A take on Medicare as a recipient and supporter

[KAOSkins]

Since most of us are too young to have first hand experience with Medicare, yet it's something that's driving a good deal discussion these days, I'm going to tell you what I've found. Sucks to throw our resident right this kind of bone, but fair is fair.

Brief background, I had to retire on medical a couple years ago due to MS and I kept my health insurance policy from my old job because it is great coverage for a decent, but by no means cheap, price as part of a pretty big group. Also because I have MS and kinda had to. Went through the SS disability process knowing I would go on Medicare and figuring I would see about dropping the policy at that point. Got approved after a couple years. Figured my out of pocket medical costs surely will go down. How could they not if the Medicare was going to pay most of my medical expenses? Here's how.

Most people know that you need secondary coverage. I knew that and had vague familiarity with words like donut-hole and such. The biggie it turns out, at least in my case, is copay for prescription drugs. Didn't Bush fix that?

Pre-Medicare money breakdown. $500/month for BC&BS for the full plan where my copay for my MS drugs is $150/month for drugs that cost $2500/month.

With Medicare money breakdown and the best secondary policy I was able to find. $260/month plus 20% co-pay for MS meds.

Do the math and because of the drug co-pay I'm better off keeping the policy I had, which I was happy enough with anyway, and which is what I've done.

I have the same policy, paying the same premium and same co-pays as when I worked. BC&BS collects their same premium and same co-pays as when I worked (when they paid for most of my medical expenses and for which they must make an acceptable profit). Only Medicare now pays for most of my medical costs, which are pretty substantial on a yearly basis.

Good insurance lobby or what? MS is not that rare and there are innumerable other chronic conditions which require equally specialized, hence expensive, drugs with patients who also had decent insurance from prior employment, so I figure there are a lot of other people in my same boat.

Maybe the overall stats don't work out so messed up for most people, but even so. It's just wrong and not what any sane person would expect to encounter and it seems it would be easy enough to identify these cases and have a more sensible solution. I'm not paying more, so as an individual I have no reason to complain but as a tax payer it really bugs the **** of me.

Happy to try to explain my situation more clearly if I haven't done so and sorry to ramble. For the record I'd like nothing better than to be shown that my cynicism is misplaced.

[Wrong Direction]

Man, I typed a long response and it didn't go through. Third time in 2 days that happened to me here. Don't understand why. I'll try again.

Part B: If your drugs are injectible, they're likely covered under Part B. This is a 20% copayment, but you can sometimes find Medigap to wrap around that. I'm guessing this is not the case since you can't seem to find supplemental insurance.

Part D: The donut hole is being closed gradually, but it's still there. Even once it's closed you'll go to the 25% copayment for Part D. What's important here is that you understand there's a catostrophic benefit in Part D that doesn't exist in Part B and likely doesn't in your private insurance. After you spend $5,000 to $6,000 (I forget the exact amount), your cost sharing goes to 5%.

Actually, after reading your post again, I think you might have both Part B and Part D drugs, which is tough. In that case, you should look into Part C. That's the private insurance part of Medicare and they are allowed to cover drugs under one benefit. Definitely check that out. Also, you might want to look into Medicare Chronic Special Needs Plans. There's a category of these C-SNPs that allows for specific benefit packages (doctor networks, different copays for drugs) for people with MS and related conditions. I have no idea if one of these plans is available in your area, but you might want to check.

My guess is that a Part C insurance plan would be cheaper for you than your employer plan, but it really is just a guess based on my assumption that the federal subsidy to the insurance company is higher than your employer's payment to your insurance company. It's worth looking into.

[Lombardi's_kid_brother]

I'm trying not to insult you, but private insurers do not want you because too many patients like you will bankrupt them.

Group health insurance is kind of a scam when you think about. The vast majority of people in their 20 and 30s never need health insurance. In your 40s and 50s, you start to need it some. It's in your 60s that health care costs start to get alarmingly high and then you are suffled into a government plan.

Private health insurance benefits are great. They are great because not many people with MS or other horrible chronic diseases need them.

[Larry]

My thinking was along the lines of LKB, but I was phrasing them differently.

Your BCBS plan lumps you in with a large group of people in their 30s and 40s, who were screened to be generally healthy by their employers, before they were hired. Your rates and benefits are calculated so that the insurer makes a slight profit on the average member of that group.

Your Medicare plan lumps you in with every person in America who's over 65, no matter how healthy or un- they may be.

[KAOSkins]

I'm trying not to insult you, but private insurers do not want you because too many patients like you will bankrupt them.

Insult me by stating the obvious you mean? Never hurt me to hear it reiterated. Sometimes the obvious sails right over my head, not this time though. The issue I would take is that I can't just continue to pay BCBS and leave Medicare out since I would get the same benefits I do now and save the tax payers the money. BCBS agreed to cover me and took the gamble I would be healthy. Everyone loses once in a while. Only in this case BCBS doesn't even lose, the taxpayers pick up the loss for them. How it seems to me.

Man, I typed a long response and it didn't go through. Third time in 2 days that happened to me here. Don't understand why. I'll try again.

Part B: If your drugs are injectible, they're likely covered under Part B. This is a 20% copayment, but you can sometimes find Medigap to wrap around that. I'm guessing this is not the case since you can't seem to find supplemental insurance.

Part D: The donut hole is being closed gradually, but it's still there. Even once it's closed you'll go to the 25% copayment for Part D. What's important here is that you understand there's a catostrophic benefit in Part D that doesn't exist in Part B and likely doesn't in your private insurance. After you spend $5,000 to $6,000 (I forget the exact amount), your cost sharing goes to 5%.

Actually, after reading your post again, I think you might have both Part B and Part D drugs, which is tough. In that case, you should look into Part C. That's the private insurance part of Medicare and they are allowed to cover drugs under one benefit. Definitely check that out. Also, you might want to look into Medicare Chronic Special Needs Plans. There's a category of these C-SNPs that allows for specific benefit packages (doctor networks, different copays for drugs) for people with MS and related conditions. I have no idea if one of these plans is available in your area, but you might want to check.

My guess is that a Part C insurance plan would be cheaper for you than your employer plan, but it really is just a guess based on my assumption that the federal subsidy to the insurance company is higher than your employer's payment to your insurance company. It's worth looking into.

I got into the specifics of the Parts myself but it's beyond my ability to lay it all out here without going to a ridiculous post length, so I didn't. It's some ridiculously confusing **** IMO and sick people are in the worst condition to have to wade through that stuff. I know there is help for them but understanding it even with help is a lot to ask.

Points that I might have mentioned though are - I worked for local government and the retirement plan doesn't include health insurance to be paid by the employer. I pay my entire premium though I stay within the group as long I keep the policy. That's a reason I didn't want to let policy go. It's also really good insurance hence the reason it's cheaper for the meds than a supplemental plan - more so than the premium cost was higher.

As secondary insurance (which it automatically became once Medicare went into effect) it covers all costs not covered by medicare or the BCBS copays. Supplemental plans I looked at covered Part C and D.

I wasn't aware of C-SNPs, I will do so.

Thank you for taking the time to write such a well thought out response, sorry the first one went into the ether like. I hate it when that happens.

My thinking was along the lines of LKB, but I was phrasing them differently.

Your BCBS plan lumps you in with a large group of people in their 30s and 40s, who were screened to be generally healthy by their employers, before they were hired. Your rates and benefits are calculated so that the insurer makes a slight profit on the average member of that group.

Your Medicare plan lumps you in with every person in America who's over 65, no matter how healthy or un- they may be.

Nice phraseology Larry.

BCBS plan was local government, no health screening whatever. No preponderance of young people either. Though there were always a fair number. The group is about 600 people. Knowing how the rates were formulated in a broad sense, my comment about their profit was looking at it from the pov that their profits are based on the whole group, obviously not just me. Now they pay out a pittance and still collect the same. We taxpayers have picked up the difference for them.

Medicare also must include a fair number of people in the same boat as me,i.e. having the option of retaining private insurance. It's to them I would compare my situation. An option to continue to use private insurance would be sensible.with the requirement that you demonstrate you have that other policy. We'll soon have a bureaucracy that deals with that specific issue I think.