Where Does Medicare Fall Short?

[marko]

Seeing a foreign doctor for a minor issue and prescription is not going to be covered by Medicare. Read what you posted. They all contain the word "emergency". So it's no better than my Advantage plan. And I agree with the comments that travel policies are the best protection.

I've had to visit "foreign" doctors for a few minor (and one major) issues while out of the US. It usually cost me less than $100 (and some even took American Express). Rx: $5.

 

[Katsmeow]

In round numbers my PCP billed $807, Medicare reduced it to $378 and paid all of it, so my Plan G didn’t have to pay anything (I stand corrected on that, supplements don’t pay for claims Medicare disallows).

But that was the primary point I was making! What concerned me about your original post was the notion that Plan G provided some extra coverage for physicals that Medicare itself didn't cover! I didn't want anyone to think that was the case.

As far as the "pnysical" issue the rest of your post confirms my other point. Medicare doesn't pay for it if it is coded as a physical. They will pay for things that get coded in a way where Medicare will pay. I am not suggesting that your doctor's office did anything improper. There are certain preventative things that Medicare will pay for me (various screenings for example) and some bloodwork is paid for periodically. And, honestly, for most people over the age of 65 Medicare will end up paying for lipid testing more often than once every 5 years because most people have something that makes it "necessary" to do it. I don't take a statin as my cholesterol is not all that high and my ratio is OK but I do have higher than normal so they pay for it, etc.

Sometimes my doctor has a test done and Medicare does not pay for it. But I don't end up paying for it because I didn't sign advance notice that it might not be covered.

Anyway, I don't think I am saying anything different. If it is called a physical Medicare doesn't cover it. If it a strict wellness check what is done is very limited. On the other hand, if the doctor can come up with a legit reason to do other stuff (some of which might be the type of things some doctors do in a physical) then Medicare would pay for that.

https://www.medicare.gov/coverage/yearly-wellness-visits

The thing people have to be careful about is that some doctors offices would simply code the request for a physical as a physical and you would pay for it all (which many people are OK with). Others will try to find a way to do as much as possible within the rules. And what they can do is probably related to each individual's personal history and health.

 

[Buckeye]

Traditional Medicare (TA) has NO total out-of-pocket (OOP) maximum costs. Not only for prescription drugs (initial co-pays, 'donut hole', then 5% above that) but also for skilled nursing (even IF one initially qualifies, no coverage over 100d/yr) and inpatient care (no coverage over 90d/yr after one has used their "lifetime reserve days", lifetime max 190 mental health inpatient days). Private Medigap insurance can cover some of those gaps, but not all.
According to an Urban League study published this month, over 4 million Medicare recipients had over $5,000 in OOP medical expenses. Some 800,000 has OOP expenses over $15,000, with some much, MUCH higher than that.

Medicare Advantage (MA) with its HMO-like structure offers some OOPmax protection, but those limits are now up over $7,500k/yr ($11,300 for in- & out-of-network care if MA plan allows). And that does not include expenses not approved by MA (deemed "not medical necessary", which commonly crop up).
https://www.urban.org/research/publication/adding-out-pocket-spending-limit-traditional-medicare


DW & I are transitioning to Medicare this year and our total costs (inc premiums, IRMAA (TM supplement & Part D), deductibles/co-pays) will likely be a bit lower than when we were on ACA (no subsidy) & COBRA ... IF we have no medical catastrophe. But the lack of an OOP max with TM (or a 'true' OOPmax with MA) is (to use the OP's words) is a big feature where Medicare 'falls short'.

Yup, and why hubby has a supplement policy. He doesn't get much use out of it but it's the kind of insurance you hope to never have to use. $160 a month for piece of mind.

 

[bigreader]

Prescription Costs

I'm not on Medicare yet, but my MIL was surprised at how big her prescription bills were compared to her previous employer health insurance. She has several thousand dollars a year in prescriptions even after part D.

This.

Even if an expensive drug is covered, the doughnut hole gets pricey. And if your expensive drug it isn't in the formulary, you must pay the full price and can't use the manufacturers' savings plans. I am thrilled to be on Medicare but in my situation the drug coverage was better on my pre-Medicare plan.

BR

 

[CRLLS]

This.

Even if an expensive drug is covered, the doughnut hole gets pricey. And if your expensive drug it isn't in the formulary, you must pay the full price and can't use the manufacturers' savings plans. I am thrilled to be on Medicare but in my situation the drug coverage was better on my pre-Medicare plan.

BR

Outside of Part D, one can opt to use GoodRX pricing or possibly the Mark Cuban offering. There are others too. Just do a small amount of homework, and I do mean small. You won't get credit toward Part D deductibles or making your way thru the doughnut hole, but a buck is a buck. You almost always have options. It may take moving pharmacies. Even GoodRX has different prices at different pharmacies.

 

[harllee]

So far my biggest expense is dental bills--Medicare does not cover dental and I have not found any dental insurance that is any good.

 

[bigreader]

Outside of Part D, one can opt to use GoodRX pricing or possibly the Mark Cuban offering. There are others too. Just do a small amount of homework, and I do mean small. You won't get credit toward Part D deductibles or making your way thru the doughnut hole, but a buck is a buck. You almost always have options. It may take moving pharmacies. Even GoodRX has different prices at different pharmacies.

Sometimes generics don't work and the alternative is an expensive drug that is not on the formulary. There really isn't any price competition on these kinds of drugs. There is no generic on the horizon. Mark Cuban doesn't deal with this part of the market. GoodRX and various pharmacies offer virtually identical prices. Canadian pharmacies might be an option. Or, if you are going to take the drug for awhile, maybe your doctor can help you appeal to have the drug covered by your insurer. To me, this is the only part of Medicare that is not as good as my pre-Medicare plan, since I can no longer take advantage of the drug providers' savings plan.

CRLLS, the good news for you is that you obviously haven't run into this situation. I hope it holds. However, you might want to lighten up on the "just do a tiny bit of homework" riff since it is, at best, simplistic.

BR

 

[Sunset]

Sometimes generics don't work and the alternative is an expensive drug that is not on the formulary. There really isn't any price competition on these kinds of drugs. There is no generic on the horizon. Mark Cuban doesn't deal with this part of the market. GoodRX and various pharmacies offer virtually identical prices. Canadian pharmacies might be an option. Or, if you are going to take the drug for awhile, maybe your doctor can help you appeal to have the drug covered by your insurer. To me, this is the only part of Medicare that is not as good as my pre-Medicare plan, since I can no longer take advantage of the drug providers' savings plan.

.....
BR

And when you change Drug plans each year, or search them each year on medicare.gov there are no plans that cover your expensive drug ?

I know for DD , when I found out he was paying $8K per year for drugs, I searched and got his total yearly price down to $2,500 by changing to a different plan D.

 

[CRLLS]

Sometimes generics don't work and the alternative is an expensive drug that is not on the formulary. There really isn't any price competition on these kinds of drugs. There is no generic on the horizon. Mark Cuban doesn't deal with this part of the market. GoodRX and various pharmacies offer virtually identical prices. Canadian pharmacies might be an option. Or, if you are going to take the drug for awhile, maybe your doctor can help you appeal to have the drug covered by your insurer. To me, this is the only part of Medicare that is not as good as my pre-Medicare plan, since I can no longer take advantage of the drug providers' savings plan.

CRLLS, the good news for you is that you obviously haven't run into this situation. I hope it holds. However, you might want to lighten up on the "just do a tiny bit of homework" riff since it is, at best, simplistic.

BR

I didn't address generics alternative. Good that you mentioned it. They often do work as well as the name brand drugs. Of course, sometimes not. The only way to know if one will work is to try them. As for alternative drug treatments for a particular issue, I never mentioned that either. I don't think anyone else had in this thread. Thanks for bringing up that option also. Ask the Dr. for something on one's formulary that might work as well as what he originally prescribed is a good one too. We have actually done that with success, albeit for low priced meds. Every little bit helps, no? My experience is that few people actually do any cost shopping for meds. The doctors just send the prescription to the patient's chosen pharmacy and that is all.

My post was intended for people to try to find less expensive places to get their prescribed medications. Was it a simplistic post? Sure. It really doesn't take much effort to at least try.

You have obviously done your homework on your particular drugs. I am sorry that you have found no cost-effective alternatives for your situation. At least you tried, which is what I was trying to convey.

 

[harllee]

There are many very expensive drugs that have no low cost alternative. My DH takes Humira by injection--every other week. It has been a life changing drug for him, without it he would probably be in a wheelchair. But it is VERY expensive (over $5000) per month and so far no generics (but I keep reading there should be generics in the next few years). DH has not been able to order from Canada because it has to be refrigerated and the price in Canada is about the same as the U.S. So far DH has qualified for assistance from the manufacturer and has been able to get the drug at a reduced cost. But he will not qualify for assistance starting next year because you can only qualify if family income is under $86,000 (we can not longer meet that requirement due to SS and RMDs). So starting next year DH will immediately go into the donut hole and pay a very large copay. We have spent many many hours looking for less expensive alternatives.

 

[MissMolly]

There are many very expensive drugs that have no low cost alternative. My DH takes Humira by injection--every other week. It has been a life changing drug for him, without it he would probably be in a wheelchair. But it is VERY expensive (over $5000) per month and so far no generics (but I keep reading there should be generics in the next few years). DH has not been able to order from Canada because it has to be refrigerated and the price in Canada is about the same as the U.S. So far DH has qualified for assistance from the manufacturer and has been able to get the drug at a reduced cost. But he will not qualify for assistance starting next year because you can only qualify if family income is under $86,000 (we can not longer meet that requirement due to SS and RMDs). So starting next year DH will immediately go into the donut hole and pay a very large copay. We have spent many many hours looking for less expensive alternatives.

Under the circumstances, you may want to consider an Advantage plan. I am on Humira also. Weekly shots. The cost is over $12,000 a month. If I had a regular Part D Plan with Original Medicare I would be paying thousands of dollars a year. However, my doctor got it approved through my Advantage plan so I only pay $35/month for the first few months and then once the total cost (to both me an my plan) reaches a certain point it goes up to $110/month for the remainder of the year. So my total cost ~ $1,000 a year. My particular drug plan with my Advantage plan does not have a donut hole.

 

[harllee]

Under the circumstances, you may want to consider an Advantage plan. I am on Humira also. Weekly shots. The cost is over $12,000 a month. If I had a regular Part D Plan with Original Medicare I would be paying thousands of dollars a year. However, my doctor got it approved through my Advantage plan so I only pay $35/month for the first few months and then once the total cost (to both me an my plan) reaches a certain point it goes up to $110/month for the remainder of the year. So my total cost ~ $1,000 a year. My particular drug plan with my Advantage plan does not have a donut hole.

Thanks for this. I did not know any Advantage plans covered Humira, could you share the name of your plan?

 

[bigreader]

And when you change Drug plans each year, or search them each year on medicare.gov there are no plans that cover your expensive drug ?

I know for DD , when I found out he was paying $8K per year for drugs, I searched and got his total yearly price down to $2,500 by changing to a different plan D.

Every year, as a part of my little bit of homework, I check to see if the drugs I am interested in are covered by a different plan. The Medicare.gov site is a great tool for this. What I have seen is that over time, some drugs that were never covered enter formularies, albeit with high deductibles and normally when there is a competitive non-generic drug to push things along. But unfortunately, there are drugs that aren't covered by any plan.

 

[MissMolly]

Thanks for this. I did not know any Advantage plans covered Humira, could you share the name of your plan?

Humana Medicare PPO

 

[harllee]

Humana Medicare PPO

Looking at the Humana Advantage plans available where I live they all have the donut hole and it appears that the cost to DH for Humira will be about the same as his cost under Part D so does not look like any savings there but I will look at other advantage plans in our area to see if any eliminate the donut hole. Thanks for the suggestion.

 

[MissMolly]

Looking at the Humana Advantage plans available where I live they all have the donut hole and it appears that the cost to DH for Humira will be about the same as his cost under Part D so does not look like any savings there but I will look at other advantage plans in our area to see if any eliminate the donut hole. Thanks for the suggestion.

I have the “Premium” drug plan that has no donut hole. You could ask if that’s available to you. The regular drug plan has the donut hole. I have the premium. My husband has the regular since he doesn’t take any meds.

 

[harllee]

I have the “Premium” drug plan that has no donut hole. You could ask if that’s available to you. The regular drug plan has the donut hole. I have the premium. My husband has the regular since he doesn’t take any meds.

I did not see that option on the website for my state, I will have to check. Thanks. Did you use an insurance agent to help you find this?

 

[braumeister]

I've had to visit "foreign" doctors for a few minor (and one major) issues while out of the US. It usually cost me less than $100 (and some even took American Express). Rx: $5.

Same here. When in Norway I was treated exactly the same as a Norwegian citizen. They have government health care but with a reasonable copay. There was a credit card kiosk where I paid the same as everyone else.

Like athena53, I always have evacuation insurance for anything really serious. It's not that expensive.

 

[MissMolly]

I did not see that option on the website for my state, I will have to check. Thanks. Did you use an insurance agent to help you find this?

No. It's through our retirement system.

 

[harllee]

No. It's through our retirement system.

Aha! This type of plan does not seem to be available to the general public. You are very lucky to have it through your retirement system. My research does show that the Humira patent is expiring in 2023 and that several biosimilar drugs will be available in 2023 to take the place of Humira. The cost should be substantially less. So that is good news for everyone on Humira and similar drugs.

 

[MissMolly]

Aha! This type of plan does not seem to be available to the general public. You are very lucky to have it through your retirement system. My research does show that the Humira patent is expiring in 2023 and that several biosimilar drugs will be available in 2023 to take the place of Humira. The cost should be substantially less. So that is good news for everyone on Humira and similar drugs.

Yes. I just saw my doctor this past week and he told me the same about the generic. He says Humana may or may not make me switch. He said generics are a different formulation than the patented formula and don't always work/work as well. So he says "we'll see". He says if I have to switch and it doesn't work as well he will fight to switch me back.

 

[Koolau]

Whoever mentioned drug costs touched on one of the biggest (potential) issues when it comes to Medicare. It may be necessary to change plans around to fit your specific drug profile. Even then, drugs may be very expensive. BUT thank God for some of the new drugs that can preserve life, make life more enjoyable and limit side-effects over older drugs.

Since going on MC I've had to take several drugs that started at $1500 to $2000 list prices. By playing the game, I've gotten those costs down, but I'm still paying thousands per year - and it's worth every penny.

A bit off topic, those who condemn drug companies out of hand forget what some very expensive (at the beginning) drugs have accomplished. I'll mention just one as no one even thinks about it anymore.

Years ago, my dad had ulcers and eventually had to have surgery which removed a fair portion of his stomach. He suffered for a long time and then had to have life-threatening surgery. That sort of surgery is virtually unknown now. Why? Enterprising drug companies developed acid controlling drugs (several generations of them) that essentially ended GERD and ulcers. Today, these are typically OTC. True enough, the drug companies got rich for a while but look at what it bought us.

So somewhat back on topic, drugs will become MORE important as we go along. I consider that a good thing (in general.) Finding ways to deal with those costs will be one of the few ways to limit costs while you are on MC. You may have to change plans. YMMV

 

[target2019]

On Friday I discussed this problem of impending drug cost. He will work with us if we find that XYZ plan offers this drug at a lower cost.

The cost is now $5 monthly through group insurance, that will rise to $1,000 (Aetna part D) or over $3,000 with the hospital pharmacy. Every state is different, and so on. Follow the lobbying money...

Doctor did mention that if Medicare were permitted to negotiate drug prices, this problem would be eliminated.

 

[Sunset]

DW & I were discussing and realized we don't know the steps/process of medicare.

I'm on medicare A&B plus a plan G.
If I go to a doctor (first time this year) that takes medicare: Do I pay anything at the doctor office ?
Or do I wait a few months for some letters from medicare or my plan G to say what I owe?

 

[REWahoo]

DW & I were discussing and realized we don't know the steps/process of medicare.

I'm on medicare A&B plus a plan G.
If I go to a doctor (first time this year) that takes medicare: Do I pay anything at the doctor office ?
Or do I wait a few months for some letters from medicare or my plan G to say what I owe?

No, you shouldn't be asked to pay anything up front, and yes, wait for medicare and your supplement to send you an EOB which will state what you owe.