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Old 08-21-2015, 12:56 PM
 
797 posts, read 1,385,421 times
Reputation: 656

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I will be going on Medicare (part a & b) in a couple months. My husband just started a new job and he has the option to add me to his insurance there. The PPO plans being offered are too costly and so my hubby wants to sign himself up and our kids up for the HMO and then I will just be on Medicare. I have some reservations in doing this. Medicare part a & b has NO out of pocket maximum (unlike Medicare advantage which has a $6700 oop max but the Medicare advantage plans are too pricey so I'm going to stick with traditional Medicare- a & b). Also- there is no list of what estimated costs will be on Medicare. For example I looked on Medicare website re: diagnostic labs. It says lab work is covered 100% but that there still may be a copay. I call Medicare to see how much that copay will be? They say they don't know, it could vary. Wtf! So I am going into this unsure of how expensive it really will be... Anyone here on JUST Medicare part a & b? What is your experience like? Do u have a lot of expenses?

It is the same price for my husband to add our kids onto his HMO as it is to add me too.. It is just a family plan rate.. BUT the thing is, Medicare said it can be very difficult to be on an HMO (primary insurance) and have Medicare (secondary insurance). The woman I spoke to said that due to the nature of an HMO typically paying more than a PPO would, often times Medicare doesn't wind up paying anything (because what the HMO paid is more than what the Medicare allowable amount is). She said the only way it would be advantageous to me is if I planned on seeing docs that were out of the HMO's network (yet were still contracted with Medicare). I specifically asked if I were to see a doctor without getting a referral first (which would cause the HMO to deny the claim), would Medicare pay? She said she didn't know because typically when it is the secondary insurance, Medicare only pays when the services wouldn't be covered under the primary insurance plan. In that scenario, the visit WOULD have been covered, but I would have not followed proper protocol of obtaining referral, which means Medicare would deny it...

As much as I would be grateful the HMO would cover so much (it seems like a great plan!), I see a LOT of specialists. I hate an HMO because every time you need a referral you have to see your PCP which is a $20 copay all for the doc to give me a look-over, hear me say what's bothering me, and refer me to the specialist. 99% of PCPs have no clue how to manage my health due to the rare complexity of my medical problems... I did have one good PCP who understood my health issues were more than she could handle, so she would happily write a referral to whomever I requested, without requiring I be seen first... But now due to affordable health care act ("Obamacare"), PCPs have had to crack down and require me to be seen first. In a given week I could see 4 specialists! If I had to see my PCP for those 4 referrals that would be double the copays


I am just trying to decide what to do..... Any advice? Input?
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Old 08-21-2015, 01:13 PM
 
Location: Wisconsin
23,621 posts, read 50,545,612 times
Reputation: 18425
Your age??
Your state?
Are you going on Medicare because you are on SSDI?
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Old 08-21-2015, 01:15 PM
 
797 posts, read 1,385,421 times
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Quote:
Originally Posted by Ariadne22 View Post
Your age??
Your state?
Are you going on Medicare because you are on SSDI?
I'm under 65, in CA, on SSDI. Permanently disabled...
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Old 08-21-2015, 01:33 PM
 
Location: Wisconsin
23,621 posts, read 50,545,612 times
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The purpose of either Medicare Advantage/Medigap is to cap or mitigate out-of-pocket exposure. As you've said, because your hubby is considering an HMO, there is more (and expensive) red tape. Some HMO's allow you to self-refer, some don't.

Under 65 gives you no good inexpensive options in the Medigap/Medicare Advantage realm. I have read of MA's for the disabled costing about $365/mo. Medigaps - which would allow complete provider flexibility as long as the doc accepted Medicare - for the disabled under 65 are relatively rare.

In the end, if you're really worried about a worst-case scenario. you may be best off going with the HMO, and fighting with the HMO and/or Medicare when necessary, if charges are denied,

Also, if you haven't already done so, you might want to talk with a CA insurance broker about your situation.

Wish I could be of more help. Perhaps someone else here will have more concrete ideas.
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Old 08-21-2015, 01:51 PM
 
797 posts, read 1,385,421 times
Reputation: 656
Quote:
Originally Posted by Ariadne22 View Post
The purpose of either Medicare Advantage/Medigap is to cap or mitigate out-of-pocket exposure. As you've said, because your hubby is considering an HMO, there is more (and expensive) red tape. Some HMO's allow you to self-refer, some don't.

Under 65 gives you no good inexpensive options in the Medigap/Medicare Advantage realm. I have read of MA's for the disabled costing about $365/mo. Medigaps - which would allow complete provider flexibility as long as the doc accepted Medicare - for the disabled under 65 are relatively rare.

In the end, if you're really worried about a worst-case scenario. you may be best off going with the HMO, and fighting with the HMO and/or Medicare when necessary, if charges are denied,

Also, if you haven't already done so, you might want to talk with a CA insurance broker about your situation.

Wish I could be of more help. Perhaps someone else here will have more concrete ideas.
Thank u for the advice. There is a PPO that is offered (just learned about it today) for $30/month with a $300 deductible ($900 for the family) BUT the thing that scares me with the PPO is they don't cover lab work in full. I often have expensive lab work (most expensive I can recall was $5k.. Plus I've had MRIs and CT scans, etc).. The PPO covers 90% but even 10% of $5000 is still $500 I just don't know what to do. Finances are tight (as are most people's with medical problems lol)... So I don't want to break the bank... Ugh idk what to do!

Medicare recommended I call some "CHIP" program (I think is what it was called?) and left them a message but they said it can take up to 5 business days to get a response :-/
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Old 08-21-2015, 02:35 PM
 
Location: TOVCCA
8,452 posts, read 12,915,443 times
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Is the HMO you're considering Kaiser?
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Old 08-21-2015, 02:51 PM
 
797 posts, read 1,385,421 times
Reputation: 656
Quote:
Originally Posted by nightlysparrow View Post
Is the HMO you're considering Kaiser?
No, it is Anthem Blue
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