Where Does Medicare Fall Short?

[Time2]

What’s confusing? You’re saying much the same, although you’re Plan G is the highest I’ve seen (1 person?). Your Part D is higher but you probably have better Rx benefits.

The confusing part is Rianne is paying $92 for Medicare, while I pay $170.10, Why the difference, I thought we all paid the same for Medicare.
Part B is about the same and I'm paying a little more for Part D.
But I don't get how Medicare can be $92.

 

[steelyman]

The confusing part is Rianne is paying $92 for Medicare, while I pay $170.10, Why the difference, I thought we all paid the same for Medicare.
Part B is about the same and I'm paying a little more for Part D.
But I don't get how Medicare can be $92.

Could it be that it’s referring to a Medicare Supplement? (not an expert here)

 

[Midpack]

The confusing part is Rianne is paying $92 for Medicare, while I pay $170.10, Why the difference, I thought we all paid the same for Medicare.
Part B is about the same and I'm paying a little more for Part D.
But I don't get how Medicare can be $92.

Look at the color coding in post #24 again to compare directly, she’s paying $92 for her Plan G supplement as it says. It’s a Medicare supplement. She notes she’s paying the same as you for Part B. You’re both using different terms.

 

[Time2]

Look at the color coding in post #24 again to compare directly, she’s paying $92 for her Plan G supplement as it says. It’s a Medicare supplement. She notes she’s paying the same as you for Part B.

OK, thanks, now I get it.

 

[athena53]

+1
For all its "shortcomings", I'm getting better care than when I was paying $13k a year with a $3000 deductible. I may have had no insurance as I never went beyond the deductible.

That was me for 4 years except my deductible was $6,000. The insurance companies made a fortune on me.

One area that I don't think has been mentioned is hearing aids. I don't need them but my late husband did and the good ones are expensive. It's also a bewildering process. We had Costco and I trusted them but we got mailings all the time for free hearing tests, undoubtedly leading to recommendations to buy overpriced hearing aids. At the time I this decent ones from Costco were about $5,000 a pair and there were others in the market that were a lot more.

One of the advantages being married to a man 15 years older was that I realized how much it cost to have a decent quality of life in old age and saved accordingly.

 

[target2019]

If an article comes up with $250,000 they may be using a number derived from the cost of medical divided by the number of individuals.

If this is a straight $250,000 per covered individual, 25 years of retirement times $10,000 per year is very believable, at least to me. The costs for LTC alone could tip the scales way past this number.

In her last year of LTC, M-I-L ran out of LTC insurance and the cost wen from $0 monthly to over $7,500.
If you're just comparing what you spend in a year for insurance, co-pays and so on, then your particular year is below the average.

FYI, I'm going off group insurance and my total costs for 6 months will be way above an average of $10,000 yearly ($250,000/25 years). And this is for just 7 months.

 

[Rianne]

OK, I am confused.

Your Medicare is $92?

My Medicare is $170.10
My part B plan G is $188.30
Drug plan is $22.70.
What am I doing wrong?

Time2, your zip code makes a difference. And for some reason, I was offered an $11 drug plan that covers my meds. My total OOP cost for meds + premium (all generic) is $92/year. Of course, that could change very quickly. My broker said I could change my drug plan every year if I wanted to. So, say I had to take an expensive med not offered on that plan, I could upgrade to a plan that covered it.

My part G plan is with Mutual of Omaha in Illinois. The premium $92 was less than I expected.

I logged into Medicare.gov and was able to sign up for the drug plan without the broker. I don't start Medicare until Sept. but have my number.

Now to cancel my ACA. I understand that's an ordeal from what I've heard.

 

[Katsmeow]

I start Medicare this year. I read articles talking about how healthcare in retirement will cost $250K +. How does that happen if you're on Medicare? I understand a specialist not accepting Medicare would be expensive.

My premiums including prescription drugs will be @ $280/month. I really don't expect to live past 95. That's $100,800 for premiums alone for 30 years. What are these extraordinary health expenses? I'm asking about OOP expenses that might be expected.

Many have mentioned Long term care and dental and vision. Also, hearing aids aren't covered. DH recently got hearing aids and paid about $2k for the hearing aids and accessories (note: getting these at Costco was far cheaper than other alternatives).

There are a few other things that may or may not be important. There are things that Medicare simply doesn't cover or limits. So you can't get an annual physical with Medicare. They can't just do full lab panels. Last year, for example, my doctor ran some lab work on me and one test was an A1C. I am not diabetic. Medicare disallowed it. Now since the lab accepted Medicare assignment, I didn't have to pay it. The doctor though had originally wanted me to use a different lab where I would sign in advance to pay anything Medicare didn't pay. I refused to do it so they sent the lab work to Lab Corp. However, it is possible that I might want some lab work Medicare wouldn't pay for and I might pay out of pocket for that.

Years ago, when my father was dying he was in the hospital for months (complications from surgery) and he was getting close to the maximum time period Medicare would pay. After that it would have been considered long term care and not covered even though he wasn't in a skilled nursing facility. He actually needed to be in a full hospital.

In some parts of the country it can be hard to find good primary care doctors that you can get into see in a reasonable period of time. On Medicare I've never had trouble finding specialists and they've all taken Medicare. Lots of primary care doctors do not do so or you have to wait months for an appointment. I know a lot of people who do pay for a concierge doctor (in many cases this will include the cost of an annual physical).

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'.

If the claim is covered by Medicare then my Plan G does pay all the rest. So in that since where it has a OOP Max doesn't matter. Now for some things, Medicare does limit for how long they provide coverage.

Time2, your zip code makes a difference. And for some reason, I was offered an $11 drug plan that covers my meds. My total OOP cost for meds + premium (all generic) is $92/year. Of course, that could change very quickly. My broker said I could change my drug plan every year if I wanted to. So, say I had to take an expensive med not offered on that plan, I could upgrade to a plan that covered it.

Zip code makes a difference for your supplement and for the Part D plan. The Part B premium ($170.10) does not vary with Zip code.

Oh - another thing that makes a difference. Most drug plans have a deductible of $480. Sometimes generics are covered without regard to the deductible. The bigger issue is what the copayment is for Tier 3 (preferred brand name drugs) and Tier 4 (non-preferred brand name drugs). Tier 4 drugs often have a very long percentage co-payment of 40% or 50%. That can be a lot of money. Also, most drug plans simply don't cover lots of brand name meds. They will always cover something for the condition in my experience but they may not cover the specific med your doctor wants you to take.

Also, if a drug is very expensive and it is a Tier 3 drug and your co-payment is low then the part paid by the insurer is high and they amount they pay can lead you into the donut hole pretty quickly. My doctor prescribed a medication for me that is several hundred dollars a month. My co-pay (after deductible) was only $35. Now, I only took this med a few months so it was fine. But if I had taken it for much longer it would have knocked me into the donut hole and my costs would have gone way up.

All of that is not a big issue for me since I don't take a lot of meds. During my mom's last few years of life prescription meds were a huge expense for her even with the Part D coverage as she was on so many meds.

 

[Rianne]

There are a few other things that may or may not be important. There are things that Medicare simply doesn't cover or limits. So you can't get an annual physical with Medicare. They can't just do full lab panels. Last year, for example, my doctor ran some lab work on me and one test was an A1C. I am not diabetic. Medicare disallowed it. Now since the lab accepted Medicare assignment, I didn't have to pay it. The doctor though had originally wanted me to use a different lab where I would sign in advance to pay anything Medicare didn't pay. I refused to do it so they sent the lab work to Lab Corp. However, it is possible that I might want some lab work Medicare wouldn't pay for and I might pay out of pocket for that.

Years ago, when my father was dying he was in the hospital for months (complications from surgery) and he was getting close to the maximum time period Medicare would pay. After that it would have been considered long term care and not covered even though he wasn't in a skilled nursing facility. He actually needed to be in a full hospital.

In some parts of the country it can be hard to find good primary care doctors that you can get into see in a reasonable period of time. On Medicare I've never had trouble finding specialists and they've all taken Medicare. Lots of primary care doctors do not do so or you have to wait months for an appointment. I know a lot of people who do pay for a concierge doctor (in many cases this will include the cost of an annual physical).




If the claim is covered by Medicare then my Plan G does pay all the rest. So in that since where it has a OOP Max doesn't matter. Now for some things, Medicare does limit for how long they provide coverage.



Zip code makes a difference for your supplement and for the Part D plan. The Part B premium ($170.10) does not vary with Zip code.

Oh - another thing that makes a difference. Most drug plans have a deductible of $480. Sometimes generics are covered without regard to the deductible. The bigger issue is what the copayment is for Tier 3 (preferred brand name drugs) and Tier 4 (non-preferred brand name drugs). Tier 4 drugs often have a very long percentage co-payment of 40% or 50%. That can be a lot of money. Also, most drug plans simply don't cover lots of brand name meds. They will always cover something for the condition in my experience but they may not cover the specific med your doctor wants you to take.

Also, if a drug is very expensive and it is a Tier 3 drug and your co-payment is low then the part paid by the insurer is high and they amount they pay can lead you into the donut hole pretty quickly. My doctor prescribed a medication for me that is several hundred dollars a month. My co-pay (after deductible) was only $35. Now, I only took this med a few months so it was fine. But if I had taken it for much longer it would have knocked me into the donut hole and my costs would have gone way up.

All of that is not a big issue for me since I don't take a lot of meds. During my mom's last few years of life prescription meds were a huge expense for her even with the Part D coverage as she was on so many meds.

If your doctor orders a blood test for a reason, are you saying Medicare can refuse to pay it and the supplement kicks in? I get bi-yearly blood tests for a kidney condition and have for years. Don't they look at your previous health issues and allow treatment that you've had for years? A1C tests alert you for a heart or cholesteral condition that you can fix if caught early.

 

[Midpack]

There are a few other things that may or may not be important. There are things that Medicare simply doesn't cover or limits. So you can't get an annual physical with Medicare. They can't just do full lab panels. Last year, for example, my doctor ran some lab work on me and one test was an A1C. I am not diabetic. Medicare disallowed it. Now since the lab accepted Medicare assignment, I didn't have to pay it. The doctor though had originally wanted me to use a different lab where I would sign in advance to pay anything Medicare didn't pay. I refused to do it so they sent the lab work to Lab Corp. However, it is possible that I might want some lab work Medicare wouldn't pay for and I might pay out of pocket for that.

While Medicare does not pay for physicals, they do pay for a "wellness check" which could lead to further tests. More importantly...

...the OP does have a Plan G supplement, and IME that does pay for bloodwork and other tests that would be part of a legit physical. Mine includes most every useful test - CBC, CMP, lipid panel, Hemoglobin, PSA and Vitamin D. I have never paid a dime for the physical I have every January, thanks to Plan G. So a physical is covered by the supplement (and some Advantage plans).

 

[athena53]

Last year, for example, my doctor ran some lab work on me and one test was an A1C. I am not diabetic. Medicare disallowed it. Now since the lab accepted Medicare assignment, I didn't have to pay it. The doctor though had originally wanted me to use a different lab where I would sign in advance to pay anything Medicare didn't pay. I refused to do it so they sent the lab work to Lab Corp. However, it is possible that I might want some lab work Medicare wouldn't pay for and I might pay out of pocket for that.

I almost got bitten by this. My fasting glucose is over 100 and my total cholesterol level is high. Doc ordered an a1c and lipids panel among other tests. Her office must have coded it as "routine" because Medicare denied it and I was billed for nearly $800. Fortunately they forgot to have me sign the Advanced Beneficiary Notice agreeing to pay whatever Medicare denied. I now get my own tests through requestatest.com.

If your doctor orders a blood test for a reason, are you saying Medicare can refuse to pay it and the supplement kicks in?

The supplement covers only what Medicare approves so no, it doesn't kick in

Years ago, when my father was dying he was in the hospital for months (complications from surgery) and he was getting close to the maximum time period Medicare would pay. After that it would have been considered long term care and not covered even though he wasn't in a skilled nursing facility. He actually needed to be in a full hospital.

I've read cautionary tales about people who were in the hospital for couple of overnights but the hospital classified them as "Under Observation" and not as "Admitted"- They were discharged to rehab and Medicare wouldn't pay because they'd never been admitted.

Another thought: international travel (or even domestic travel if you have Medicare Advantage). Medicare does not cover anything outside of the US. Advantage plans may have arrow networks except for emergencies. My supplement has a $50K lifetime benefit outside of the US but I always get extra coverage.

 

[braumeister]

Medicare does not cover anything outside of the US. Advantage plans ay have arrow networks except for emergencies. My supplement has a $50K lifetime benefit outside of the US but I always get extra coverage.

Also worth noting that many supplements (such as mine) require you to pay the bills yourself while overseas, and then file for reimbursement when you get home.

Last time I used it I didn't bother about reimbursement since the charge over there was less than $100.

 

[Katsmeow]

If your doctor orders a blood test for a reason, are you saying Medicare can refuse to pay it and the supplement kicks in? I get bi-yearly blood tests for a kidney condition and have for years. Don't they look at your previous health issues and allow treatment that you've had for years? A1C tests alert you for a heart or cholesteral condition that you can fix if caught early.

Medicare can refuse to pay it if it doesn't fit within Medicare guidelines. It is often very important how your doctor codes the test. For example, Medicare only pays for a routine screening blood test for cholesterol once every 5 years. However, both I have usually had it more frequently than that. I have high cholesterol so it isn't routine for me and gets paid.

In general Medicare has very specific rules on how often it will pay for things that it sees as preventative or screening.

However -- if your doctor sends that test to a lab that takes Medicare assignment and you didn't sign an advance notice that it might not be covered then you aren't liable if it isn't covered. That is what I refused to sign when I last had blood tests done. So I had no liability.

As for whether they allow treatment you've had for years, well it depends. I mean, yes, I get cholesterol tests every year because I meet the criteria to be able to have them more frequently than every 5 years. On the other hand, Medicare does sometimes have rules of what criteria has to be met for certain treatment. If you don't meet that criteria then Medicare might not pay even if some doctor has been providing that treatment. FWIW, by and large I think that most of the time Medicare's protocols are grounded in science. The reason Medicare doesn't pay for a routine physical every year is because that hasn't really been shown to be of that much benefit. Medicare would say that examinations need to be tailored to the individual.

While Medicare does not pay for physicals, they do pay for a "wellness check" which could lead to further tests.

That is true. But wellness checks are really just talking to you. They don't involve any examination or testing. They don't lead to anything that you couldn't get just be telling the doctor what your complaints are or asking for the routine testing that Medicare routinely allows.

More importantly...

...the OP does have a Plan G supplement, and IME that does pay for bloodwork and other tests that would be part of a legit physical. Mine includes most every useful test - CBC, CMP, lipid panel, Hemoglobin, PSA and Vitamin D. I have never paid a dime for the physical I have every January, thanks to Plan G. So a physical is covered by the supplement (and some Advantage plans).

No, no, no. Plan G does not cover anything that Medicare doesn't already. Yes, doctors can often code things so that those things are covered by Medicare. Go look at your Medicare Summary Notice. If your supplement paid for testing I guarantee you that it paid after Medicare already paid its part (well, after the deductible).

Many of the things you are talking about will be covered under Medicare as screening every X amount of time. Others can be coded to be covered. But the fact you have Plan G is irrelevant to what is covered.

 

[marko]

That is true. But wellness checks are really just talking to you. They don't involve any examination or testing. They don't lead to anything that you couldn't get just be telling the doctor what your complaints are or asking for the routine testing that Medicare routinely allows.
.

Someone should tell my doctor. I get a full physical every year. Takes about an hour.

In fact, I've seen no difference in my doctor's procedures, tests or costs from before I had Medicare.

 

[Rianne]

Someone should tell my doctor. I get a full physical every year. Takes about an hour.

In fact, I've seen no difference in my doctor's procedures, tests or costs from before I had Medicare.

It seems it's all in the coding. I recall having this issue with our corporate health insurance policy years ago. It was considered gold standard insurance. But the Dr or whoever does the coding coded incorrectly or intentionally. I fought it and it was coded differently and covered.

 

[Sunset]

Does medicare cover the yearly flu vaccinations ?

Do they cover tetanus shot if the last one was a long time ago ?

 

[marko]

It seems it's all in the coding. I recall having this issue with our corporate health insurance policy years ago. It was considered gold standard insurance. But the Dr or whoever does the coding coded incorrectly or intentionally. I fought it and it was coded differently and covered.

Exactly! It is not a case of " where Medicare falls short "

 

[REWahoo]

Does medicare cover the yearly flu vaccinations ?

Do they cover tetanus shot if the last one was a long time ago ?

Your Medicare Coverage: Is my test, item, or service covered?

 

[jollystomper]

This thread is helpful. DW will go on Medicare later this year. Since I do not turn 65 until next year, she can stay on my Megacorp retiree plan until then. Medicare becomes the primary provider, the retiree plan covers what Medicare does not. The retiree plan monthly cost will drop.

I did a quick analysis of costs of (a) her going on Medicare + Medigap + drug plan vs. (b) Medicare + retiree backup plan (which also include dental and vision) , and option (b) is cheaper.

We will have to fully deal with the coverage gaps based on our situation in 2023 when I turn 65 and we both lose access to retiree health insurance - and I am doing a lot of analysis now for that situation.

 

[harllee]

Does medicare cover the yearly flu vaccinations ?

Do they cover tetanus shot if the last one was a long time ago ?

Medicare covers annual Flu shots and so far Covid shots have been covered. On Tetanus I think that comes under Part D so you would have to look at your Part D coverage. Same for Shingles vaccine. Shingrix is very expensive and most Part D plans cover very little.

 

[braumeister]

you would have to look at your Part D coverage. Same for Singles vaccine.

I got that once a long time ago but it wasn't effective. I wound up married anyway.

 

[harllee]

I got that once a long time ago but it wasn't effective. I wound up married anyway.

Ops! Fixed it

 

[ncbill]

"All about the coding"

Yeah, the PA at mom's first ALF got to spend a couple of years in federal prison via 'up-coding' too many of his patient interactions...

 

[CRLLS]

Medicare covers annual Flu shots and so far Covid shots have been covered. On Tetanus I think that comes under Part D so you would have to look at your Part D coverage. Same for Shingles vaccine. Shingrix is very expensive and most Part D plans cover very little.

I think Shingles is covered by all Part D plans. It depends on the plan selected as to how much one pays. However, the Shingrix vaccine requires 2 shots. For DW, It was around $160 copay each. Virtually identical to the price if gotten via GoodRX discount. No real Medicare help there except it can be used toward the copay.

 

[Scuba]

After paying COBRA for 18 months and a United Healthcare plan for 19 months between the time DW retired and her Medicare eligibility - I’d agree Medicare is a real bargain. I’ve been on for 3 years and DW is coming up on 1 year. Costs are more than reasonable IMO and claims handling has been great so far. Anyone who thinks Medicare isn’t a good value, needs to shop medical coverage on the open market…

Exactly! Our premium is $1,800/month with a $5,900 deductible each and a $17,700 OOP max each per year. Can’t wait to get on Medicare!