medicare and supplement ?

Scooterr

I have a quick question on Medicare and supplement insurance. I figured if anyone would know you guys would. My wife doesn't qualify for Medicaid our income level is about $100.00 over. Do you have to have a supplement insurance with Medicare? Since we live in OK and my wife is Native American and she is a tribal member, the tribe has it's on health care services and covers what  Medicare doesn't. The tribe has it's on hospital, dental and doctors. I'm thinking about dropping her supplement insurance because it's eating us up financially. One more thing they contract out to other doctors if they don't have the services there.

ImMaggieMae

We have United Healthcare supplement insurance. It is definitely expensive, but it picks up everything that Medicare doesn’t cover. (As long as Medicare approves the charge.) It doesn’t cover drug prescriptions. It’s definitely worth the cost for us. One hospital stay can be astronomical.

Bill_2001

Hi Scooterr, it sounds like the tribal health care coverage she has is doing what a Medicare supplement would do anyway: Pay what Medicare leaves behind. Sounds like a good plan. Anyway, there are also Medicare Advantage plans, which usually include prescription coverage. I would sit down and carefully compare them. You did not mention if the tribal plan covers medicines.

Each state is different, and many Medicare Advantage plans are local. Medicare Advantage plans are also known as "Medicare Part C." It sounds confusing, but it really is not. My wife is on a Medicare Advantage plan. Her meds are all generic, and there are no copays or meds or doctor visits. However, my wife is also covered by my major medical coverage since I am still working, so apples-and-oranges.

On a very basic level, you can have plain old Medicare only. You can then add a Supplement, OR a Medicare Advantage plan (Part C). They are mutually exclusive - it is either-or. Medicare Advantage plans tend to be much more affordable than supplements, but then you will need to compare what they cover and how much. I know it's boring, but read the plans carefully and select.

Jo C.

Hello Scooterr; this is a problem for many; the costs of supplements are terribly expensive.  The tribal healthcare sounds as though it would be good from a financial point of view.  However, ease of choices for specialists you and your wife need may limited especially with need for specialists.  Also important is how close the clinics and hospitals are to you and just how skilled with dementia and dementia treatment the providers are.   You mention the tribal healthcare system contracting out to specialties they cannot cover; you would want to check to ensure the quality of the specialists that your wife needs and find out if the tribal healthcare entity also contracts with hospitals that provide care they cannot, and what they have regarding hospice and home heath entities which at some point may become important.

Another option would be to look into the Medicare Advantage Plans, (Plan C), available in Oklahoma in your area.  Here is a link that is current that explains the Advantage Plans and is done for Oklahoma.  When a person is in a Medicare Advantage Program, they cannot get Supplemental Insurance Policies as they are not needed and no one can sell a supplement to a person in an Advantage Program as it is not needed.  Most Advantage plans are an HMO model with some being a PPO.  Some have co-pays and deductibles, others do not.  Some have a Plan D for meds; mostly generic, (but sometimes one can get a prescription cheaper with a GoodRx discount card.)

If an Advantage Program sounds right for your wife, then you must wait for the next Medicare enrollment period to make a change.  That is discussed in the link:

 https://www.medicareplans.com/medicare-advantage-plans-oklahoma/

You mention being "over the income limit by $100," in order to obtain Medicaid. IF you are referring to Long Term Medicaid coverage for care in a facility, there is help for that.   If you qualify for Medicaid except your iincome goes over the allowed amount, Oklahoma is one of the states that has Miller Trusts, also called Qualified Income Trusts.  In this, only the person who is applying for Long Term Care puts all their sources of income into the Miller Trust.  This includes all income for the appliant - Social Security, Pensions etc.; any income from any source. The spouse who is not applying for benefits will be able to keep all of their own retirement funds that are in their name only - so your pension, social security, etc. is yours and will not count in the Medicaid approval process.

In this, each month when the bill is received from the care facility, a check is written out of the Trust to the facility and Medicaid picks up the rest of the shortfall.  This has been very helpful for many.

So hope that you will find the best fit for you and your wife.

J.

Scooterr

Thank you guys, yes IMM one hospital stay can be very expensive. Bill I did forget to mention about the pharmaceutical the tribe has  a pharmacy, but it only carries half of DW medications. Her Aricept and Namenda we have to get at a regular pharmacy which her supplemental covers. 

Bill and Jo I never thought about Medicare Advantage (well I should say I thought about it then it was gone). It sounds like you guys are on the same page about the Advantage plan. I will DEFINITELY look into it. Thank you much Jo for the link.

Jo you had mention about the tribe contacting with specialists. My DW neurologist and neuropsycholoist are contacted with the tribe. We have been seeing them for 4yrs now and are very satisfy with their services so far. 

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Quilting brings calm

I am confused.  Supplements do not cover prescriptions … unless you got a particular supplement prior to 2006.    Medicare part D covers prescriptions.    I do not think you want to get rid of part D unless you do move to a Medicare  Advantage Plan  that covers prescriptions. As mentioned, Medicare Advantage plans also often cover some deductibles  and copays that supplements also cover.   

However I think you really need to contact the tribal office and find out exactly what they would cover if you gave up your supplement and picked up a Medicare Advantage ..: or if they would even accept it since  they do not have to.  So you might end up having more costs. 

  

Jo C.

When one signs up for a Medicare Advantage program, the subscriber can sign up with either an HMO or a PPO.  HMOs are more cost effective; PPOs give more freedom and one can go to any doctor who contracts with the PPO.  There are lists of doctors who are contracted with the PPO if one sign up for one - however; that being said, it is commonly a nightmare in that the lists of contracted providers is almost always very out of date and very incorrect, so one has to be very cautious when making appointments to ensure that doctor is indeed a contracted physician with that particular PPO.

Here is a link comparing HMOs and PPOs:

https://www.retireguide.com/medicare/medicare-advantage-plans/coordinated-care-plans/hmo-vs-ppo/

J.

Scooterr

   Well I'm still doing my research. This can be very confusing and frustrating. I spoke with Medicare this morning and I have to say I wasn't impressed. I know very little about Medicare Advantage (which is obvious). I don't know if any of you guys have spoken with Medicare before?  I asked the Medicare representative a question and she keep putting me on hold over, and over. Then there was the old disconnect routine (amazing). That's all after a 10 minute wait time.

   I did speak with the tribal health care this morning. The tribe has inform me, "they contract with all major hospital and specialist in OK and do cover everything Medicare doesn't and they have several members who use tribal health care as a supplement." I also spoke with tribal members who use the tribal health care as a supplement and they all seem quite pleased with it. Now that being said none of them have any form of dementia.

   I've been reading a lot of reviews on Medicare Advantage and it's a mixed review some like it, and some don't.  Like anything else, it's all a matter of preference.

   I did found some local pharmacies who have in house discounts for those who don't have, or don't use insurance. One of my medications is $2.00 more and the other is actually cheaper. My DW med's that the tribe doesn't cover is $25.00 more. I think the insurance is giving us the once-over (bamboozling). 

  Thank you guys for the in put I'm using all of it. 

     

    

loveskitties

When I was looking at supplement vs advantage programs there were some things I took into consideration:

Once you "leave" medicare for an advantage program, it can be difficult to get back into medicare with a pre-existing condition.

On the advantage programs I looked at, you were limited on choice of doctors.  With medicare, it seemed there were more choices...of course not all doctors take medicare either or have their quota of medicare patients.

There are options on the supplement plan you can choose.  I picked the one (no longer available for new participants) which covered the co-pay and deductibles on any medicare covered expense.  Therefore I can see a doctor or be in the hospital with no out of pocket expenses except meds...which of course require a part D policy.

I went to the AARP web site to get most of my information.  It was very helpful.  It has been some years since I did my research so be sure to check to make sure my decision basis is still accurate.

MaryG123

These programs are very state specific.  Also, there are many companies that pose as “Medicare” so they can manage your care.  I’ve been happy using the federal Medicare site which shows you the options for your specific location.  We have a very good Advantage plan with a reasonable selection of providers, with prescription, dental, eye, and hearing aid coverage at no additional cost.  That being said, I’m guessing the Indian Health Service will be your most economical choice.  They have a website as well, which I’m sure you already have. Any offers I get in the mail go into the trash.

 https://www.medicare.gov/plan-compare/#/?year=2022&lang=en

https://www.ihs.gov/aca/

Pat6177

When I was approaching 65 and trying to figure out Medicare, I attended a class put on by the county’s council on aging. It was well done and helped me to understand. Medicare Advantage really varies, not just by state but by county. If you travel or you’re a snowbird, then you may do better getting Traditional Medicare. Sounds like the tribal coverage would work well as supplemental coverage. Good luck! It takes a bit to sort it all out in your mind.

shimalkharia

It depends on your wife's specific healthcare needs and the coverage provided by the tribe. If the tribe's coverage is comprehensive enough, it may be worth considering dropping the additional insurance to save money. However, you should carefully review the coverage options and consult with a healthcare professional before making any decisions. By the way, you can easily find out the cost of individual services using some data. When I want to know the price of dental care, I look at the NPI of my specialist. It would be better if you study what is an NPI number to take advantage of my suggestion.

Jo C.

Shimalkharia, if your friends have plain Medicare and not an HMO or PPO, and have no secondary insurance, they are then financially responsible for all the outpatient as well as inpatient deductibles, co-pays, etc., which can go well into the thousands of dollars. Each time a person is admitted to the hospital, it is a Medicare, "New Spell Of Illness, which means the deductibles and co-pays must be met again.  The supplement insurance plans are to cover co-pays and deductibles. There are many different supplements and one must also screen them for their coverage and premium costs.

It is a significant liability for most people not to have a supplement insurance coverage as well as Plan D for prescriptions if one is on plain Medicare and not a managed PPO care or HMO plan.  Many people opt to go into an Advantage Plan to avoid having to pay the cost of supplemental coverage. When they do this, they must see only those physicians including specialists and hospitals that contract with their Advantage Plan and each Advantage Plan is different.

Each state has a federally mandated SHIP; "State Health Information Assistance Program," that is at no cost.  This program has information and counseling regarding Medicare as well as supplemental coverage issues.  States often have their own name for their SHIP. The following link has names of states; click on your state and the contact number for your SHIP will pop up.  In our state which is California, our SHIP is titled, HICAP.

https://www.shiphelp.org/about-medicare/regional-ship-location

J.

JJ401

Check CostPlus Drugs for your wife's medication. He has a part D prescription plan, but it has a deductible for some drugs. I ordered one of them from cost plus and saved $200 for a 90 day supply.

toolbeltexpert

Scooterr I first want to say it's Good to see your post, I have been down this road. First I learned the unless you have a LTC,  medicare doesn't cover any mcf. My dw has original Medicare and a supplement plan F. I got her statement for her geripsych stay 139k. I about dropped dead, I haven't payed 1 dime. Not the ambulance, not any medicine zero. That was just the geripsych stay. The only thing I pay was a part of the cost for a rollator and her meds which are running 60 a month. I pay everything for her mcf. 3659 a month, it's like taking a great cruise to nowhere. That is cheap. I do not know how it works in other states but when I applied for medicaid for dw they included my financial stuff,  which was a rollover from my work 401k. They basically wanted us broke.Long story you know what I am going thru to fund her care.  I have the same coverage except I have plan g, F is no longer available. Dw coverage is 147 a month and it goes up every year. So I may have higher premiums but not paying for anything except meds has been a big win.

You definitely have some other options I do not know about but it sounds like your doing the right thing dig deep and study, you have asked others how the tribal coverage works, I personally would present what your situation is to ones who are in charge of that plan and see what it looks like. Still praying every day for you both.

Stewart 

Jo C.

For those who do now know and are feeling a bit confused, Medicare "plan" G is a supplemental plan one pays for, it is not a specific Medicare plan, but supplements Medicare.  Since there is significant costs for plain Medicare co-pays and deductibles, it is far best,, (and for most it is necessary), to have a supplement under such circumstances.

NOTE:  If it says that a supplemental plan, "Covers Skilled Care," this does not mean custodial care in a long term care facility - the skilled care mentioned is meant for rehab if approved by Medicare criteria for medical necessity for the limits of time Medicare permits.  Sometimes Skilled Care will not be for rehab, but for continued IV therapy or continued complex wound care that can be safely mangaged at a lower level than in an acute hospital setting but still requires the ongoing licensed nursing care support and oversight that cannot be provided in the home setting.

Supplemental plan F was a very comprehensive supplemental plan, however, is is no longer available for newer Medicare beneficiaries; those who already had Supplemental Plan F from prior enrollments can continue with that through choice.

Plan G being a Supplement like any other Supplement, has a monthly fee. In some states, at some ages, it is not highly expensive; but the costs can be different state to state and in different circumstances. Sometimes, (often), as one ages, the costs of Supplements can be tremendously and even prohibitively expensive.  Best to enroll in a choice of Supplements early when one first qualifies for Medicare, but fees will in all likelihood increase as one ages.  My MILs fees for her Supplement climbed from $300/month to a bit over $800/month!

It is complex and certain facets within our governing bodies in D.C. are looking at changing benefits with some stating not changing the here and now BUT moving to make changes for future recipients of both Social Security and Medicare - that reminds me of the old Shakespeare quote . . .  "Something wicked this way comes . . . "

Here is a link discussing Supplements:

https://www.medigap.com/medicare-supplements/

J.