Medicare insurance question

This is not specifically a Q about diabetes but I’m sure there are folks on this forum who will know the answers I’m looking for.

My wife and I are in our mid 70s. For years we have had a Medicare advantage HMO insurance plan. Any and all medical care we get must come from in-network providers or it won’t be covered. It’s renewal time and we are considering an alternative.

There is a small chance my wife could need treatment and possibly major surgery by specialists our HMO network would not cover. If we decide to hedge our bets, one way, I guess, would be NOT to renew her HMO plan but revert to Original Medicare. Then we would also consider some sort of medigap plan.

I’ve read the Medicare and You 2022 book that just came in the mail and I’m confused about medigap plans. The book seems to be written mostly from the viewpoint of someone just beginning to use any form of Medicare, not someone our age, who might be thinking about medigap now, after years of not using it.

I can’t figure out if the fact that my wife is already seeing specialists in our HMO for a possible problem qualifies as a “pre existing condition”, and if so, would it disqualify her from buying any sort of medigap plan?

IMO your wife would definitely have “pre-existing conditions” and it is unlikely that she would be accepted by a Supplement plan. But I suppose the best thing to do would be to contact an independent Medicare agent and/or your state SHIP office. There are a few states which do not allow Supplement plans to consider pre-existing conditions but I don’t think SC is one of them.

My understanding is that Advantage plans do not take into account pre-existing conditions so maybe you can find a plan that might better suit her needs.

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Thx. Pretty much what I suspected also. I need to learn more about the various PPO plans we could consider. Something that would help if we end up needing something like Mayo.

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My supplement plan in Minnesota has several riders that I pay extra for. One of them is coverage at Mayo since they are able to bill higher than normal Medicare rates.

Followup Q on pre-existing conditions.

Clearly I’ll eventually have to ask an insurance company this, but if I do that now, it would be like asking my best friend “Hey, Bob, you didn’t know I’ve been sleeping with your wife, did you?” And when he goes “No, Tom, I didn’t know that,” I go “Well, then, forget I even mentioned it.”

If my wife sees a specialist because she thinks she may have a problem, and her family doctor referred her to the specialist for that reason, and the specialist does some tests and does not diagnose that she has the problem, would THAT constitute a pre-existing condition to an insurance company (which by definition will try anything to get out of paying for anything). What d’ya think? Or would it only be a pre-existing condition after her medical record includes an actual diagnosis of the problem?

You really need to talk to an independent agent and/or your local SHIP. I assume that the ultimate test would be applying for a Supplement plan and see if she is accepted. I am not quite sure of how quickly that happens but an agent could help you. If she was denied a Supplement hopefully she can find a better Advantage plan. Or do the math and see if you can afford the 20% cost that Medicare doesn’t pay. In future years she can always go back to an Advantage plan.

I suspect this article will make you feel more frustrated than you already are. But IMO it is a crime that seniors are paying hugely different amounts for healthcare because we don’t have the “same Medicare.” And people on Advantage plans don’t really have Medicare.


Good idea re SHIP. Also an independent agent.

As for the math, the issue now is the risk of needing major surgery. In-network with an HMO might not be the best medical care and expertise she could get. Going out of network to nationally recognized specialists via orig Medicare without medigap leaves us with 20% of a ginormous financial risk. I don’t need an abacus to do that math! :scream:.

Lots more homework to do.

Thx for your help.

I hope you find a solution that balances affordability with the best medical care for your wife. :blue_heart:

We do too! Thanks.

Tom have you come to any decisions? We are just starting to look at an HMO plan. We are 70 and 72 and we kept my husband’s university insurance after he retired which was excellent along with Medicare. Now this plan is over $800.00 monthly to cover both of us, and that seems ridiculous.

The HMO plan is United and it costs $49.00 dollars each. Two of our specialists aren’t covered. They cover CGM ‘s 100% and cover Tresiba at about the same copay as I pay now. I would have to switch back to Humalog insulin from Novolog, but I have made that change before with no problem. The CGM’s are sent by a company I have never heard from and I love US Med.

I need to explore Medicare to see what they would cover for these specialists and I need to call those doctors to see if they are considering using United since it is brand new to our area.

So much to research. We are used to having almost everything covered 100%, but realize that we are paying way too much for that privilege.

Hi. I share your frustration at the complexity of it all! I’m not sure what we’re looking at will help much since everyone’s situation is different. But here’s where we’re t right now.

We’re 77/76. I’m diabetic on a Tandem pump, Dexcom G6, and Novolog. I’m probably going to renew the Humana HMO I’ve been on for several years. It has a $0 premium. Every one of my diabetic items is covered by Medicare Part B, not as Medicare Part D. My other regular prescriptions are covered by the Part D part of my HMO, but the total annual cost, much less my meager share, is hundreds of dollars, so the Part D coverage I get is nearly negligible.

So far I’ve been lucky that if I did need a specialist I could find it in our HMO network. Even when it turned out I needed specialist prostate cancer treatments, one of the best anywhere in the US is in our network! Can’t get much luckier than that!

I pay 20% copay for my diabetic Part B items. The total annual cost for my diabetic items will pbly exceed $10,000 and unless I paid for a medigap plan to cover the 20% Medicare doesn’t cover, I’m liable for 20% of that. Trouble is, all of the medigap plans we’ve seen cost more annually than the 20% for my diabetic stuff so it’s still cheaper for me to just pay the difference myself.

My wife is looking at a PPO instead of just renewing the Humana HMO we’ve both had for several years. She is experiencing some increasing difficulties requiring specialists amd a PPO would let her go out of network. In SC we do have access to some PPO plans with $0 premiums, but with higher out of pocket annual limits. And they do still include Part D, which she needs to about the same extent I do (I.e., not very much, not much of a decision factor).

We found a local office of Blue Cross Blue Shield where we could make an appointment to talk to (actually listen to :laughing:) a human talk about their plans. That helped a lot since we could pepper him with questions and get answers on the spot, whether we wanted to consider BCBS or not. Maybe you could do that. We’re also seeing independent agents setting up shop in local Walmart’s, etc. They’ll talk to you too about a range of alternatives, not just one company’s plans.

I hope I’ve helped a little. Good luck!

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Thanks Tom. I am frustrated at how difficult all of this is for older people. So many choices which take so much research. While we are quite capable of making these decisions, I feel terrible for people, who for one reason or another, aren’t capable of figuring this out.

We have just started the process.We did have an independent insurance rep come to our house, and he thinks that United is the best way to go for our situation, although he gave us information about other plans. I found out that my eye specialist is covered through some of the United plans, but not this one. I need to call our gastroenterologist to see if he is covered since my husband has had esophageal cancer. He has also had prostate cancer, so we can’t just take a chance with having to cover the 20% ourselves over what Medicare pays. We could travel to Seattle where my husband had his two surgeries and be covered, but we would rather not have to travel.
We might be better off paying for our expensive insurance just for peace of mind. I don’t know. During all four of my husband’s bouts with cancer we have never paid anything but the small yearly deductible, and of course our expensive premiums. During our future years the last thing we want to worry about are medical expenses. If we were healthier, it might be different.

Obviously I need to continue to research this. Thanks for explaining your situation, it really did help and gave me more ideas to find out about.

The infuriating part of this is that it’s different in Every state.
I can’t look at your situation and say” yea I’ll do that” because it’s likely different where I live.

I still have 9 years before Medicare if they don’t reduce the age. The could reduce it to 60.

It took me long enough to figure out regular insurance where I only have 2 choices at work.

Medicare seems daunting

I bet I could get educated and become a Medicare and health insurance consultant for people.

I’m guessing that exists but I don’t know for sure

Medicare is so daunting that it is ridiculous. And yes, I bet you could train to explain policies to people and make money doing so. We had one guy come to our house and also our insurance man is helping us.

We are very tempted to just keep our state insurance policy which costs a lot more, but in the last 10 yrs we have had 5 cancers, 2 being very serious, diabetic retinopathy and have seen many specialists all without having to call doctors and hospitals to see if they are on our plan. Everything has been 100% paid for. I have never once had to worry about my Dexcom products arriving on time. Oh yes, 11 yrs ago I needed heart stents.

Until 51 yrs with type 1, 1 was fine and until 61 my husband was perfectly healthy.

At 70 and 72 we want easy.