the policy, so I do not have to choose a supplemental carrier, but I do pay the premium that my employer would have paid if I were still an employee (it is much less than I would pay with my own individual policy). It is a PPO policy, so I choose the doctors whom I see (no doctor has ever refused it), and I hardly ever pay anything beyond my annual Medicare deductible. My spouse, on the other hand, pays $2200/yr to be part of a concierge practice, because he really likes his g.p. Although he has had some expensive surgeries in addition to treatment by many specialists, he has never had to pay more than minor sums on the major charges. He takes multiple medications, but has Medicare Part D, which covers all but the co-pays and the annual deductible. My group insurance covers prescriptions, but the $5 co-pay is negligible, since I take no routine medications. My group insurance also covers $2400/yr worth of dental work, which I manage to use up or exceed every year; my spouse has no dental insurance, and pays everything out of pocket.

 

None of these things are set in stone till we die. My employer could find it necessary to stop carrying me on the group policy, and I would have to purchase my own supplemental insurance. My spouse's g.p. might retire, and he might decide not to pay to be with another physician's concierge practice. Insurance companies change their policies and raise their rates. Congress might decide to radically alter Medicare and/or SS. It's important not to take anything for granted, or to assume that the set-up you have this year will still be the right one for you next year. Welcome to your Golden Years!

 

 

Charlie, again thank YOU for your detailed information.. For me to comprehend ALL of this, I need an interpreter because I am terrible at instructions. Any piece of IKEA furniture I ever bought FELL APART simply because I didnt have either the patience or intelligence to deal with the instructions. I have always needed an "advocate" to simply tell me in an abridged version the details. Bullet points are my "friends".... I do have a broker working on my behalf and am waiting for the options she presents which will fit within the financial guidelines I have given her. While I am retiring with decent SS and a nice IRA, I feel awful for those people who havent been financially able to build that proverbial "nest egg". It's bad enough we have to worry about wrinkles, loss of sex, liver spots, aches and pains, yellowing teeth, velcro footwear.... we shouldnt have to worry about finances !

[LADoug1]

I have Kaiser-Permanente Advantage Plus. My co-pay on most of my scrips is $5. I have one that is a schedule 3 that has a co-pay of $15. If I use the mail order pharmacy I get a three months supply for the price of two. I have friends who say they would not be happy with Kaiser because it is " like socialized medicine", everything is done within their system. They own and operate their own hospitals, labs, re-hab facilities, and pharmacies.If my Doctor orders tests and X rays or other imaging, he enters it into the computer and I go downstairs to the lab or imaging and get it done the same day. I have had health insurance through them for over 20 years ( pre-Medicare), and have been happy with the quality of care I have received. They operate in California extensively, and I believe in a few other states. They are not National like Cigna or United Health.

Do you need a supplement plan with that?

[wisconsinguy]

That is true. I was also surprised that they cover you for the Full month of your 65th birthday. Now, since I am still covered until Jan 1 2017 by my jobs medical plan, i need to inquire which insurance is considered my PRIMARY. I have not yet gottten a Medicare supplemental plan so I probably wont have full coverage until some supplemental plan is in place. I am hoping to have that wrapped up this week.

I had the same situation. Your private insurance remains primary until the private insurance is no longer in effect.

[+ honcho]

Do you need a supplement plan with that?

 

I'm a bit unclear what you're asking about. Kaiser Advantage Plus is considered a medicare - based

supplemental plan in that Kaiser will bill Medicare for what it can get out of it, and then pay itself

for what it can't out of the premiums it collects from everybody.

 

Now, if you're wondering if it would be prudent to obtain additional coverage *beyond* what

Kaiser provides, that's an entirely different discussion. I will acknowledge that I've been covered by a Kaiser plan for more than 30 years and I'm pretty satisified. I'm 64 and 3 months so this is coming up for me.

[wisconsinguy]

This is a great thread, and I would like throw in a few thoughts. I like lists so here goes:

1) Supplemental plans are simply agents to administer the Medicare program. What they "authorize" is what the federal program has set forward. When you start looking for plans I would recommend finding an insurance agent who you can sit down with to explain the different plans. The difference is within a plan.There are optional plans you can choose. That changes the cost of premium. I went with Humana a couple of years ago. At that time and to date, I pay no monthly premium to Humana. I still have the "premium" taken out of SS, I believe it is $104.00.

2) The plan is referred to as "basic." Now here is my take on this.

a) If you are in good health, and have routine visits to your PCP, and x-ray/labs here and there, no big deal.

b) If you have some event, say even just your gallbladder removed, your deductibles will start to add up. My deductible for a year is near $7,000. This is close to what many private insurances are.

c) If you have a major event...I had what is referred to as a "catastrophic and devastating" event starting this summer. A delayed infection of a shoulder replacement. A couple of surgeries thus far, two more in Dec...sitting here with continuous/24/7 IV antibiotics running. Point being: Supplemental plans can have restrictions on physicians you can see. My plan limited that to a 100 mile radius of my address. HOWEVER, to the credit of Humana, they were outstanding in "granting " all referrals I requested (there were many). A few out of network.

d) Again, hook up with a insurance agent or two, write down your questions.

e) It is a confusing time, and wish everyone smooth sailing. WG2

[body2body]

Do you need a supplement plan with that?

No it covers everything. You have co-pays that are capped. It has made it very affordable for me, so far. An "Advantage" plan is an HMO where you essentially sign over your Medicare benefit to a single provider. My Kaiser Advantage plan covers Dr. visits, prescriptions (with no gap or "doughnut hole" as in traditional part D, surgery, hospital stays, tests, imaging, physical therapy, convalescent care. Dr. visits are $5 currently. My prescriptions have co pays that vary from $5 - $15 (everything I take currently is a generic). Hospital stays are $250 per day for the first 5 days, and are at no charge after the 5th day.

I saw an Opthalmic Surgeon on Wednesday about removing a cataract. My co-pay was $5. He ordered a series of tests to measure my eye on the 19th of this Month, and will have the surgery at the end of the month.

[+ ursalex]

Thank you all for this interesting discussion. I signed up for Part A the day I was eligible last year, but did not need Part B when I turned 65 in January. Having retired somewhat unexpectedly in July and giving up my health insurance, I signed up for Part B and was handed a whopping bill because the premium was based on my 2014 income, admittedly rather high. I recently met with a counselor and finally understand my options. I now have to sign up for a Medicare Advantage Plan which will be little different than the health insurance I had when employed. Big difference? At the moment I have no income and I am going to try to defer Social Security until I turn 70, so it's all out of savings and hopefully a part-time job. Fortunately I am healthy and have very limited needs, so I just have to accept it as the same health insurance I have paid for at my former job and hope my health lasts and recognize that, for the moment, I am really paying for someone else's benefits.

[wisconsinguy]

Your Medicare Advantage plan covers prescriptions? Which one do you have?

I have Humana Gold Plus (HMO). I can add dental, $36.00 mth, and vision for $15.00.

[+ honcho]

I saw an Opthalmic Surgeon on Wednesday about removing a cataract. My co-pay was $5. He ordered a series of tests to measure my eye on the 19th of this Month, and will have the surgery at the end of the month.

 

My particular Kaiser plan (not the Medicare advantage one yet) had a $25 copy for the initial surgeon visit, $100 for the surgery itself, and $1200 for a toric lens for the right eye (regular non-astigmatic-correcting lens for the left - no extra copay).

 

Same copay for a colonoscopy. Go figure

[LADoug1]

No it covers everything. You have co-pays that are capped. It has made it very affordable for me, so far. An "Advantage" plan is an HMO where you essentially sign over your Medicare benefit to a single provider. My Kaiser Advantage plan covers Dr. visits, prescriptions (with no gap or "doughnut hole" as in traditional part D, surgery, hospital stays, tests, imaging, physical therapy, convalescent care. Dr. visits are $5 currently. My prescriptions have co pays that vary from $5 - $15 (everything I take currently is a generic). Hospital stays are $250 per day for the first 5 days, and are at no charge after the 5th day.

I saw an Opthalmic Surgeon on Wednesday about removing a cataract. My co-pay was $5. He ordered a series of tests to measure my eye on the 19th of this Month, and will have the surgery at the end of the month.

I have a Kaiser's Medicare HMO. There is a doughnut hole for the Part D prescription coverage. Maybe I chose the wrong plan.

[+ quoththeraven]

I have a Kaiser's Medicare HMO. There is a doughnut hole for the Part D prescription coverage. Maybe I chose the wrong plan.

 

Part D was designed with a donut hole, so if that is your issue, it's not your plan that is at fault.

[LADoug1]

Part D was designed with a donut hole, so if that is your issue, it's not your plan that is at fault.

B2B said his plan had no doughnut hole. That's why I was commenting.

[body2body]

B2B said his plan had no doughnut hole. That's why I was commenting.

I just double checked the information sent with my enrollment- there is a donut hole, however the co-pay for prescriptions remains at the pre donut rate, or 40-51% Whichever is lower.

[+ LIguy]

OK so I admit I'm not too smart about insurance plans but my mom has Medicare and that payment is deducted from her Social Security check every month and then she has what I assume is a supplemental policy through Emblem Health which I pay 260 a month for. With both insurances she pays no copays or deductibles and her prescriptions depending on the drug cost 2.60 and 2.95 for a 90 day supply...Her diabetes meds are no cost at all.

[bigvalboy]

Guys, I started this thread as a personal "bitch fest", but happily it seems to have turned into a thread which provided valuable information to many who might have needed it, like myself.

 

thanks for your openess and sharing your experiences. Its threads like this that shows we are actually "more alike" than different, and many of us share the same experiences as we grow older. Its like being at a drop-in senior center but without the checkers and jello cups.

 

+1

 

What a mountain of information.

[jjkrkwood]

Your employer's plan will be primary until you are no longer covered by it.

 

I spent part of my time as a lawyer fighting with Medicare administrators over coverage for retirees, so I've had the dubious pleasure of reading the statute that makes Medicare secondary to just about everything.

 

 

I just got off the phone with my carrier AETNA, and very interesting development. They tell me, according to their by-laws, if my MEDICARE is in effect (which it is now) that Medicare is the PRIMARY for all procedures and pays the original 80% for the procedure, with my AETNA then pickup the 20% co-insurance at 100% regardless if my deductible has been met. It sounded odd, so I had her repeat it 3-4 times to make sure there were no cracks in her story. If this is true, it is very good news.

[Phil_musc]

Yes, that is my understanding also, jj. Thanks for this informative thread.

[+ MasssageGuy]

Page 26 of the "Medicare and You" will provide you how coverage is co-ordianted with other insurance you may have. For me, I had a group health plan with an employer of 20 or more employees. So my primary was my employer's plan.

 

https://www.medicare.gov/Pubs/pdf/10050.pdf

 

There is an important phone number on page 27 for "Medicare's Benefits Coordination & Recovery Center (BCRC)" which I had to deal with when my primary was no longer in effect...

[jjkrkwood]

Page 26 of the "Medicare and You" will provide you how coverage is co-ordianted with other insurance you may have. For me, I had a group health plan with an employer of 20 or more employees. So my primary was my employer's plan.

 

https://www.medicare.gov/Pubs/pdf/10050.pdf

 

There is an important phone number on page 27 for "Medicare's Benefits Coordination & Recovery Center (BCRC)" which I had to deal with when my primary was no longer in effect...

 

 

I am not one to take things for granted, so I also called MEDICARE, and was given the same information AETNA provided. So being 2-for-2, I think the info is reliable, but I guess I will find out once the bills arrive ?

[+ quoththeraven]

I am not one to take things for granted, so I also called MEDICARE, and was given the same information AETNA provided. So being 2-for-2, I think the info is reliable, but I guess I will find out once the bills arrive ?

 

That is good news. And I agree, you're not likely to get misinformation from both sources.

[jjkrkwood]

That is good news. And I agree, you're not likely to get misinformation from both sources.

 

 

I hope I have coverage for ASPIRIN because this whole thing has given me a fierce Headache.