Medicare. The dirt.

[mitch777]

I would think this topic might have been brought up before but I don't remember reading about it so I'll ask.

I'm curious as to what to expect getting on Medicare as far as the downsides are concerned.

I know that some docs do not accept Medicare patients. How prevalent is that and has it caused problems with anyone here?

Also, I noticed Miss P. was turned down for a med after several attempts by his doc. How common is that? I know insurance companies do the same thing. Is Medicare better or worse? Government bureaucrats vs. Corporate greed.

Any other issues?

I hope to be leaving the land of insurance companies soon but I'm not sure if I'm really giving up many benefits or not.

[Jeff G]

I have been on medicare so long I have not much to measure the difference between it and private insurance but I did have a doctor tell me once that medicare was the best insurance there is ... still not sure about that .

[Tonny2]

I would think this topic might have been brought up before but I don't remember reading about it so I'll ask.

I'm curious as to what to expect getting on Medicare as far as the downsides are concerned.

I know that some docs do not accept Medicare patients. How prevalent is that and has it caused problems with anyone here?

Also, I noticed Miss P. was turned down for a med after several attempts by his doc. How common is that? I know insurance companies do the same thing. Is Medicare better or worse? Government bureaucrats vs. Corporate greed.

Any other issues?

I hope to be leaving the land of insurance companies soon but I'm not sure if I'm really giving up many benefits or not.

Hi Mitch, how are you?...I have medicare and private insurance since 2002...I was going to cancel my private insurance when I applied for MEDICARE, but a friend of mine told me to keep my private insurance, so I wouldn't have any co-payments....so, now I don't have any out-of-pocket expenses, MEDICARE and my private insurance pay for everything (except my meds, I get them through my private insurance)....I haven't had any problems, I see any doctor I want and any hospital...so my friend, no dirt from me   ;p

[Miss Philicia]

First of all, I had things turned down back when I was on private insurance -- when viral load testing first was FDA approved my expensive Cadillac Blue Cross insurance denied me more than one time, then restricted it to "x" times per year.

As far as my issues with prescriptions, that's not Medicare per se because they do not provide prescriptions, it's done through Medicare Part D which is actually farmed out, courtesy of the Bush 2.0 administration, to third party private insurance companies. And all of them will force you to accept a generic when available, no exceptions I think. But ADAP does that too.

As for Medicare A & B (and since I'm sure you don't know the difference google it) you have to know you're responsible for 20% of everything meaning it's necessary if you want good service to have supplementary insurance to cover that 20%. Things vary state by state in terms of what supplementary insurance will be available to you. If anything that is what I would look into as it's really key when you are seeing a lot of specialists. Something with a low premium will have high deductibles and high co-pays where something with a higher monthly premium will have the reverse. I would sit down with a case manager when you are at the point where you need to do this part.

I've never had issues finding doctors accepting my coverage, but then here in Philadelphia most doctors are part of the Penn Medicine network (meaning affiliated with the Univ. of PA Medical School), Drexel Univ., Temple Univ. or Jefferson University. So I stick with specialists that are part of those organizations.

Anyway, the way I have myself set up is I have the standard $104 Medicare A/B premium deducted from my monthly SSDI check and then pay an additional $103/month premium to the state for a policy that gets me on Medicaid as a dual eligible, even though I'm not technically qualified for Medicaid -- this is done through a state program called "Medical Assistance for Workers w/Disabilities". I can't tell you if your state has something like this. But when I go to doctors/specialists/lab work/hospital visits etc. I never pay a co-pay and everything is covered 100%.

[mitch777]

Hi Mitch, how are you?...I have medicare and private insurance since 2002...I was going to cancel my private insurance when I applied for MEDICARE, but a friend of mine told me to keep my private insurance, so I wouldn't have any co-payments....so, now I don't have any out-of-pocket expenses, MEDICARE and my private insurance pay for everything (except my meds, I get them through my private insurance)....I haven't had any problems, I see any doctor I want and any hospital...so my friend, no dirt from me   ;p

No dirt is good dirt. lol. Gotta figure all of these "parts" out. Parts A, B, D. Been delaying even trying to understand them all until now due to my horrible memory and the length of time to get a disability hearing. Now that it's approaching I had better get in gear.

I know it is a no brainer to get extra Part D drug coverage and also extra medical coverage. I'm not impressed so far with the limited time I have spent with my local ASO. Maybe I'm short changing them. 

[mitch777]

First of all, I had things turned down back when I was on private insurance -- when viral load testing first was FDA approved my expensive Cadillac Blue Cross insurance denied me more than one time, then restricted it to "x" times per year.

As far as my issues with prescriptions, that's not Medicare per se because they do not provide prescriptions, it's done through Medicare Part D which is actually farmed out, courtesy of the Bush 2.0 administration, to third party private insurance companies. And all of them will force you to accept a generic when available, no exceptions I think. But ADAP does that too.

As for Medicare A & B (and since I'm sure you don't know the difference google it) you have to know you're responsible for 20% of everything meaning it's necessary if you want good service to have supplementary insurance to cover that 20%. Things vary state by state in terms of what supplementary insurance will be available to you. If anything that is what I would look into as it's really key when you are seeing a lot of specialists. Something with a low premium will have high deductibles and high co-pays where something with a higher monthly premium will have the reverse. I would sit down with a case manager when you are at the point where you need to do this part.

I've never had issues finding doctors accepting my coverage, but then here in Philadelphia most doctors are part of the Penn Medicine network (meaning affiliated with the Univ. of PA Medical School), Drexel Univ., Temple Univ. or Jefferson University. So I stick with specialists that are part of those organizations.

Anyway, the way I have myself set up is I have the standard $104 Medicare A/B premium deducted from my monthly SSDI check and then pay an additional $103/month premium to the state for a policy that gets me on Medicaid as a dual eligible, even though I'm not technically qualified for Medicaid -- this is done through a state program called "Medical Assistance for Workers w/Disabilities". I can't tell you if your state has something like this. But when I go to doctors/specialists/lab work/hospital visits etc. I never pay a co-pay and everything is covered 100%.

lol. Your'e right. I don't know the difference between Parts A and B. ( btw- was there ever a Part "C" and if not WHY?!! lol.) I figured you get what you pay for. As I said, I know that I will need Part D but I didn't know if the government put more restrictions on the insurance policies. I guess not from what you are saying. I also didn't know that this was courtesy of Bush2. UGH!

Anyway, I have the feeling living here in CT that I probably don't have to worry too much about docs not accepting Medicare. I will need to find out somehow about the program of which you speak my dear. I won't qualify foe Medicaid either.

So... over all I take it that you seem happy with Medicare?

[mitch777]

ok, just Googled ABCD.

Seems like Part C rarely gets a mention. I'm not sure why they separate Parts A & B but going on the assumption that some insurance companies may offer one without the other?

[Miss Philicia]

Medicare in and of itself is no issue to me -- they pay doctors for their services fairly immediately. Their fees are pre-negotiated for coded services so doctors, as long as they accept it, know what they are getting paid. But HMO's do that similarly.

Medicare has in no way limited the QUALITY of my care -- I get to see top tier specialists, but like I said it's because where I live all of the top ones work within university systems. Now, if I was back in NYC where many top specialists work out of private offices I don't know what the situation would be with Medicare. I can only speak for where I am living right now.

I did try and make an appointment with a dermatologist that was outside of any university and they would not take Medicare, so after that I just stuck with U-Penn, Drexel doctors. U-Penn is an Ivy League school so the doctors are top notch, and Drexel is like a local version of MIT.

I'm not sure if you've ever done it because it's an hours drive, but it would be like using Yale School of Medicine doctors.

[mitch777]

I have used Yale once and am about to use them again next month. (basal cell MOHS surgery)

All good to know. Thanks!!

The dinner bell just rang.

[tednlou2]

My parents are both on it and I know many others, too.  I think if you tried to take away their Medicare for a private company, they would go ape-shit.  They can see specialists, without having to first see their GP for a referral.  It is a very popular program.  The V.A. is actually still very popular, even with their recent issues.  But, I digress. 

I have never heard any of them say they couldn't get a doc to take Medicare.  But, I do know it happens.  When I was shopping around for another ID doc, two practices (which were basically it for our area) said they take just about every insurance-- except Medicare.  I didn't ask why.  I am curious why, though.  Maybe I will call them again and ask.  Must have something to do with reimbursement??  I think it is fairly rare to run into too many docs not taking it. 

[Since1993]

Medicare is basically broken down into two main categories: the "Original Medicare Plan" and the "Medicare Advantage Plan." Each category is made up of four sub-categories: Part A, Part B, Part C and Part D.

The Original Medicare Plan

The Original Medicare Plan consists of Part A (Inpatient Hospitalization). You do have the option of adding Part B and D. You will automatically be enrolled in the Original Medicare Plan unless you specifically choose to join a Medicare Advantage Plan (Part C).

The federal government manages the Original Medicare Plan. It operates on a fee-for-service plan. Most people pay a deductible and then a co-pay or co-insurance.

Medicare Advantage Plan

The Advantage Plan or Plan C combines your Part A and B coverage, but is provided by private insurance companies. You have the option of adding Part D if coverage is not already included. Advantage Plans include HMO, PPO, private fee-for-service plans, and Medicare special needs plans.

Medicare Part A Overview

Part A is hospital insurance provided by Medicare. Most people do not pay a premium for this coverage. Part A covers inpatient care in skilled nursing facilities, critical access hospitals, and hospitals. Hospice and home health care are also covered by Part A.

Medicare Part B

Part B is medical insurance to pay for medically necessary services and supplies provided by Medicare. Most people will have to pay a premium to receive this coverage. Part B covers outpatient care, doctor's services, physical or occupational therapists, and additional home health care.

Medicare Part C (Medicare Advantage Plan)

Part C is the combination of Part A and Part B. The main difference in Part C is that it is provided through private insurance companies approved by Medicare. With this program, you may have lower costs and receive extra benefits.

Medicare Part D

Part D is stand-alone prescription drug coverage insurance. Most people do have to pay a premium for this coverage. Plans vary and cover different drugs, but all medically necessary drugs are covered. You can choose what drug plan will be best suited to your needs.

Medigap Policies

A supplemental plan you pay for which reduces the amount of out-of-pocket expenses if you have A,B, and D.  You cannot have both a Medigap and C simultaneously.

[Since1993]

Anyway, I have the feeling living here in CT that I probably don't have to worry too much about docs not accepting Medicare. I will need to find out somehow about the program of which you speak my dear. I won't qualify foe Medicaid either.

So... over all I take it that you seem happy with Medicare?

At the time you become Medicare-eligible, any physician you are currently seeing has to accept Medicare as your payer source.  With a referral to a specialist from your primary care provider, there is typically no issue being a Medicare patient.  If at any time you choose to switch primary physicians, it might be more difficult to find new providers because some physicians don't accept new Medicare patients.  This restriction is typically restricted to finding a primary care provider. 

[tednlou2]

This thread got me to thinking, so I hope Mitch will indulge me.  We all could learn something, perhaps.  Another thing that got me thinking was being at the HIV doc and chatting with someone in the waiting room.  We were watching the local news LIVE in Cincy, covering the 6th Circuit Federal Appeals Court holding oral arguments today, over marriage equality for KY, TN, OH, and MI.  He said he was so happy to see the progress, but he said he would not be able to marry his partner.  He said it would knock out him being qualified for Extra Help.  He said it was very depressing that he will likely have the chance to marry, but won't be able.  I've talked with others about this, previously. 

I have come to learn a lot about Medicare and Extra Help, by chatting with folks like him and people in my family.  For those who don't know, it pays co-pays, deductibles, and premiums.  You pay like $2.50 for generic and $6.50 for brand.  Being the curious person I am, I got the phone number of my mom's Part D company.  She and my dad meet the requirements for the income part of the Extra Help program; however, it is the resources part that they have too much. 

So, I called just a while ago to see what someone with Part D, but without Extra Help, would pay.  I asked, if my mom or any consumer needed Stribild, for example, how much would the out-of-pocket price be without being eligible for Extra Help?  The rep said the customer would have to pay 25%, which would be $615.00.  That's $615 a month. 

How do people with HIV on Part D and not eligible for Extra Help afford that?  I've heard ADAP will assist, even if you get SSDI and have Medicare, when you don't qualify for extra help.  I am curious whether anyone knows how much ADAP helps, in this situation.  Would it be anywhere near paying $6.50 a month for Stribild or any HIV drug?  Would drug companies assist, where your out-of-pocket would be anywhere under $100 a month?  I felt bad this guy said he would want to get married, but just would not be able to.  Plus, he wouldn't just lose the $6.50 a month for brand.  He would lose getting his Part B and D premiums paid, so that's another $200 a month, at least.  He would lose the 20% Medicaid pays, that Part B doesn't.  So, he would need that insurance to cover that.  He would likely be paying $300 a month for all those premiums, on top of the $615. 

Basically, for those here on part D and I believe Mitch will soon be approved, how much do you pay out of pocket for HIV meds?  I figured this thread was already going and discussing the ins and outs of everything Medicare, so I thought no need to create a separate thread.

[Tonny2]

This thread got me to thinking, so I hope Mitch will indulge me.  We all could learn something, perhaps.  Another thing that got me thinking was being at the HIV doc and chatting with someone in the waiting room.  We were watching the local news LIVE in Cincy, covering the 6th Circuit Federal Appeals Court holding oral arguments today, over marriage equality for KY, TN, OH, and MI.  He said he was so happy to see the progress, but he said he would not be able to marry his partner.  He said it would knock out him being qualified for Extra Help.  He said it was very depressing that he will likely have the chance to marry, but won't be able.  I've talked with others about this, previously. 
Hi tednlou2
I have MEDICARE PARTS A AND B, I did not get part D because I woulh hsve to pay more for meds, my private insurance takes care of my meds...I used to pay 55 dollars for a three monts supply, I take four hiv meds and another brand med so every 90 days I had to pay 275, now I pay just 30 with the co-pay program
...this is something that we (people who have private insurance) hsve to consider...MEDICARE PART D  VS PRIVATE INSURANCE...I hope, I explained myself...remember, English is my second language   ojo

[Since1993]

This thread got me to thinking, so I hope Mitch will indulge me.  We all could learn something, perhaps.  Another thing that got me thinking was being at the HIV doc and chatting with someone in the waiting room.  We were watching the local news LIVE in Cincy, covering the 6th Circuit Federal Appeals Court holding oral arguments today, over marriage equality for KY, TN, OH, and MI.  He said he was so happy to see the progress, but he said he would not be able to marry his partner.  He said it would knock out him being qualified for Extra Help.  He said it was very depressing that he will likely have the chance to marry, but won't be able.  I've talked with others about this, previously. 

I have come to learn a lot about Medicare and Extra Help, by chatting with folks like him and people in my family.  For those who don't know, it pays co-pays, deductibles, and premiums.  You pay like $2.50 for generic and $6.50 for brand.  Being the curious person I am, I got the phone number of my mom's Part D company.  She and my dad meet the requirements for the income part of the Extra Help program; however, it is the resources part that they have too much. 

So, I called just a while ago to see what someone with Part D, but without Extra Help, would pay.  I asked, if my mom or any consumer needed Stribild, for example, how much would the out-of-pocket price be without being eligible for Extra Help?  The rep said the customer would have to pay 25%, which would be $615.00.  That's $615 a month. 

How do people with HIV on Part D and not eligible for Extra Help afford that?  I've heard ADAP will assist, even if you get SSDI and have Medicare, when you don't qualify for extra help.  I am curious whether anyone knows how much ADAP helps, in this situation.  Would it be anywhere near paying $6.50 a month for Stribild or any HIV drug?  Would drug companies assist, where your out-of-pocket would be anywhere under $100 a month?  I felt bad this guy said he would want to get married, but just would not be able to.  Plus, he wouldn't just lose the $6.50 a month for brand.  He would lose getting his Part B and D premiums paid, so that's another $200 a month, at least.  He would lose the 20% Medicaid pays, that Part B doesn't.  So, he would need that insurance to cover that.  He would likely be paying $300 a month for all those premiums, on top of the $615. 

Basically, for those here on part D and I believe Mitch will soon be approved, how much do you pay out of pocket for HIV meds?  I figured this thread was already going and discussing the ins and outs of everything Medicare, so I thought no need to create a separate thread.

If getting married disqualifies an individual from "Extra Help" offered by Medicare, Ryan White Part B/ADAP can assist with Medicare Part D premiums/co-pays for HIV-related medications on their states formulary.

Ryan White Part B/ADAP does not pay Medicare Part B premiums.

You must enroll in Medicare Part D to receive Ryan White Part B/ADAP assistance.

Ryan White Part B/ADAP does pay for Medicare Part D premiums (some states have limits up to $50 monthly) and 100% co-pays for HIV-related medications listed on their states formulary.

Ryan White Part B/ADAP is a means-tested program, by which your income and assets are used to qualify.  Each state has different asset qualifications (i.e. 200-500% of the Federal Poverty Level) and how much money you currently have in the bank.

"Extra help" from Medicare is available for some people who don't make enough money to pay for the premiums, deductibles, and co-payments that are part of Medicare Part D. If you make less than 150% of Federal Poverty Level (FPL) - about $16,755 - and don't have a lot of money in the bank you need to apply for "Extra Help." If your income is a little more than $16,755, you should still apply. "Extra Help" is free, but you must apply for it. The Federal Poverty Level (FPL) changes every year. You can apply for "Extra Help" by calling the Social Security Administration at 1-877-772-1213 or go online to their http://www.socialsecurity.gov.

[Since1993]

"I have MEDICARE PARTS A AND B, I did not get part D because I woulh hsve to pay more for meds, my private insurance takes care of my meds...I used to pay 55 dollars for a three monts supply, I take four hiv meds and another brand med so every 90 days I had to pay 275, now I pay just 30 with the co-pay program
...this is something that we (people who have private insurance) hsve to consider...MEDICARE PART D  VS PRIVATE INSURANCE...I hope, I explained myself...remember, English is my second language   ojo"

There is a monthly premium for Medicare Part D. If you have comprehensive health insurance that will pay for your prescriptions, you might not have to enroll in Medicare Part D. ADAP is NOT comprehensive health insurance. If you don't have other insurance, and do not enroll in Medicare Part D plan within 3 months of your eligibility month, your monthly premium will increase by 1% for every month that you delay enrollment. All premium increases are permanent. ADAP cannot help pay increases in premiums because of penalties.

[Miss Philicia]

I qualify, in terms of Medicare Part D, for "low income subsidy" and have my premium paid in full by the state. At the beginning of the year I pay co-pays until I reach a deductible that changes every year -- but it's low, like $75 -- after that I don't pay any copays the remainder of the year. I don't know if this is a Pennsylvania thing or if other states do this.

http://www.phlp.org/wp-content/uploads/2011/10/Part-D-Manual-2011.pdf

BOTTOM LINE: this is all confusing, varies by state, and is dependent on your income which you may not wish to discuss on a forum. While a lot of great and well-intentioned advice/information is give in this thread, I still recommend sitting down with a case manager and discussing all of it.

[Since1993]

BOTTOM LINE: this is all confusing, varies by state, and is dependent on your income which you may not wish to discuss on a forum. While a lot of great and well-intentioned advice/information is give in this thread, I still recommend sitting down with a case manager and discussing all of it.

Excellent point.  Every state has different Ryan White/ADAP guidelines.  One size doesn't fit all.  Local Medical Case Managers are always the best "go to" in these situations because they know their individual state guidelines for income/assets. 

--Every state has different qualifications for Medicaid.
--Each state offers different Medicare Advantage Plans (Medicare Part C).
--Medicare Part D premiums vary among insurers/states.
--Medicare "Extra Help" qualification is the same across the board in every state. 
--Medicare premiums for part B are the same for every eligible recipient.


It is in everyones best interest to seek the advice of Medical Case Managers who can help reduce and often completely eliminate any out-of-pocket expense related to HIV-medications and barriers to seeking care.

[Miss Philicia]

At the same time, not all case managers are equal -- some know all of this info inside and out, others get tripped up if your situation is a bit outside of the box. So good to double check the information with what is here, or use this to get yourself familiar with the lingo so that you can ask appropriate questions.

Also, this is one reason I go to a local support group of LTS'ers -- I can bounce information of them as well especially in terms of what is specific to my geographic area.

[Since1993]

Goes without saying, you can't be qualified for any Ryan White Care Act Program/ADAP, Extra Help for Medicare or any other means-tested entitlement program by participating in an online discussion group. 

You can gather information to guide you in the appropriate direction and learn information from numerous sources that could be of assistance.  Knowing what to ask for is sometimes helpful in dealing with newer Social Workers.  Your mileage may vary.  I've had "okay" to "excellent" in that regard. 

When applying for an ACA plan, I had to explain to my navigator (sponsored by a local HIV/AIDS provider) that in spite of being disabled and Medicare-eligible in 2015, I was still eligible for Advance Tax Premium Credit in 2014. 

Being your best advocate means gathering as much information and arming yourself with knowledge to stay linked into care and undetectable to live as long as possible.  It isn't, or will it probably ever be an easy process, but it is one worth investigating.

I look at it like this.  If it takes two hours of my time at a local HIV/AIDS service organization twice a year to continue eligibility for Ryan White/ ADAP assistance that saves me thousands of dollars/year I don't have, it was well worth the trip.

[Miss Philicia]

That's all well and good, but it's all way to complicated.

Imagine yourself with less than a high school graduation, single mother with four kids, rural environment with no access to a car in the Deep South. Newly diagnosed with AIDS cd4 numbers and two OI's and having to navigate all of this BS.

It's one thing for a college educated gay white male with stable housing to make his way though all of this -- but even then it's confusing. There have been times when I get the recertification forms for my secondary insurance state Medicaid and have five days to turn it around. Heaven forbid that I'm down visiting my aging parents three states away when that form arrives. All I can think is what someone does with mobility issues and some other ailment, dependent on public transportation and with four kids and an eviction notice.

... boggles the mind. And they wonder why people fall out of the system. It all repulses me.

[mitch777]

I got much more helpful information from this thread than expected.

@Since- you may not claim to be an expert but you do have a way of spelling things out that is helpful to me at least. Much appreciated.

@ Miss P.- Hearing the practical aspects of your experience is just as helpful if not more so.

@ Ted, or anyone else- pile on the questions. I'm just trying to get myself prepared as I'm sure many others here are as well. It seems like this section of the forums could use more of this kind of information as more and more of us are likely to need it.

This quote says it all... "boggles the mind. And they wonder why people fall out of the system. It all repulses me."

I've found the system more difficult to navigate at a time when my brain is having it's own issues along with depression, stress, etc. A complex maize just keeping up with rules and requirements IS repulsive. I think I can cope ok now but...

OK, I digress. Don't want to get knee deep in frustrating political shit even though it burns my titties.

[TnMan62]

This may be off subject, but am curious if Medicare pays for Sculptra Injections?

[Miss Philicia]

This may be off subject, but am curious if Medicare pays for Sculptra Injections?

Technically yes, effectively not. It will pay 80% of the "negotiated" change for the actual filler, but NO secondary insurer will pay the remainder, meaning Advantage plans and/or Medicaid. And mind you, that 80% payment is well below what the doctor charges other patients who will pay cash.

And for some reason Medicare will NOT cover the actual fee for doing the injections (could be wrong on that but I don't think so).

Bottom line, you are most likely better off financially using the patient assistance program run by Valeant Aesthetics and locating a doctor who will do the injections at a reduced fee.

[Jeff G]

This may be off subject, but am curious if Medicare pays for Sculptra Injections?

I had one round of the stuff and the hospital graciously wrote it off when they found out medicare wouldn't hardly cover the cost of the Sculptra . I could go back for more but they are not very keen on providing the service as they were initially . 

[Tonny2]

that's another thing we have to check, what MEDICARES pays...one time my ID doctor orfer a IViG INFUSION (THREE INFUSION OF "BLOOD", ONE EACH MONTH) I went to a place who does that, anyway, when I got the bill $164,000, wow, I couldn't belived it, so MEDICARE doesn't cover this kind of infusions, so I called my private insurance and the guy that talked to me on the phone told me, that they didn't cover it either, grrr, I couldn't sleep that ninght, the next day I called again to my private insurance, because they suppose to pay what MEDICARE doesn't pay, the lady that answer my call, told me that they (my private insurance) will pay for those charges, uff what a relif...so I just wanted to share    ;p