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Medicare and Health Care


*This is a non-medical board. This site shall not be used to seek professional, medical or legal consultation.

Medicare is health insurance for people age 65 or older, under age 65 with certain disabilities, and any age person with End-Stage Renal Disease (ESRD). There are many different parts to Medicare; with all of these options, it can be confusing.

This forum will allow members to share their experience with medicare and seek advice* on certain medicare-related situations.

To read today's top news stories on federal employee pay, benefits, retirement, job rights and other workplace issues visit FederalDaily.com.

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fedwife  
#1 Posted : Friday, February 22, 2019 4:54:23 PM(UTC)

Rank: Newbie

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Joined: 7/24/2008(UTC)
Posts: 6

Hello - We have been with high option NALC for some years. My husband decided to stick with it and Medicare A when he turned 65. I've got less than a week to make my decision and not have to pay a penalty for Medicare Part B. I've been close to what the premium would be for Part B the last two years, but not the previous years.

One concern I have is if Medicare doesn't cover something, and NALC does, NALC will pay 100% of their allowance for it, but we would have to pay anything over their allowance. We also wouldn't have the protection of a contracted allowance amount between them and the provider. There also isn't an out of pocket limit anymore. That is a scary thought to me.
Does anyone have any experience with having these two where they had to pay something out of pocket? I know it's supposed to be nothing out of pocket, but that isn't 100% sure.

I am very new here, so if I could have posted this in a better place of with a better subject, Place let me know!

Thank you in advance!
OUtside  
#2 Posted : Saturday, February 23, 2019 10:11:43 AM(UTC)

Rank: Senior Member

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Joined: 8/19/2008(UTC)
Posts: 912

Was thanked: 39 time(s) in 37 post(s)
Sorry, I thought initially you were asking about the rates for medical services and limits on out of pocket expenses for someone such as your spouse who has NALC and Medicare Part A only.

Out of pocket expenses are pretty much the same as prior to obtaining Medicare age with the added provision that Medicare rates would be used for dr services by NALC which, in effect, protect him on a charge by charge basis from paying more than his usual copays he would have paid at a younger age. Medicare rates are typically low, sometimes quite low. If you review his EOB's for dr services without Part B and the rules in the plan brochure explicitly for subscribers age 65+ who do not have Medicare (there will be a separate page in the brochure for this), you should see how this works.

But your question seems to be if you enroll in Part B and Medicare doesn't cover something, how would the plan cover it and would you be at risk of high out of pocket costs?

I don't think there are many instances where this happens and when it does happen, your regular plan benefits would apply, including limiting plan allowances for in network providers, which would protect you from high out of pocket costs, and continuing your plan catastrophic limitation protection. With Medicare Part B, your plan copays would be waived for Part B-type services (dr, lab, test, etc), so it would be difficult to reach your catastrophic limitation anyway, which is a good thing..

Still, if you know of a specific illness or condition where the benefit from Medicare may differ markedly, making you wonder if Part B would be advisable for you in that instance, you may want to ask NALC specifically for the best answer.
fedwife  
#3 Posted : Monday, March 04, 2019 8:32:11 PM(UTC)

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Joined: 7/24/2008(UTC)
Posts: 6

Hi OUtside,

Sorry to be thanking you so late. Thank you so much for your answer. Yes, the second question is what I was asking. I must have misunderstood what I was told by someone at NALC. It sounded like there would still be some out of pocket, without a contract or out of pocket limit anymore. I will call them back. What you say makes more sense. Thank you again.
OUtside  
#4 Posted : Tuesday, March 05, 2019 3:47:18 PM(UTC)

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Joined: 8/19/2008(UTC)
Posts: 912

Was thanked: 39 time(s) in 37 post(s)
It's usually a good idea but is even an excellent idea with something like this, to ask the representative for the page and paragraph in the plan brochure which answers your question in specific words. That way, you know you have have the chapter and official verse to refer to and, if necessary, to read again later to make sure you understand it, and possibly to come back in future with another question, if necessary.
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