Medicare: What covers? What not?

fifthyear

For those of us who are about to embark on the journey of golden age healthcare: The Original Medicare, the Supplemental plants, we need your experience so we know how to navigate the new sea.

In specifics:

What treatments got paid? E.g. Neulasta shots? Chemo? Rads? Surgery?

What treatments that got a hard time to get approval?

What drugs got paid? E.g. Ativan, Emend etc…

Anything else you can think of, we can benefit from it. Thank you for taking the time to help.

WinningSoFar

I'm on the original Medicare plus a supplemental plan and a Part D plan. Everything has been paid for--surgery, reconstruction surgery, chemo, rads, all meds, all scans, all blood tests. Nothing has been difficult, that I know of. I have been on Abraxane, Emend, Xgeva, xanax, ativan, antidepressants, heart meds, what else? I've had quarterly blood tests, including vit C and D levels, and cancer marker (15-3) tests. All paid for. I get pet/ct scans regularly, used to be quarterly, now biannually. No problems.

Spookiesmom

I have a Medicare Advantage plan, not a supplement. I don't pay for it. I have no to low copays for Dr and tests. No copay on tier 1 meds. Just got pump for my LE arm. 0 out of pocket.

fifthyear

Good to hear this ladies... Thanks for sharing.

fifthyear

Anyone using Aarp supplemental plan? I am looking between aarp and Blueshield both cost around $170/month and NOT including RX.

WinningSoFar

I have aarp and am happy. I have to admit that I didn't research or compare Blueshield. I live in California, if that makes a difference.

Spookiesmom

I need to say the Advantage plans are NOT income related. They are for anyone eligible for Medicare. Mine is from Humana.

MinusTwo

I'm on traditional medicare, AARP supplemental & a plan D for drugs. While I had to pay an average of $4-7 for my drugs outside the chemo center or hospital, the only other expense I had to cover was the $147 yearly deductible for docs. I had 4 chemo's the first round & two more the second. Some of the infusions were $20K each time and were paid in full. All surgeries & reconstruction were paid. All radiation paid. All doc visits paid, including consults with neurologist & LE specialist, and physical therapy. I've been more than pleased.

fifthyear - I've had an AARP supplement for 5 years and am very satisfied. I know they change the alphabet selections of what's covered every year, so pick a plan that works best for you. I chose to pay a one time yearly deductible and after medicare pays their 80%, the remaining 20% is paid in full. Some people choose co-pays for doc visits. Etc.

tgtg

I'm on traditional Medicare A and B, plus a Blue Cross/Blue Shield medigap plan (65 Special) with Rx included in it. Paid nothing except the annual required $150 Medicare deductible while under treatment (only surgery and rads, no chemo or hormonal therapy; post surgical mammos and an MRI; vit D tests). Medicare only refused a claim once, for the Oncotype DX test, but when the claim was resubmitted, Medicare paid for it with no complaints or glitches.

Friends who started out in "Advantage" programs with both Aetna and Humana dropped them after learning the hard way that some hospitals refuse to take Advantage patients. This limitation can restrict one's treatment options, especially in an area (like Boston, NYC, Philadelphia, Baltimore) where there several topnotch medical choices are available only to regular Medicare folks.

fifthyear

I am leaning toward the aarp supplemental plan, the plan F one (I went to their site, they have 4 plans the plan F is most comprehensive). I need the plan to be PPO not HMO, hence the supplemental and not the Advantage.

Winningsofar, may i ask what plan D for Rx do you use? I live in San Jose, CA. With the aarp I will need a plan D Rx.

Also do I need to join aarp? I don't want to :-))

This is so very helpful for all of us. Please keep adding data as they come. We all benefits from your shared experience. Thank you so much you all.

MinusTwo

Fifth - agree entirely about problems getting docs you want on the Advantage plans. That's why I stayed w/traditional medicare. I don't think you have to join AARP to select their supplement, but I can't remember. The plus side of joining is discounts at restaurants, theaters, hotels, etc. and the fee is nominal. It's often a better discount than AAA.

Choosing a drug plan will depend on whether you take lots of meds or not. If so, you need to find the names of your drugs on their 'formulary lists' and see which has the better deal. Each state is different and those lists change every single year. Sooooo... annoying. I don't take any drugs regularly so I stayed with the absolute cheapest program available in Houston - which turned out to be Humana/WalMart. I'm sure that will change next year since Humana is just going to be bought or sold - can't remember which.

fifthyear

MinusTwo, I don't take any drugs now just vitamins so the cheapest plan will do, thanks for the tip. Where I live (in California), some docs don't take the advantage, and the advantage plans require that you go to specific docs/hospitals. You're right when it comes to treatments, one wants to be able to pick and choose med team, and travel where ever you want to seek treatment.

I can't believe that I am entering this decade. My DH said look at the bright side, I live this long to collect my SS money that I put in all my working life, and then some with the Medicare thingy :-))

MinusTwo

fifth - I grew up in Palo Alto years ago - when Silicon Valley was green hills w/cows. You do have some great medical care in the area. Good luck w/your sign-ups. And now, reaching this grand age, you can have fun. You earned it, you paid your dues, you deserve it!!!!

luvmygoats

I do not look forward to navigating this for both of us in 2 years. DH turns 65 in January but is still working to keep me mostly in health insurance. Thank goodness he is much healthier than I am. I understand he will only need part A since he has a decent BCBS PPO plan thru work. Higher deductibles than I would like to see but overall I've been very pleased with the coverage and no quibbles with paying.

fifthyear

MinusTwo, thanks. Yes the valley has changed. Been here since 1975, SF then down south to San Jose. Still a cool place but VERY crowded. Traffic is awful, and people are not that polite anymore. Oddly enough, DH and I are thinking about moving to Houston, maybe Sugarland but heard that property tax is really bad there. Is it true MinusTwo?

fifthyear

luvmygoats, I have the option to stay with private insurance where my DH is working, but opted to go the Medicare round. The ups are more for me. If I waited until later when my DH stops working, I may have less options than I do now turning 65. You can get supplemental plans at good price and pre-existing does not count. If I pass Medicare when I become eligible, I will have to pay more for part B and plans.

That's how I interpreted the data from Medicare.gov. I could be wrong tho. Check it out first before you decide. Based on what Winningsofar, MinusTwo, tgtg, and Spookiesmom wrote here, it looks like a decent path.

luvmygoats

Oh I'm not eligible yet. Only turning 63 this year. Just commiserating with the decision process. He's the one turning 65 but staying in work force to keep me insured until I turn 65. Just reading to get ideas here. Keep them coming. Friends are all younger except for one and she had to shop around for the very best pharmacy plan. She actually used an agent to find one. And no not for CA drugs of any sort.

MinusTwo

fifth - No one can believe the difference in prices here compared to Northern Cal. We never had Prop 13, but over all from what I've seen, you can buy 3 houses for the price of your one CA house. Property taxes are based on the value of the house, so... We have no income taxes so part of that is made up w/property taxes. But some of the taxes are frozen once you're 65. Below is the appraisal district website that includes Sugarland. You can put in any name or address in the search bar and see what the property value is and what the taxes are.

http://fbcad.org/Map

What you will have to put up with is heat & humidity.

fifthyear

MinusTwo, many thanks for the link. We will investigate. We figure if we sell our home here we will be able to retire in Houston and doing ok with it. We bought the house 18yrs ago so we are not doing too badly in that department.

Thanks again, be well.

mysunshine48

Will Medicare pay for a PET scan

MinusTwo

mysunshine - it depends on the individual circumstances and the way the doctor presents the need for PET/CT and the codes the billing office uses when submitting the bill, etc. Personally I have had several in the last two years. When my MO retired last December he said I would probably have to fight to get more or find a different doc who believed they were critical to ongoing care. Someone else told me there was a life time limit, but I don't know if that's true.

mysunshine48

Anyone have a really good part D plan? (RX) I just got the notice that 2016 deductible will go to $350.00. That seems like a lot. Thanks!

dsgirl

Hello. The most important thing is to ask up front it the clinic. doctor etc. ACCEPTS medicare, if they do there should be no cost to you. ALL my tests, scans, biopsies, surgery, radiation and follow up appointments with surgeon, and now MO, were and still are at NO Cost to me. I am on original medicare and have a supplemental ins., plan F.

Hope this information helps someone.

dsgirl

MinusTwo

MySunshine - Am I correct, you are just asking about Part D - the drug plan? I chose the cheapest one available here and it costs $12.95 per month. There is no deductible and the drugs I need are usually around $4.00.

If someone chooses one of the HMO plans, it includes drugs - but I didn't want to give up all my regular doctors that I'd been seeing for 20 years. On an HMO/Avantage plan, I believe there is a deductible but not sure, and also a monthly payment

Like dsgirl, I too have original medicare a supplemental plan with AARP. I have not had to pay for anything except my $147 deductible every year for medicare and a reasonable monthly fee for the AARP supplement. Then, no co-pays, no over-runs, absolutely nothing. Everything relating to both of my cancers was covered 100% - 80 by medicare & 20 by United Health. I continue to be very grateful!!! Unfortunately I don't think the plan I have is available any more.

mysunshine48

Yes, Part D, the drug plan. I just started on this Medicare roller coaster and the drug plan just went into effect. Now, like I said, just got a letter about open season for Part D plans and I want to change. Cost is $67.00 a month and now $350.00 deductible. I only have one RX and it is not expensive. I get Arimidex through the manufacturer.

MinusTwo

mysunshine - For better or worse, the plan was designed that we can (have to) review everything every fall & can change as desired. 'Open season' is right - and we're the ones under the gun. I HATE having to do this every single year. The formulary drug lists change every year for every company too, so we need to make sure "our" drugs are still on the plan. All the drug company offerings for your state will be in the back of the Medicare book you get in the mail each year, or you can go on line. You have several months to make changes. I haven't seen my book yet but I usually get it in October. I just pick the very cheapest one since I'm fortunate not to have any regular prescription drugs. If you can't find the links, let me know and I'll dig it out for you.

mysunshine48

Thank you! All this Medicare stuff is new to me. My Part D just started and now it looks like I will be looking to change already! I do not want a $350.00 deductible and I the monthly cost of this one is around $67.00 a month. I choose this one as there were only 2 I could find that covered Arimidex. But, having just started Arimidex, I am getting it directly from Astro Zenika, so Part D won't play a part in that. I hsve United through AARP, I think, for a supplemental and will see if they might offer Part D too. Why does all this have to be so complicated? Why not one for everything? That would be too easy!