Insurance Enrollment Period

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petec

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My wife was diagnosed with ALS on 10/14/21. Needless to say we are overwhelmed. But with all the things going on we are hit with the Medicare open enrollment period for 2022. Currently she has Medicare as her primary insurance and AARP MedicareComplete as her secondary insurance. We don't know if this is the best insurance given this new diagnosis. We need to make up our minds by December 7.

So far the Dr. put her on Riluzole and mentioned edaravone. He said edaravone is covered by Medicare.

The Riluzole co-pay was $45. I saw on GoodRX that it could be over $300 so I guess this is good.

But I am concerned about when she starts edaravone. What does "Medicare covers" mean? I get infusions for Rheumatoid Arthritis. The hospital bills Medicare over $23,000. Medicare approves about $2,600 and pays 80% or about $2,100. My AARP supplemental plan pays the rest so I pay nothing. But years ago when I had a Medicare Advantage plan the Dr. told me my costs would go up significantly if I stayed in the same plan for the next year and recommended I change to the supplemental.

I have talked to her MedicareComplete people but I have little confidence in their answers.

Can anyone tell me what their experiences are with Medicare and insurance plans?

Thank You In Advance.
 

Nikki J

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Plans vary so much state to state. Every state has trained volunteer medicare counselors called SHIP counselors. Another resource might be a social worker connected with her clinic or your alsa. Since you attend an infusion center you might ask them if they know

you can likely figure out some of the costs to her current plan for infusions by careful reading of the plan documents. An advantage plan might be home visits rather than infusion center. Or not. I imagine copays could be an issue but eventually you must hit an out of pocket max.

you live in a state that will allow switching without underwriting or she hasn’t been on medicare very long?
 

lgelb

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Type your zip code into medicare.gov and you can get a list of MA plans and Part D plans that you can enter drugs into as well, to see annual costs. Generally, though, outpatient infusions are under Part B.

And of course you want to enter the hospitals/docs you use to see if they are in network. Generally the large national networks have more options (e.g. Blue Cross, UHC). You should also look at the quality ratings, though this is a flawed scale, to at least not consider any plans under three stars.

With a Medicare Advantage plan, medical and drug coverage is included within the same plan, instead of needing to buy Part B, a supplement, and a Part D separately. Each includes Part A coverage as well. The MA advantage is "skin in the game" as regards your medical and pharmacy costs as a whole, and fewer plans to deal with. The disadvantage is the inability to switch back to the supplement strategy for someone with a serious illness.

As Nikki says, the offerings vary by state, so we cannot generalize.
 

petec

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Plans vary so much state to state. Every state has trained volunteer medicare counselors called SHIP counselors.

I contacted the Tennessee SHIP. I had to leave a message. Call back could take 5 to 7 days. I also went to the website and left a message. Time will tell.
Another resource might be a social worker connected with her clinic or your alsa. Since you attend an infusion center you might ask them if they know
We don't have a clinic, her Dr will do it in his office. And when I questioned (via secure messaging), the reply was "they don't know". We have a return appointment in 23 days so I will try to get more info at the personal level.
you can likely figure out some of the costs to her current plan for infusions by careful reading of the plan documents. An advantage plan might be home visits rather than infusion center. Or not. I imagine copays could be an issue but eventually you must hit an out of pocket max.
I called her AARP plan just now. Ii spent about 10 minutes with someone who couldn't help and transfered me to another person. That person never came on the line so after 25 minutes I hung up. I think Monday is a bad day because people think about it over the weekend then call Monday AM.
you live in a state that will allow switching without underwriting or she hasn’t been on medicare very long?
Her medicare card says Part A since 06-01-2012 and Part B since 09-01-2013. Up until a week ago or so I was not aware of a problem if trying to change from an Advantage plan to a supplemental. I need to look into that.

Thanks.
 

Nikki J

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I would find out if your state allows changing without underwriting at this point. I believe the rule often is you can change FROM MA for the first year with guaranteed issue. If you can’t there is zero chance a PALS will pass underwriting It does vary by state so it may or may not be true where you live. But if you can’t change all the other questions become moot. There is an online organization ( insurance brokers) called boomerbenefits. You might ask them
 

petec

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Sorry for the delayed response. I haven't paid anything to be a member so my reply rate is throttled.
I have too many things to deal with at this time to be messing with payments. Forget about me.
 

Nikki J

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the limit is annoying and apparently implemented somehow by the software without the admin knowing. He said he was looking into it.

in the meantime please post when you want/ can. Eventually it goes away.

I hope you were able to find out whether she can change her plan at least so you know whether this issue is worth pursuing. Good luck
 
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