Hi Toni,
I have just been diagnosed with Stage 3 CKD (Chronic Kidney Disease). I’m concerned about dialysis treatment and cost if I reach Stage 5, which is called ESRD (End Stage Renal Disease). Currently, my husband and I are members of a Medicare Advantage HMO. I take extensive RX meds and it seemed like a good fit because most of our Doctors are Providers on that plan. I am now in the coverage gap and generic drugs are at no cost.
The co pay for each dialysis treatment on this Medicare Advantage HMO is $30. Dialysis is usually required 3X per week with $$$$ maximum out of pocket. So I’m trying to decide if I should go back to regular Medicare and purchase a Medicare supplement with a standalone Part D Medicare prescription drug plan.
Any advice you can give me would be greatly appreciated.
Thank you, Mary… A Memorial Examiner reader
Hello Mary:
Most receiving their Medicare benefits from Medicare Advantage plans, do not realize that their plan has protection from spending a lot of money on co pays until they have a serious illness like you have. They are surprised when they are paying a lot on co pays.
Your Medicare Advantage plan has maximum out of pocket which is much less than being on only “Original Medicare”.
Let’s talk about applying for a Medicare supplement when you have a serious illness. If you are past 65 and 6 months, you are not in a Medicare supplement’s guarantee issue period and you must answer health questions. Serious illnesses such as cancer, COPD, Alzheimer, MS, lupus, heart or vascular conditions including stroke, insulin dependent diabetes and even the current problems with your kidneys can keep you from qualifying for most Medicare supplements. But…there are some Medicare supplements which can accept applicants with serious health conditions. These Medicare supplements may have a 90 day pre-existing clause for any type of medical treatment you have had and will not be covered for the first 90 days of the policy. Since you will be on “Original Medicare”, you will have to pay for the Part A & B
co pays or deductibles out of your pocket for any pre-existing medical treatments that the “new” Medicare supplement will not cover for the first 90 days.
The positive side to being on “Original Medicare” with a Medicare supplement is that you can go to any doctor or Medical provider including dialysis centers that accepts Medicare anywhere nationwide, not just the Houston area.
Currently, you belong to a Medicare Advantage plan that your doctors/providers are included in the network. I know this Medicare Advantage plan very well and even though your kidney dialysis will have a co pay. I am seeing many of the Medicare Advantage plans have a percentage for outpatient benefits such as 20% until you meet your Medicare Advantage Plans maximum out of pocket.
You will not spend any more out of your pocket for your medical needs until January 1 of that next year. Remember you must stay in network. Some plans have out of network benefits and those costs are more than when you are in-network.
My advice to you would be:
- Talk to your doctor before you make any changes to your Medicare.
- See what the cost will be for a Medicare supplement that accepts your health situation.
- Be sure of the cost for your prescriptions if you change Medicare Prescription Drug “Part D” plans. You might spend more on your prescriptions.
- You have until Medicare’s Open Enrollment ends Sunday, December 7th, to make a change from your Medicare Advantage plan to “Original Medicare” and enroll in a standalone Part D prescription drug plan. Don’t wait until the last minute.
Toni King, author of the new Medicare Survival Guide®, which is a simple guide explaining Medicare is on sale at www.tonisays.com. Email questions to www.tonisays.com/ask-toni.
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