Medicare Advantage for ESRD

[Shaks24]

Starting January 1st 2021 all ESRD will be allowed to sign up for Medicare Advantage plans in lieu of Original Medicare. Right now I have Original Medicare and Medigap F but the premium for Medigap F is now more than $600 per month as I am under 65 and have few options. I think the main benefit of Medicare Advantage is that you will have a limit on your Maximum Out Of Pocket expenses. We should be able to look at these plans for 2021 beginning on October 1st. I know Fresenius is having an online seminar on enrollment options. I saw this on the patient portal and they even appear to have teamed up with a company that brokers Medicare policies. I am going to study the options carefully. My current coverage is awesome as I virtually pay no medical bills (except prescription drug copays) in my plan D. That $600 per month premium for Medigap F is getting tough though. I imagine it will jump to about $700 for 2021 and just keep sky rocketing until and if I make it to 65 years old and get another open enrollment window with no underwriting. By the way after 7 years on PD I had to switch to hemo after my PD Cath failed. We tried to keep me on PD but after 3 surgeries that did not resolve my issues I decided to give up on PD and switch to hemo for now. Its been about 3 months on hemo now and I sure miss the gentle side effects of PD vs the side effects of hemo that kick my but. Is anyone else considering making the switch from Original Medicare plus a gap policy to Medicare Advantage?

[SooMK]

I noted with interest this "opening up" of Medicare Advantage for ESKD patients. I'm post transplant and have Medigap F like you. Great coverage but the cost goes up every year--over $300 a month now and I'm 71. I'm very skeptical about Medicare Advantage so I will be following your post. Please update as you learn more.

[Alexysis]

I'm in the same situation, although my Medigap type F policy here in NY state is still under $400/month. I'm going to call the insurance coordinator at my clinic this week to ask about this. Probably will stick with what I have for next year, but who knows what the future will bring?

[Simon Dog]

I believe that one you are in a Medicare Advantage program and decide to go back to a conventional supplement, the insurance company selling the supplement can apply underwriting standards, denying or rating you based on health history.

[Alexysis]

I believe that one you are in a Medicare Advantage program and decide to go back to a conventional supplement, the insurance company selling the supplement can apply underwriting standards, denying or rating you based on health history.

New York State does not allow insurance companies to do this, so that's not a worry for myself. However, other states have different rules......

[Shaks24]

I'm in the same situation, although my Medigap type F policy here in NY state is still under $400/month. I'm going to call the insurance coordinator at my clinic this week to ask about this. Probably will stick with what I have for next year, but who knows what the future will bring?

I think I am going to do the same for 2021 and try to see how the medicare advantage works out for those who switch. What scares me the most are the networks you have to stay in to get the lowest costs. Unless you go with a PPO type plan where there is more flexibility but in the plans for my area the maximum out of pocket for the PPO's are a lot higher than the HMO's. The safe bet is to stay on original medicare with medigap F and know what I got for at least another year. I guess we will find out shortly how much the medigap F premium for 2021 is going up.

[Shaks24]

So I got my Medigap F payment coupon book for 2021. Starting January my premium goes up from 620 a month to 774 a month. Thats a 25% increase. Its an AARP medigap policy underwritten by Unitedhealthcare. They also sent me a letter encouraging me too look at their Medicare Advantage policies. I did and I talked at length with an agent. There are just so many variables in the medicare advantage plans and it seems like they leave themselves a lot of room to make subjective decisions about what they will cover. In the EOC (explanation of coverage) for their AARP Medicare Advantage Plan 1 under outpatient dialysis it even says "your provider may need to obtain prior approval". LOL WTF?  I think over all its too risky to switch the first year they allow us to join. Also your neph is classified as a specialist with higher copays and you also are required to have a primary care physician that coordinates all your care. I think its insane not to allow your neph to be your primary care person when you are on dialysis. I'm going to forget about medicare advantage for 2021 and revisit it in 2022 if I'm still kicking. Its very tempting as the maximum out of pocket for the year is 3700. But if they deny coverage by nit picking and playing games a single hospitalization could be big bucks. I also read reviews about this AARP plan and there were quite a few negative feedbacks. Specially pertaining to trying to get help when there is a dispute about coverage. 774 a month for medigap F is going to hurt my budget but I am sticking with it for another year and will pinch pennies elsewhere. At least we get like 20 bucks COLA for 2021. LOL

[SooMK]

Wow! I have the same AARP/UHC Medigap F plan that you do. I’m paying about $320 a month which I think is ridiculously high. I’m in New York where the cost of living is deadly. Why is your plan so much more than mine? Is that because you’re under 65? Will the price drop after that? I can’t even get my mind around having to pay that much money every month. Thanks for this information about the Advantage plans. It’s as I expected--too many ways we can end up owing a ton. The whole Medicare scenario depends on being a fortune teller.

[iolaire]

@Shaks24 thanks for the breakdown on pricing and your decision (and thanks to SooMK for your pricing).  I don't have skin in the game because I've had corporate insurance and am no off Medicare 3 years post transplant but I've been reading some of these discussion on the Facebook group as well. 

My gut feeling is always stay with the "old" program whatever it is, as governments usually offer "new" programs to save money by shifting the difficult choices (i.e. cost cutting) to the commercial programs.  Maybe for the first year or so the new programs would save you money but more than likely quickly the nickel and diming will start and costs will rise.

[MooseMom]

I've been reading this thread with dread.

The day after my tx when I was still in the hospital, I started getting deluged by people from the insurance department warbling on about Medicare.  Since I had not been on dialysis, I really did not understand Medicare, so I just followed their advice.  Basically the hospital peeps told me to sign up for everything, which I did despite not being mentally up to speed yet.

I got home and started getting all the bumph from Medicare, paying particular attention to the ESRD bit.  The very very very last last last sentence advised checking with your private insurance to see what they would cover.  As I started getting bills for premiums from Medicare, I couldn't help but wonder why I (well, my husband) should be paying two lots of premiums, one for Medicare and the other for the insurance we get through his employer.  After checking with the HR department, we were advised that the insurance we already had would cover everything post tx, even during the coordination period of 30 months or whatever it is, so I never paid the Medicare premiums at all.

Eight years later, I found myself having to be admitted to the hospital for treatment for a stomach flu that caused severe dehydration (I've already told that story).  It was the first time post tx that I've had a hospital stay.  So, I was lying there, and the hospital's insurance department called me and asked me if I was on Medicare.  I said no, and they said that my records showed I was.  I was in a hospital out of state, so I don't know they got "my records" and why they showed I was on Medicare, but I told them that must be some mistake.

I ended up having to call my insurance carrier, and yes, they even had my Medicare number!  I had thrown out my Medicare card 8 years ago, figuring that since I'm not eligible, I'd "reapply" when it was time.

Anyway, I'm getting into the weeds here, for which I apologize, but in a way, that's the point.  I really dread the prospect of having to deal with it all.  I have not been paying into Medicare because my working life was spent overseas.  I can qualify for Medicare, but only once my husband reaches 62, and I will reach 65 one month after he reaches 62, blah blah blah.  See, it's the little crappy details like this that make me worry,  Some little tiny thing is gonna trip me up, I can just feel it in my waters.

Ugh.  All of this assumes we even have Medicare in a few years' time.  I might be dead from covid this time next month for all I know.  At least I wouldn't have to worry about signing up for Medicare and trying to decide if plan Zeta offers me more than plan Epsilon or some such thing.

[MooseMom]

@Shaks24 thanks for the breakdown on pricing and your decision (and thanks to SooMK for your pricing).  I don't have skin in the game because I've had corporate insurance and am no off Medicare 3 years post transplant but I've been reading some of these discussion on the Facebook group as well. 

My gut feeling is always stay with the "old" program whatever it is, as governments usually offer "new" programs to save money by shifting the difficult choices (i.e. cost cutting) to the commercial programs.  Maybe for the first year or so the new programs would save you money but more than likely quickly the nickel and diming will start and costs will rise.

Yes, this.

[Shaks24]

Wow! I have the same AARP/UHC Medigap F plan that you do. I’m paying about $320 a month which I think is ridiculously high. I’m in New York where the cost of living is deadly. Why is your plan so much more than mine? Is that because you’re under 65? Will the price drop after that? I can’t even get my mind around having to pay that much money every month. Thanks for this information about the Advantage plans. It’s as I expected--too many ways we can end up owing a ton. The whole Medicare scenario depends on being a fortune teller.

Yes I am under 65. I'll be 62 next year. When I hit 65 I will get another guaranteed issue window to sign up for a supplement at the same premium rate other 65 year olds get. I've had this policy since 2013. It was $280 a month at that time point. They just keep jacking up the premium because they legally can in my state (Tennessee) when you are under 65. I had major medical issues this year and they have had to pay a lot out for me. They are trying to push me out. LOL Unfortunately for them, I can pay their jacked up premiums until I turn 65 if I want to. If medicare advantage felt safe to switch to I would but right now I feel uncertain about it so I will pay more and be certain I am well insured. Hopefully over the next year we will get some feedback about how medicare advantage has worked out for dialysis patients.

[Shaks24]

One last thought on my process for making the decision to stick with the over priced medigap F supplement vs the new (open to dialysis) medicare advantage plan.
I asked myself 2 questions.
1. If cost of the policy was not an issue, which one gives better coverage with more certainty and more freedom of choice. The answer for me was clearly Original Medicare with the medigap F policy. I know exactly what I am getting here. No network of provider limitations as long as providers accept medicare assignment. Actually medigap F even covers what they call excess charges for providers that bill more than the medicare approved amount.
2. Will paying the higher total costs in a year be devastating to my financial well being. In my case no. It hurts when on paper the yearly financial outlay appears to be about $5000 more per year for the medigap but the uncertainty of the medicare advantage because of all the potential loopholes and the fact that it is administered by a for profit private insurance company weighs heavily in my decision.
I will be digging for information about how this new medicare advantage for dialysis patients works out over the next year or so. Clearly there is potential savings if the coverage works out well based on the plans offered in your area and the specifics of the plan. There are PPO plans in my area but the out of pocket max are quite high and are not much less than the gap premiums. If anyone experiences dialysis coverage through a medicare advantage plan I would appreciate their sharing information with us about the pros and the cons.

[Alexysis]

Wow! I have the same AARP/UHC Medigap F plan that you do. I’m paying about $320 a month which I think is ridiculously high. I’m in New York where the cost of living is deadly. Why is your plan so much more than mine? Is that because you’re under 65? Will the price drop after that? I can’t even get my mind around having to pay that much money every month. Thanks for this information about the Advantage plans. It’s as I expected--too many ways we can end up owing a ton. The whole Medicare scenario depends on being a fortune teller.

States with 'expanded Medicaid' like NY subsidize things like the Type F policies, and other states like Tennessee don't help for squat. I did the math, and for myself, the Advantage plan makes no sense currently. But, in a state that doesn't help you hardly at all, it probably does.

BTW, for people considering moving to a 'lower tax state', things like this need to be considered. I've been considering relocating to NM, but I'm still trying to figure out where that would leave me with my Medicare. I'm certain my NY type F would be gone, but haven't yet had a full accounting of what would be available to me in New Mexico.

[SooMK]

I totally forgot about Medicaid expansion. I hope improvements will be coming. It's hard not to believe that the system isn't broken, it was planned that way.

[Michael Murphy]

When my wife retired we were offered a improved Medicare package from Aetna that was designed to entice my wife to drop her private insurance option and switch to Medicare.  This program looks like all the others with some differences.  When I reach the prescription donut hole all the drug costs are paid by the company my wife retired from.  It was significantly cheaper for my wife’s old company and since I have plan f I just spent 2 weeks in the hospital 1 week in the icu and 1 week in ccu with no costs to me.

[Shaks24]

When my wife retired we were offered a improved Medicare package from Aetna that was designed to entice my wife to drop her private insurance option and switch to Medicare.  This program looks like all the others with some differences.  When I reach the prescription donut hole all the drug costs are paid by the company my wife retired from.  It was significantly cheaper for my wife’s old company and since I have plan f I just spent 2 weeks in the hospital 1 week in the icu and 1 week in ccu with no costs to me.

What is you Plan F premium? If you are 65 or older its likely very reasonable. I'm under 65 and as posted above my plan F premium will be 774 a month starting next January.

[enginist]

When I first got sick, at age 69, I had basic Medicare, which I thought would be enough because I was never sick.  After two weeks in the hospital, Medicare covered the amounts specified in their contract.  This contract, however, didn't keep the doctors from billing me for their jacked-up personal fees, which totaled more than $12,000.  The following year, I was lucky to get on a Medicare "G" plan, which is backed by BC/BS and fortunately will enroll patients with a pre-existing condition.  My monthly tab for this blanket coverage is a very manageable $180, and no one sends me a bill for personal fees.  When I get a statement from Medicare, I am always shocked by the gap between how much the hospital tries to charge and how much the government is willing to pay. 

[Michael Murphy]

If the doctors accepted Medicare payments (billed Medicare and was paid directly through Medicare). They have agreed to Medicare rates and my understanding is that patients can ignore the doctors bills.  This is from the early 1990’s when I did the billing for my mothers bypass surgery.

[enginist]

You're probably right.  When I was getting these bills, I didn't know, or even suspect, that I could legally ignore them.  It was my first introduction to the health care system, and it's not too much to say that the system saved my life.  So I didn't question the high fees.  It pains me, of course, to be out 12 grand, but it's not the only damage that the hospital has inflicted on me.  I'm sure that Kristina and I are not alone in our resentment of some of the treatment we've received at the hands of our caregivers. 
 

[BlueKat]

Reading these posts, scaring me to nightmares. Husband has been on dialysis 3 1/2 yrs. He's 71. He's on medicare, but I also cover him under my employer insurance. I put him on Medicare B, after I started getting bills from transplant workups, (a big money making racket for the transplant centers) I'm over 65, want to retire in 2023. Biggest issue is going to be picking out what type of supplemental insurance for my husband. If the premiums discussed in this thread are correct, Medigap F, along with his Medicare B, will take his entire SS check, plus he will owe more. Plus it appears he needs something called D to cover meds. Medicare Advantage will work for me, I hate Doctors, won't go anyway, unless I'm crawling on the ground. But for my husband on dialysis, who has to go to Doctors and Dialysis to live, Medicare Advantage might be a real pit. I could see them refusing to cover things. 

[Simon Dog]

If the doctors accepted Medicare payments (billed Medicare and was paid directly through Medicare). They have agreed to Medicare rates and my understanding is that patients can ignore the doctors bills.  This is from the early 1990’s when I did the billing for my mothers bypass surgery.

You, or your supplement policy, are liable for 205 of the Medicare allowed rate which is generally a fraction of the price of the rack rate.

The Normal Parathyroid Center in Tampa (big place doing parathyroidectomies) got in big trouble ($4M fine) playing the "We charge the Medicare rate, but will not do your surgery unless you pay us about $1400 directly for a mandatory pre-consult which is not covered by insurance, and you should not even attempt to collect.".    The patient who sued for about $2K had the case taken away by the Feds ("it's our case now") and got a $600,000 whistleblower commission.