I feel overinsured and it’s costing me money. I am wondering from other users of the forum whether it is common to ever break that enormous level of copays and what situations cause them to actually have such copays?
In the United States: For 8 years since getting Social Security Disability and Medicare, I’ve had both good old Medicare parts A+B+D. And by good old Medicare, I mean GOOD, AWESOME OLD MEDICARE. I can see any specialist I want without referral. I didn’t get trapped in a terrible disadvantageous medicare plan that in the U.S. is given the doublespeak name of “medicare advantage plan” wherein a general practitioner is incentivized by money bonuses at the end of the year if they don’t refer you to see a specialist.
I have also paid to have a Medicare Supplement plan. If you haven’t had one yourself, then you cannot provide a knowledgeable reply that contributes to this discussion. But in case someone is reading and wants to know what that is, it’s a plan that covers the 20% copays for doctor visits. Mine is they type with a huge deductible, called a “High Deductible F Plan”. I would have to spend approximately $2500 just on copays in 1 year before my plan would start covering my copays.
I haven’t come close to breaking my deductible in 8 years, and the cost of maintaining the secondary insurance is feeling like a long waste of money that could have been much better utilized. I am wondering from other users of the forum whether it is common to ever break that enormous level of copays and what situations cause them to actually have such copays?
I initially thought that autoimmune diseases run in herds and I would have expensive copays for disasterous autoimmune diseases that followed the psoriatic arthritis. While there have been additional autoimmune diseases that spontaneously appeared out of nowhere and piled on the psoriatic arthritis, they have been mostly short-lived or have minor symptoms. None of the additional autoimmune diseases caused a substantial increase in my copays for a given year. I do seem to get about 1 new short-lived autoimmune disease a year. As of today none of the additional ones have produced any symptoms in the past 9 months.
I have never been hospitalized in my life, ever. With good old medicare, that’s usually one of the expensive things that can cause approximately $1200 in copays.
For me, the extra insurance seems like a waste of money, though it probably was diligent of me to have it for the first few years just as protection since I was new to having autoimmune problems.
Do people here have supplement plans? What would cause someone much younger than 65 to need a supplement plan? (At 65 if good Medicare is still around, you can elect to buy a supplement plan again.) How much are typical totaled out-of-pocket copays for all doctor appointments for all health conditions in those with the awesome good old Medicare having PsA (and whatever additional diseases you have)?
Hi @Courtney.S! I cannot directly contribute to this discussion. However, there is an amazing show on Doctor Radio on Sirius XM that is called Healthcare connect. An insurance specialist can answer all of your questions and I believe that they are on are on Thursdays from 12 to 2. This is the link to his Twitter page and information. He might be a really good resource, whether it not you have Sirius XM
Hi Courtney, and welcome!
That is quite a high copay for your Medicare supplement, I think. I’m having a personal battle making the decision to retire—all because of the fact I don’t think Medicare or a supplement will pay for my Enbrel. So for now I’m sticking with the insurance I get through my job.
However, my husband is on “good old Medicare” and a supplement. It’s not called Medicare Advantage, though—his supplement is Blue Cross Blue Shield. It cost $198 per month. His copays are minimal ($5 per doctor visit, $20 for a specialty such as P.T., $50 if he’d need an ambulance, small copays for medicines, etc., etc.). We think it’s an okay deal.
I would retire tomorrow if I could continue to get Enbrel as inexpensively while on Medicare and a supplement, but I don’t think that’s possible. I read about a program for retirees that covers Enbrel and some other biologics, except if you have any money in savings (401K, etc.) you would need to use that up for copays first. Our savings is our ticket to doing anything fun or pay for home upkeep and improvements. Life would be pretty blasé if we didn’t have that nest egg to fall back on.
If anyone out there can provide more info about this subject, please do!
Hi Grandma_J. Thank you for the reply. I did not actually post the monthly premium cost of my supplemental insurance because it’s the doctor visit 20% copays and their deductible that is my primary concern.
As for your Enbrel medication copays (a whole other issue in good old medicare), you might try calling the Enbrel Patient Support program. They would have a better idea based on your retirement income whether you might qualify for a lower copay program to get you through something called the “donut hole”.
Hi Courtney. I do benefit from the Enbrel Support Program. I don’t pay anything for my Enbrel. But Enbrel Support stops when a person retires and goes on Medicare. It’s only for people with a private insurance policy. Unless something has changed. Do you still get Enbrel Support?
The only way we can know for sure is if you call and find out for yourself. Maybe you will qualify for some assistance coving the “donut hole.” After that it will be a 5% copay. You can look up what a “donut hole” is or they can explain it.
My rheumy told me he had a PsA patient who had the same concerns as me about affording Enbrel while on Medicare. So the patient did all the research - supposedly- and went ahead and retired, thinking he had coverage for the “donut hole”. Unfortunately, because he had savings (401K) in the bank, he found out after the fact he had to deplete his savings before he’d get complete coverage for his Enbrel. I’m glad my rheumy told me that—I want to retire eventually, but I can hold out for awhile yet if I have to.
I have awesome supplemental and basicly have no out of pocket. My Dr bills are very high because I have Remicade infusions at cost os 9k each time. My Medicare supplemental ins Pan F through AARP United Healthcare . Highly recommend. Good luck.
Also the extra Help program for drugs has been expanded though most people don’t know about it:
There is NO ADVANTage to an advantage supplements hey are cheap and you get LESS than you pay for. Your best bet is a regular supplement and Silver script for drugs there are two silver scripts get the good one.
I cancelled my Medicare Supplement in fall 2019 and have not needed it since. I wasted a lot of money on it because my conditions are handled by outpatient appointments. I would need to be hospitalized regularly several times a year in order to have benefited from the Supplement and after 10 years with this disease, that hasn’t happened.