Treatments not covered by Medicare

[joesxm3]

I was reading the thread about high PSA and prostate MRI's and not being covered by some insurance policies. I am going on Medicare in a few months and it got me wondering.

As I understand it, Medicare has what it covers and if I have a Medigap Plan G, it will add on to what Medicare covers. But Medigap only covers what Medicare covers.

However, what happens in the case of a newer procedure or treatment that Medicare does not cover? Will I just have to pay the full price for it and neither of the insurance policies will pay anything?

With my current high-deductible ACA policy, the insurance company re-prices the claim based on their version of reasonable charges or some sort of negotiated pricing with the providers and I benefit from the price reduction even though I have to pay the entire charge. Would this sort of re-pricing go on for something that is not on the list of Medicare approved treatments or would I just get stuck with "retail" pricing.

Thanks.

 

[Sunset]

All I know is after reviewing 10 yrs of my FIL medicare and plan F coverage statements and bills, I can hardly wait to get on medicare.

His plans covered everything that happened to him and he had over those years.

As I understand it , plan F is no longer available, and plan G is the next best thing.

I'll be interested to know what other's experience has been as I'm planning on getting medicare and a plan G, and D for drugs.

 

[ejman]

I'm on Medicare + plan G. Since I got sick last year I've had numerous hospitalizations, procedures and tests, one of the chemo treatments I receive alone is $125,000 a year. My direct cost has been the annual Medicare deductible and of course, items not covered by Medicare - vision and dental although because of my illness most of the eye doctor charges are in fact covered. Its a good thing I chose Medicare + Plan G. Out of curiosity I checked after I got sick what my coverage would have been with an Advantage plan available in my area and the particular chemo I receive would not have been covered. I would have had to undergo treatment with a much harsher cheaper drug with some very serious side effects.

 

[Bamaman]

We had Plan G, and switched to a more inclusive Plan F last September. I didn't realize you can switch plans in the middle of the year.

I was needing a new (and very expensive) insulin pump, and my wife was going to get a $2500 Medicare electric wheelchair since she was going through two major foot fusions. Plan F completely covers the 20% deductibles of Plan B--durable health devices. Also, my insulin pump supplies are quite expensive, and are covered under Part B.

Diabetics on the pump now get their insulin on Plan D at a cost of $35 a month--down from $170 a month when it was on Plan B. Those tiny vials of insulin retail for $315 each.

The big question they ask about is whether the patient has end stage renal failure when going onto Plan F--and probably Plan G too.

I am very carefully watched by my endocrinologist in every way. And I get blood work done quarterly that Medicare plans wouldn't cover had I not been diabetic. I seldom see my internal medicine physician, but he does give me a mini-physical yearly. Medicare doesn't pay for physicals, even though it should be a big part of any 65+ year old person's healthcare.

My wife is a medical professional and not a fan of Advantage plans. We carefully choose our specialist physicians and concur on the hospitals they want to use. Many Advantage patients don't get the superstar doctors and sometimes don't have access to the best hospitals. Our doctors don't accept Medicaid or Advantage plans.

 

[CRLLS]

I was reading the thread about high PSA and prostate MRI's and not being covered by some insurance policies. I am going on Medicare in a few months and it got me wondering.

As I understand it, Medicare has what it covers and if I have a Medigap Plan G, it will add on to what Medicare covers. But Medigap only covers what Medicare covers.

However, what happens in the case of a newer procedure or treatment that Medicare does not cover? Will I just have to pay the full price for it and neither of the insurance policies will pay anything?

With my current high-deductible ACA policy, the insurance company re-prices the claim based on their version of reasonable charges or some sort of negotiated pricing with the providers and I benefit from the price reduction even though I have to pay the entire charge. Would this sort of re-pricing go on for something that is not on the list of Medicare approved treatments or would I just get stuck with "retail" pricing.

Thanks.

Original Medicare covers medically necessary procedures. With a supplement, if Medicare doesn't cover it, they don't either. Always ask a Dr if what he suggests is covered by Medicare and if he "accepts Medicare Assignment". They will get preapproval for your specific procedure. I highly doubt if Medicare negotiates costs on things they don't cover. Sort of like Dental or Optical or Hearing. Original Medicare doesn't cover them. And from what I read, Medicare doesn't negotiate prices on Implants, Glasses or Hearing aids. I have never heard of ACA policies where there are some procedures that are not covered, they are still negotiate lower prices. Do yours do that? Or are all of you experiences based on ACA covered procedures but not yet met the deductible? If so, Medicare does the same thing.

 

[harllee]

The one thing that traditional Medicare and my Plan G does not cover is an annual physical. Medicare will cover something called an "annual wellness visit" which in my experience is worthless. So to get a real annual physical I have to fork out $300 from my own pocket.

 

[Ian S]

We had Plan G, and switched to a more inclusive Plan F last September.

IIRC, the only difference between Plans G and F is the Part B deductible which is paid under Plan F but not under Plan G. So it's easy to compare the actual annual cost of the two plans; when I did it some years back, the the additional premium cost annually for Plan F more than offset the savings on the Part B deductible. That made my choice of a Plan G a no-brainer. Now, Plan F is not available to new Medicare enrollees.

 

[REWahoo]

IIRC, the only difference between Plans G and F is the Part B deductible which is paid under Plan F but not under Plan G.

^ This is correct. The Part B annual deductible ($203 in 2021) is the only difference in the two plans.

 

[Marita40]

I'm going on Medicare next month. I am very glad I took a Medigap and not Advantage plan. We don't have "G" here in the outlier state of MN, but an equivalent comprehensive plan. It is more expensive than I thought, along with the fact that I have to pay IIRMA for Part B and D, but it gives me peace of mind. What's worrisome for me is Part D, because the eye drops I use can change at any time and some are very expensive. So it is simply a guess whether any Part D plan will cover them.

I did learn for those coming aboard Medicare that there's a "Welcome to Medicare" wellness exam. I don't know what to expect--whether it will be like a routine physical or not--but it is with my GP doctor. I too think it really odd that Medicare doesn't cover annual physicals. What's up with that? Don't seniors especially benefit from them?

 

[REWahoo]

I did learn for those coming aboard Medicare that there's a "Welcome to Medicare" wellness exam. I don't know what to expect--whether it will be like a routine physical or not--but it is with my GP doctor.

More of a "wellness screening" with no lab tests. Read the details here: https://www.medicare.gov/coverage/welcome-to-medicare-preventive-visit

 

[Marita40]

Curious whether those here on Medicare pay for an annual out of pocket physical. Maybe it is overkill, but I've had one for many years because they were covered by my employee insurance. I am quite healthy, but I really like getting blood tests, odd as that sounds. As one character puts it in a Flannery O'Connor story, "blood don't lie."

 

[Ian S]

Curious whether those here on Medicare pay for an annual out of pocket physical. Maybe it is overkill, but I've had one for many years because they were covered by my employee insurance. I am quite healthy, but I really like getting blood tests, odd as that sounds. As one character puts it in a Flannery O'Connor story, "blood don't lie."

Because I've been diagnosed with high cholesterol and once had borderline A1C, Medicare covers annual chem panels to monitor my situation. I take a very low dose of atorvastatin and it seems to keep my cholesterol numbers in the good range. Last A1C had dropped perhaps due to my losing some weight.