NEED INFORMATION (ALIAS MEDICARE 101)

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compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7203
   Posted 8/8/2010 2:34 PM (GMT -6)   
Here is part of an email I sent a friend.. But some background first.
I will be 65 years old in June. So, I need to figure out this Medicare stuff.
 
I currently work (College Prof) with excellent health insurance. This insurance I believe turns into a supplement policy.
 
I am also eligible to pick up insurance from the retiree system (State of Michigan). It is a BC/BS plan and it too would be a supplemental plan.
 
Here is what I wrote. Any enlightenment would be appreciated:
 
>>>>>>>>>>>>>>>>
I read your email with interest, especially the MediCare part. I fear I have a lot of research to do. First of all, I need to learn about the services. You mentioned Parts A, B, and D. I assume one is for doctors and one is for medications and maybe one for hospitalization and then medical lab tests go somewhere. I need to learn about that. Hopefully, my HR person knows a good deal or can connect me with someone who does.

But then there's the issue of supplemental insurance. I have fabulous insurance at work, which will become a supplement. But I can drop that and do the Michigan BC/BS retirees insurance, which would become a supplement. I do know my work insurance is far superior to the BC/BS policy, but that is as a primary insurer.

Then I have my own special circumstances. By the end of January I will have 2 more PSA readings. So, I might have an idea that I am heading towards using that second bullet (radiation). That might figure into my insurance choices. In fact, I suspect I will have to delineate "essential" doctors/hospitals and see if they are in network.
>>>>>>>>>>>>>>
 
OK, any comments??
 
Mel

63 years old . PSA-- 3/08--2.90; 8/09--4.01; 11/09--4.19 (Free PSA 24%),  after 45 days on cipro! DREs have always been normal. PCA-3 was about 75 (way above the 35 threshold). That led to:

Biopsy on 11/30/09. 5 out of 12 cores positive. Gleason 4+3. 2 cores were 3+3 (one 5% and the other 30%) on one side. On  other side:2 cores are 4+3 (5%)--1 core 3+4 (30%) no peri-neural invasion. prostate is 45 grams. Stage: T1C.  

Surgery with Dr. Menon at Ford Hospital, 1/26/10. He says all looked good. Spared nerves. Unfortunately: Pathology Report: G 4+3 (65%-35%). Cancer in 15% of gland. Lymph Nodes: Clear.  Perineural Invasion: yes. Seminal Vessical Involvement: No.  Extraprostatic Extension: yes.  Positive Margin: Yes-- focal-- 1 spot .5mm. Final Weight is 52.7 gms.  (Second opinion from Jon Epstein at Hopkins confirmed these results)

 Incontinence: joined that club-- definite leaks—1 pad/day. Night is dry, was  using 1 pad at night for security, but pretty much dispensed with that most nights. Update: no pads at night. No pads while at home, but still very uncomfortable. Use 1 pad for out-of-house activities. Suddenly got MUCH better on 3/10/10, almost overnight. Still some urgency but no pads about 90% of the time.  As of 3/12/10--completely continent! Uh...OH. As of about 3/16/10 problems with constant urgency although no pads needed--feels like an infection but none showing in urine.

Update: since late March all is well in that area. I would say 99.9% continent (a spurt here and there, maybe 5 spurts per week). As of 6/22/10, I would say I am 100% continent, but I do have (controllable) significant urgency.

First post-op PSA on 3/10/10--DRUM ROLL: 0.01 Next PSA in mid-June.

Second post-op PSA on 6/21/10--0.02--Not too bad!


142
Forum Moderator


Date Joined Jan 2010
Total Posts : 6946
   Posted 8/8/2010 2:51 PM (GMT -6)   
I'm not to Medicare yet, but I have noticed in my various searches for "in-network" doctors that a number of the more highly-recommended ones made the point that they did not accept Medicare, thus wanted to verify my plans for medium term care. My current GP is the same - his group does not accept Medicare.

I saw an article in on of the AARP newsletters titled "Find a younger doctor now" - they expect that most people going into retirement forget that their doctors will as well, and be caught in a transition they might not be prepared fo later on.

You are correct to pay very careful attention to the services covered by the supplemental and drug plans (part D). I had a friend in a distant nursing home who could not make her own decision and had no nearby family to help - under the state guidelines they just went down the hall assigning alternately an equal number of people to each of the part D plans that operated in the area. There were some very expensive consequences, as the match of patient and needed/covered drugs was, at best, abysmal.

FLBeachgal
Regular Member


Date Joined Mar 2010
Total Posts : 46
   Posted 8/8/2010 2:53 PM (GMT -6)   
Hi Mel,
 
Hubby & I went through this exercise a couple of years ago when he went on Medicare.  We are State of Florida retirees and carried the BC/BS state employees plan as our only insurance prior to that time.  When he went on Medicare, his State of FL BC/BS became his supplement.  This BC/BS plan has a prescription drug benefit, so he did not need to purchase Medicare Part D.  Medicare Part A is hospitalization insurance & Part B is for almost everything else besides prescription drugs.
 
In your situation I think it would be wise to compare your current insurer's benefits as a Medicare supplement against the State of Michigan's plan and decide which is best for you.  If one or both have prescription drug benefits included like ours does, you would not need to purchase a Medicare Part D plan.
 
We have a small co-pay for medications, but he has never had to pay a dime for any of his other PC - related costs, including surgery, hospitalization, MD visits, and now radiation therapy treatments.
 
Margie

Postop
Regular Member


Date Joined Feb 2010
Total Posts : 385
   Posted 8/8/2010 3:05 PM (GMT -6)   
The resource for Medicare is

http://www.medicare.gov/

Part A: Hospital
Part B: Outpatient

Part C: Medicare Advantage--private plans, better benefits, but you have to stay in network like an HMO or PPO. The government has extra costs for these plans, and these subsidies will go away in the future.

Part D: Drug coverage--have to sign up with a private plan, coverage varies widely

Doctors who don't take Medicare are typically private entrepreneurs and have enough patients with commercial insurance so that they can decide not to take it so they can get higher reimbursements. Most large clinics, and all academic centers take Medicare.

Medicare supplemental: coverage--mostly covers copayments.

After you hit 65, most commercial and retirement plans require that you get Medicare, and they act as supplementals.

FLBeachgal
Regular Member


Date Joined Mar 2010
Total Posts : 46
   Posted 8/8/2010 7:14 PM (GMT -6)   
Except for OB/GYN's & pediatricians, doctors here in Florida almost HAVE to take Medicare in order to stay afloat!

Ed C. (Old67)
Veteran Member


Date Joined Jan 2009
Total Posts : 2458
   Posted 8/8/2010 7:48 PM (GMT -6)   
Mel,
I'm an IBM retiree, a little over 2 years ago I was using my IBM medical insurance. As soon as I turned 65, my IBM insurance became supplemental insurance to medicare. Part A is for hospital, part B is for out patient (Doctor's visits and such) and part D is for medication. the medicare supplement that I carry is called part F which has covered every office visit, hospital stay and surgery 100% with no deductible ( I pay a monthly fee to IBM). For medication I do have a copay that varies depending on the medicine (generic vs non-generic). So far I have paid zero dollars during my PC journey. All my doctors accept Medicare, I doubt any Urologist will refuse Medicare patients since most of their customers are likely to be over 65. The one advice I have is to avoid "Medicare Advantage" which restricts you to a group of doctors that may not include the ones you want or need.
Age: 67 at Dx on 12/30/08
PSA 9/05 1.15; 8/06 1.45; 12/07 2.41; 8/08 3.9; 11/08 3.5 free PSA 11%
2 cores out of 12 were positive Gleason (4+4) and (4+5)
Negative CT scan and bone scan done on 1/16
Robotic surgery performed 2/9/09 Dr Fagin, Austin TX
Prostate weighed 57 grams size:5.2 x 5.0 x 4.9 cm
Posterior lateral lesions measuring 1.5 x 1.4 x 1.0 cm showing focal capsular penetration over a distance of 3mm in circumference.
Prostatic adenocarciroma accounts for approx. 10-20% of the hemisphere.
Gleason 4+4
both nerve bundles removed,
pT3a Nx Mx, Negative margins
seminal vesicles clean, lymph nodes: not dissected
continent after 5 months
2 months PSA test 4/7/09 result <0.1
5 months PSA test 7/9/09 result <0.1
8 months PSA test 10/9/09 result <0.1
11 months PSA test 1/21/10 result 0.004
14 months PSA test 4/19/10 result 0.005

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3741
   Posted 8/8/2010 8:11 PM (GMT -6)   
I hit that wall 3 years ago..I decided on Medicare Advantage - United Health Care-Secure Horizons, an HMO type network my GP belonged to. It works great in the Denver Metro area but no coverage when we travel..I chose Plan 3, which required no extra premium payment. For an extra $200-$300 a month, you can get a "Cadillac" plan with broad coast to coast coverage and few limitations..

I could find no local GP's who were willing to accept any new standard Medicare patients...

Had I been diagnosed at age 62 (or whatever) the treatment costs would have bankrupted my family...
Age today: 68. Married, 6', 215 pounds, active, no health issues.
PSA at age 55: 3.5, DRE negative. Advice, "Keep an eye on it".
PSA at age 58: 4.5
PSA at age 61: 5.2
PSA at age 64: 7.5, DRE "Abnormal"
PSA at age 65: 8.5, DRE " normal", biopsy, 12 core, negative...
PSA at age 66 9.0 DRE "normal", BPH, Finesteride. (Proscar)
PSA at age 67 4.5 DRE "normal" second biopsy, negative.
PSA at age 67.5 5.6, DRE "normal" U-doc worried..
PSA at age 68, 7.0, third 12 core biopsy positive for cancer in 4 cores, 3 cores Gleason 6, one core Gleason 9. Finesteride discontinued, still no urinary symptoms, never had any..From age 55 to 65 I had no health insurance.

I have a date with the robo surgeon on Sept 3 but I'm keeping my options open. I'm also looking at seeds combined with IGRT which seems to be having good results with high-risk patients..

Post Edited (Fairwind) : 8/8/2010 9:57:12 PM (GMT-6)


compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7203
   Posted 8/8/2010 9:20 PM (GMT -6)   
I've read all the responses and it is still confusing!!!
 
I'll be checking with my HR person!
 
Mel

63 years old . PSA-- 3/08--2.90; 8/09--4.01; 11/09--4.19 (Free PSA 24%),  after 45 days on cipro! DREs have always been normal. PCA-3 was about 75 (way above the 35 threshold). That led to:

Biopsy on 11/30/09. 5 out of 12 cores positive. Gleason 4+3. 2 cores were 3+3 (one 5% and the other 30%) on one side. On  other side:2 cores are 4+3 (5%)--1 core 3+4 (30%) no peri-neural invasion. prostate is 45 grams. Stage: T1C.  

Surgery with Dr. Menon at Ford Hospital, 1/26/10. He says all looked good. Spared nerves. Unfortunately: Pathology Report: G 4+3 (65%-35%). Cancer in 15% of gland. Lymph Nodes: Clear.  Perineural Invasion: yes. Seminal Vessical Involvement: No.  Extraprostatic Extension: yes.  Positive Margin: Yes-- focal-- 1 spot .5mm. Final Weight is 52.7 gms.  (Second opinion from Jon Epstein at Hopkins confirmed these results)

 Incontinence: joined that club-- definite leaks—1 pad/day. Night is dry, was  using 1 pad at night for security, but pretty much dispensed with that most nights. Update: no pads at night. No pads while at home, but still very uncomfortable. Use 1 pad for out-of-house activities. Suddenly got MUCH better on 3/10/10, almost overnight. Still some urgency but no pads about 90% of the time.  As of 3/12/10--completely continent! Uh...OH. As of about 3/16/10 problems with constant urgency although no pads needed--feels like an infection but none showing in urine.

Update: since late March all is well in that area. I would say 99.9% continent (a spurt here and there, maybe 5 spurts per week). As of 6/22/10, I would say I am 100% continent, but I do have (controllable) significant urgency.

First post-op PSA on 3/10/10--DRUM ROLL: 0.01 Next PSA in mid-June.

Second post-op PSA on 6/21/10--0.02--Not too bad!


Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3741
   Posted 8/8/2010 10:05 PM (GMT -6)   
"But then there's the issue of supplemental insurance. I have fabulous insurance at work, which will become a supplement. But I can drop that and do the Michigan BC/BS retirees insurance, which would become a supplement. I do know my work insurance is far superior to the BC/BS policy, but that is as a primary insurer."

See if the company you have now offers a Medicare Advantage plan..Then your coverage will be almost seamless, you keep the same doctors you have now, your network will not change..

Radiation treatments can be very expensive. Medicare will only cover 80% of that..Be sure to get "pre-approval" before you begin any treatments to avoid any nasty surprises..

Post Edited (Fairwind) : 8/8/2010 10:11:05 PM (GMT-6)


142
Forum Moderator


Date Joined Jan 2010
Total Posts : 6946
   Posted 8/8/2010 10:22 PM (GMT -6)   
Mel,
When dealing with insurance, you need to get a very detailed list of coverages under each plan, and that would have to come from your HR people. Also, be sure that there is a proper notification method of changes, as insurance plans change to some degree every year.

BTW - I was refused as a new patient at several practices, being over 55, as they do not take Medicare, and don't want new patients that are "too close" in age. I guess it may be a given in Florida that they would accept it, but not where I live.
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