Advanced PC and Insurance/Medicare

New Topic Post Reply Printable Version
[ << Previous Thread | Next Thread >> ]

compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7197
   Posted 3/13/2011 12:55 PM (GMT -6)   
When I retire eventually, Medicare will be my primary insurance and BC/BS will be secondary. I am not sure what BC/BS will even cover on that.
 
So, how good is Medicare in terms of coverage of tests/drugs/etc.
 
Mel

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25364
   Posted 3/13/2011 12:58 PM (GMT -6)   
Good question, Mel, one I have thought of asking too. Looking forward to the answers here.
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 2/11 1.24
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/10,

duke68
Regular Member


Date Joined Mar 2007
Total Posts : 242
   Posted 3/13/2011 2:18 PM (GMT -6)   
I have Medicare and BC/BC in Massachusetts.

Treatments to date RRP, Radiation with 6 months ADT2.
Multiple cat scans, prostascint scan, xrays, ekg's, extensive blood tests.
Currently on clinical trial.

No costs for these

Only pay a copay for drugs.
Gerry
age 68 diag. oct 2006 G8 T2b psa 11.7
4 of 8 cores 20% 30% 60% 100%
rrp dec 2006 G9 4+5 m+ sv+ ece after 6 weeks psa 0.6 second opinion Dana-Farber pT3b 4+4 + T5 = G9
Rt 35 sessions to lymph nodes and prostrate 4-2007
3/2007 cab 6 months lupron + casodex.
psa <0.1 from june 2007 to march 2010
psa 6/10 0.3 9/10 0.6 12/10 2.5 :(

Dana- Farber Phase 2 trial Avastin Lupron and casodex

Carlos
Regular Member


Date Joined Nov 2009
Total Posts : 486
   Posted 3/13/2011 3:28 PM (GMT -6)   
Mel,  Your coverage will depend on the Medicare plan you select.  Many (most or all?) Medicare Advantage plans require you to use a local or regional network except in emergencies.  However, regular Medicare covers you wherever you are in the US.  Details of the various supplemental coverage plans are spelled out in the Medicare handbook. Your employee supplemental plan will most likely differ from the various standard Medicare supplemental plans. 
 
One important thing to remember.  Medicare will only pay for approved treatments and the ICD code must be appropriate for the selected treatment.  For example, DR. Scholz in his video (if you hadn't fallen asleep by then) mentioned that an advanced chemo treatment would  be covered by insurance only if used after PSA relapse after HT.  Insurance would not pay for experimental use of the drug earlier in the treatment process.  I have had Medicare decline to pay for an MRI and physical therapy.  Always ask before you start.
 
Like Gerry, Medicare and my supplement have paid for everthing since my original PCa dx.  All costs for daVinci, SRT and all the associated tests and scans were paid in their entirety.  I haven't received a medical bill in over 5 years.
 
Carlos
 
 

 



Dx 2/2008, age 71, PSA 9.1, G8,T1c. daVinci surgery 5/2008, G8(5+3), pT2c. LFPF, good QOL. PSA <0.1 for 2 yrs. PSA rose to .2 at 30 months, Completed SRT 2/2011. PSA 0.1 at 3 wks post SRT.

compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7197
   Posted 3/13/2011 3:39 PM (GMT -6)   
Carlos:
 
It gets real tricky. My understanding is that right now, Medicare will be secondary to my insurance. That's not the same as a supplement. So say a doctor charge $1000 and Medicare would normally pay $600. If my regular insurance pays $600, then that's it. Medicare considers that bill paid, albeit by my other insurance (a supplement would look at the difference and pay a percentage of that).
 
When I go to MediCare being the primary and BC/BS being the secondary, I think it's the same thing. They are not a suppleement. I'm not totally sure.
 
Mel

duke68
Regular Member


Date Joined Mar 2007
Total Posts : 242
   Posted 3/13/2011 4:03 PM (GMT -6)   
On my plan, Medicare pays first then BC/BS pays.

It's important to know that Medicare doesn't pay the amount you see on the bill.
They pay a smaller amount (discounted). Then your Medex plan picks up the remainder if any.

My plan allows me to go to any Medicare approved provider.
Gerry
age 68 diag. oct 2006 G8 T2b psa 11.7
4 of 8 cores 20% 30% 60% 100%
rrp dec 2006 G9 4+5 m+ sv+ ece after 6 weeks psa 0.6 second opinion Dana-Farber pT3b 4+4 + T5 = G9
Rt 35 sessions to lymph nodes and prostrate 4-2007
3/2007 cab 6 months lupron + casodex.
psa <0.1 from june 2007 to march 2010
psa 6/10 0.3 9/10 0.6 12/10 2.5 :(

Dana- Farber Phase 2 trial Avastin Lupron and casodex

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3631
   Posted 3/13/2011 5:24 PM (GMT -6)   
I was unable to find any physician who was willing to accept new Medicare patients..Their advise, if you are sick, go to the ER, they take Medicare..My family doctor recommended I investigate Medicare Advantage, a type of Medicare managed by private insurance companies the doctors find more acceptable...Depending on how much you are willing to pay, different plans are available. In your 64th year, the offers come pouring in..Tons of it..

Medicare does a pretty good job of paying for things, the co-pays are reasonable..Except when it comes to radiation treatment, where they generally only pay 80% of the treatment cost leaving you to pick up the rest..This can be serious money..You can protect yourself from payment shocks by asking the provider get pre-approval from your insurance first...
Age 68.
PSA age 55: 3.5, DRE normal.
age 58: 4.5
61: 5.2
64: 7.5, DRE "Abnormal"
65: 8.5, " normal", biopsy, 12 core, negative...
66 9.0 "normal", 2ed biopsy, negative, BPH, Proscar
67 4.5 DRE "normal"
68 7.0 3rd biopsy positive, 4 out of 12, G-6,7, 9
RALP Sept 3 2010, pos margin, one pos vesicle nodes neg. Post Op PSA 0.9 SRT, HT. 2-15-'11 PSA 0.0

compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7197
   Posted 3/13/2011 5:40 PM (GMT -6)   
Fairwind:
 
I think I have received about 75 of these advantage plan offers. Right now I just ditch them as I am only doing the free Medicare Part A because my insurance at work is primary.
 
I know the SRT locally is in-network. I think I might still be stuck for 10% or so but I am not sure. Regardless, I think my annual out of pocket maximum in-network is $1000 and everything after that is 10%. I'm not really sure. I know with my DaVinci surgery my costs were quite small.
 
I remember my Dad spent a lot of time checking and choosing physicians based on if they accept Medicare and Supplement as payment in full.
 
Mel

caring wife
Regular Member


Date Joined May 2008
Total Posts : 20
   Posted 3/13/2011 7:19 PM (GMT -6)   
My husband has Medicare as his primary insurance and BC/BS as his secondary.   Although he is not 65 yet, he has coverage because of his spinal cord  injury disability.   He had sepsis following the prostate biopsy and was hospitalized for a week.   He was in the hospital another full week following his prostate surgery because of complications.   Medicare and Blue Cross covered all costs.  

Sephie
Veteran Member


Date Joined Jun 2008
Total Posts : 1804
   Posted 3/13/2011 7:23 PM (GMT -6)   
Mel, while we are not yet "on" Medicare, many of our friends are. The problem seems to be finding a doctor that that accepts Medicare rather than what will Medicare pay for. One of my closest friends moved to Florida about a year ago...she is on Medicaid (disability) and her husband is on Medicare (retired). Both of them are having a devil of a time finding "good" doctors that accept either coverage. And, both of them need specialists (she's diabetic and needs an endocrinologist) and he has had heart issues and needs a cardiologist.

Even up here in New York, I'm hearing more people complain about finding a good Medicare doctor as so many are opting out of this plan due to the lower-than-usual reimbursement rates.

Ed C. (Old67)
Veteran Member


Date Joined Jan 2009
Total Posts : 2457
   Posted 3/13/2011 8:03 PM (GMT -6)   
Mel,
I'm on medicare, I signed up for medicare oartr A & B with medicare supplement part "F". So far, through my treatment it has covered everything. I haven't had to pay any co-pay to doctors, labs or hospitals.
Age: 67 at Dx on 12/30/08 PSA 3.8
2 cores out of 12 were positive Gleason (4+4)
Davinci surgery 2/9/09 Gleason 4+4 EPE,
Margins clear, nerve bundles removed
Prostate weighed 57 grams 10-20% involved
all PSA tests since (2, 5, 8, 11, 15, 18, 21 months) undetectable
Latest PSA test (2 years) <.008 ?

Old Sailor
Regular Member


Date Joined Aug 2009
Total Posts : 207
   Posted 3/13/2011 9:01 PM (GMT -6)   
Mel, been on Medicare for 4 years now.  Mayo accepts medicare but not the advantage plan (many places don't).  I think the key is the supplemental plan you have.  Mine covers all that medicare does not pay in full or cover.   The Old Sailor

reachout
Veteran Member


Date Joined May 2009
Total Posts : 725
   Posted 3/14/2011 8:40 AM (GMT -6)   
I'm on Medicare primary and Tricare secondary. When I inquired from a couple of well known national PC urologists about doing robotic surgery, they did not accept Medicare. But I found several excellent local doctors in the DC area that did, so I had my DaVinci paid for with Medicare, and whatever they did not cover was picked up by Tricare. I don't remember how much I was out of pocket, but it was minimal, maybe a couple of hundred at the most, compared with the $15-20,000 cost of the surgery and hospital. From what I recall, though, Medicare only actually pays a small percentage of that, per agreements they make with doctors. The issue is, especially with the cuts we're seeing, that fewer doctors and hospitals are taking Medicare.

At one time I thought, if a doctor doesn't take Medicare because the reimbursement is too low, can I agree to pay out of pocket for the difference? For example, if a procedure costs $10k but Medicare only pays $6k can I agree to pay the doc the $4k out of pocket, instead of the entire $10k? The answer, as I found out, is no. If a doctor won't take Medicare they are not allowed to recover the difference from the patient.
Age: 66
Pre-surgery PSA: 7 tests over 2 years bounced around from 2.6 to 5.6
Biopsy 8 of 12 positive, Gleason 3+4, T2a
DaVinci August 2009, pathology Gleason 4+3, neg margins, T2c
Post-surgery PSA one year of zeros.
Continent right away.
Viagra and other pills only gave me headache
Trimix working great!

James C.
Veteran Member


Date Joined Aug 2007
Total Posts : 4462
   Posted 3/14/2011 9:29 AM (GMT -6)   
Good subject, since I will reach 65 April, 2012. I've been looking at the available advantage and supplemental plans offered by my retiree plans. They all seem similar, a little more dollars if you want a smaller co-pay. The biggie in my planning now is the SRT possibility later for me. Every one of the Advantage plans say that radiation treatmen is 'therepy' and therefore falls under the 20/80 rule.
My current plan, Cigna, says they will pay a pre-agreed amount for this treatment with the hospital. Say it is $50,000 total hospital billed. They may just pay $15,000. Of that $15,000, I would be responsilbe for 20%, or $3000. My current yearly out of pocket is $3400.

Under the Medicare plan, if I read it right, the only change is that there is no mention of me getting to pay the 20% of the pre-agreed amount. They every one just say I will be on a 20/80 plan and would be responsible for the full 20%, presumably of the $50,000, not the pre-agreed $15,000 or whatever. Is that making sense, from the experience of you guys who are already on it and had SRT?
James C. Age 63
Gonna Make Myself A Better Man tinyurl.com/28e8qcg
4/07: PSA 7.6, 7/07 Biopsy: 3 of 16 PCa, 5% involved, left lobe, GS6
9/07: Nerve Sparing open RP, Path: pT2c, 110 gms., clear except:
Probable microscopic involvement-left apical margin -GS6
3 Years: PSA's .04 each test until 04/10-.06, 09/10-.09, 12/10-.09, 02/11-.08
ED-total-Bimix 30cc

Carlos
Regular Member


Date Joined Nov 2009
Total Posts : 486
   Posted 3/14/2011 10:14 AM (GMT -6)   
James, I just completed  SRT and this is how Medicare worked for me.  Radiologist billed Medicare $82,000 for my comlete treatment.  Medicare's total approved benefit for my treatment was $32,000.  So, Medicare Part B paid $25,600 (80%) and I and my supplemental policy were responsible for the remaining $6,400.  I have a Medicare supplemental plan J and it paid the entire $6,400 (20%).
 
Carlos
Dx 2/2008, age 71, PSA 9.1, G8,T1c. daVinci surgery 5/2008, G8(5+3), pT2c. LFPF, good QOL. PSA <0.1 for 2 yrs. PSA rose to .2 at 30 months, Completed SRT 2/2011. PSA 0.1 at 3 wks post SRT.

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3631
   Posted 3/14/2011 11:37 AM (GMT -6)   
Carlos makes some good points and points out the major weakness in how health-care is provided in the U.S.

If you are uninsured or self-insured, his doctor expects to be paid $82,000 for the SRT. But this same doctor is willing to accept $32,000 from Medicare plus $6400 from whoever they can get it from...

Radiation Oncologists earn, on average, over a half-million dollars a year....

My Medicare Advantage Secure Horizons ARRP plan, by United Health-Care, is fairly low cost (zero cost actually) insurance that is similar to an HMO in structure. I must be treated in my Denver "group", a large selection of doctors, specialists, hospitals and treatment centers.. I must get referrals from my primary care physician to see specialists (he is very obliging) and while ER visits are covered anywhere, if I need treatment for chronic conditions I must get that treatment in Denver or pay for it myself..Once a year, in November, you can change plans and upgrade the services available but these upgrades can cost serious money..The top-of-the-line plan that covers everything, everywhere, anytime runs about $600 / month extra....(I think)..

compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7197
   Posted 3/14/2011 11:41 AM (GMT -6)   
Wow -- a whole new area of confusing games to play.
 
With my work plan, I think my OOP (out of pocket) maximum is $1000 in-netowrk, so I'm not too worried about my cost.
 
Again, I suspect it will be much less, if anything, because they are in-network.
 
I'm not worried about the cost. There is no question I NEED to do the SRT. It is not an option!!
 
My set-up is tomorrow.
 
Mel

James C.
Veteran Member


Date Joined Aug 2007
Total Posts : 4462
   Posted 3/14/2011 1:09 PM (GMT -6)   
carlos, thanks for that info, that makes sense and is more comforting. smilewinkgrin
James C. Age 63
Gonna Make Myself A Better Man tinyurl.com/28e8qcg
4/07: PSA 7.6, 7/07 Biopsy: 3 of 16 PCa, 5% involved, left lobe, GS6
9/07: Nerve Sparing open RP, Path: pT2c, 110 gms., clear except:
Probable microscopic involvement-left apical margin -GS6
3 Years: PSA's .04 each test until 04/10-.06, 09/10-.09, 12/10-.09, 02/11-.08
ED-total-Bimix 30cc

Ed C. (Old67)
Veteran Member


Date Joined Jan 2009
Total Posts : 2457
   Posted 3/14/2011 5:15 PM (GMT -6)   
You need to be careful when on medicare. Medicare Advantage is low in cost but you are restricted to the doctors and hospitals on their plan. Most reputable doctors and hospitals do not accept medicare Advantage. Medicare supplement is costlier but is accepted by all doctors who accept medicare.

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3631
   Posted 3/15/2011 1:05 PM (GMT -6)   
"Most reputable doctors and hospitals do not accept Medicare Advantage."

In Denver, I have not found that to be the case. Just the opposite was true..

Ziggy9
Veteran Member


Date Joined Jul 2008
Total Posts : 981
   Posted 3/15/2011 1:17 PM (GMT -6)   
Fairwind said...
Carlos makes some good points and points out the major weakness in how health-care is provided in the U.S.

If you are uninsured or self-insured, his doctor expects to be paid $82,000 for the SRT. But this same doctor is willing to accept $32,000 from Medicare plus $6400 from whoever they can get it from...

Radiation Oncologists earn, on average, over a half-million dollars a year....

My Medicare Advantage Secure Horizons ARRP plan, by United Health-Care, is fairly low cost (zero cost actually) insurance that is similar to an HMO in structure. I must be treated in my Denver "group", a large selection of doctors, specialists, hospitals and treatment centers.. I must get referrals from my primary care physician to see specialists (he is very obliging) and while ER visits are covered anywhere, if I need treatment for chronic conditions I must get that treatment in Denver or pay for it myself..Once a year, in November, you can change plans and upgrade the services available but these upgrades can cost serious money..The top-of-the-line plan that covers everything, everywhere, anytime runs about $600 / month extra....(I think)..


United Healthcare also owned and operated Pacificare in Colorado. I forgot when they bought it but I was a member of it for over 20 years. Pacificare was an HMO but was accepted by most doctors. I was able to reject TUCC care and opt for CU Med Ctr where they paid for my TFT. They only balked initially at the 3D saturation biopsy. So I had no complaints with them at all. But in 2009 they moved Pacifcare out of Colorado and tried to replace it with a united health care plan that by looking at it was much inferior. I'm a retired federal worker and the only HMO plan left now is Kaiser which I wouldn't enroll my dog in. Now I'm on BCBS It's a little cheaper but I rather have Pacificare back
New Topic Post Reply Printable Version
Forum Information
Currently it is Sunday, April 22, 2018 10:10 PM (GMT -6)
There are a total of 2,954,434 posts in 324,121 threads.
View Active Threads


Who's Online
This forum has 162162 registered members. Please welcome our newest member, Shohga.
265 Guest(s), 8 Registered Member(s) are currently online.  Details
FATPRO, bluelyme, theHTreturns..., Michael_T, Girlie, LisaInIndiana, KYLEb23, Saipan Paradise