Medicare vs Private Insurance

[MoMoJo]

I think I am headed for an implant in a year or two. For now, I can achieve an erection with an overdose of Viagra (actually generic sildenafil, to be more precise), but it is taking more and more Viagra, risking serious side effects and the erection is not very dependable. My Dr. says when i get to 200 mg of Viagra I have to stop increasing the dose and try something else. I plan to skip the injections - not excited bout sticking a needle in my dick, and also worried about Peyroe's disease and creating a lot of scar tissue that will later complicate an implant.

I am 64 and can go on Medicare in a few months if I want. I am self employed, no plans to retire soon, and have good PPO health insurance through my wife's work. My first thought was to put off Medicare and stay on wife's insurance. However, after reading this board, it appears that Medicare with a supplemental plan (probably Plan G?) is likely to cover all or almost all of hte cost of an inflateable implant, whereas private insurance is likely much harder.

I would like to hear from people who have had implants about their experiences with insurance. Is Medicare coverage a given? Any gaps in coverage to be aware of? What is best supplemental plan to get? I am still pretty confused over the many supplemental plans. I hear lot about Plans A,B, D and G, but what about all the missing letters?.
Any advice would be much appreciated. At this point, my goal is to get an inflateable implant in 1-2 years using a well established high volume surgeon and getting as much of the cost as possible paid by insurer or Medicare.

[easymoney]

I have a United Healthcare Medicare Advantage plan here in fl. I paid a 270.00 co pay for my implant 6-2023.

[Gt1956]

It is my understanding that at 65 you almost don't have a choice on Medicare. The farther over 65 you are when you enroll. The higher the monthly premium will be....for life.

Depending on your current insurance situation. You might want to look at Medicare along with an Advantage plan. Perhaps your insurance representive is the best source to explain your options.

[newbie443]

I had both of my surgeries done with self purchased insurance. My insurance was an EPO plan. Basically insurance covered it (well some of it) and they told me who I had to go to for it. Same with anything else I had trouble with. In other words Insurance controlled my medical care. I decided to self pay for my first surgery as surgeon selection was so poor. And it took over 3 years to get get them to pay for my repair. My understanding is that advantage plans are like this. If you live in a high population area and some really good doctors take your insurance or advantage plan then you have little to worry about. My understanding is that with a part G plan like I have now I can go anywhere in the US that accepts Medicare. This opens up many of the top doctors in the country to me. Not just for my implant but for other things as well. As I am in a low population area and the really good doctors are not looking to set up shop close to me I had enough. Advantage plans are advertised a great deal not to offer some of us more coverage than part G. They do it to make money by controlling our health care to reduce costs and make insurance companies more money. The part D plans that come with them are like a drug buying group that gives you a bit more discount over paying outright.

Check with your doctors (all of them) and see if they accept advantage and if your level of care changes. Not sure they will be honest with you but it does not hurt to ask. If you do not have a very good implant doctor close to you make sure you can still go to the doctor you want to and get the level of treatment your doctor thinks you need not the level of treatment the insurance company wants to pay for.

[Old Guy]

Medicare Part A is given to you when you turn 65. I don't think you have to sign up for it. Medicare Part B is the one you have to enroll in, and the cost is deducted from your SS check. I imagine there is a private pay method since you aren't retiring and won't have a monthly SS check. Medicare Part B is the insurance that covers surgeries, medical supplies, etc. As mentioned, the longer you wait to enroll in Part B the higher the monthly cost. Or look into a Medicare Advantage plan.
With your wife's insurance and Medicare Part B you should only need to pay the max out of pocket cost. This year I believe that is $266. Medicare Part A does not pay anything for an elective surgery.

[Floridaspeedo]

It is my understanding that at 65 you almost don't have a choice on Medicare. The farther over 65 you are when you enroll. The higher the monthly premium will be....for life.

Depending on your current insurance situation. You might want to look at Medicare along with an Advantage plan. Perhaps your insurance representive is the best source to explain your options.

Not exactly true. You don't have to sign up for Medicare at 65 if you have other coverage. The same is true for drug coverage. You need to look at the cost of both plans and make an informed decision. If you lose your employer coverage then yes you need to sign up for for medicare. Let's face it. The govt. would prefer you not be on medicare.

[Erwillian]

I would advise you to check out a Medicare Advantage plan, especially any with five star ratings, and particularly if you have access to one in your area that is run by a non-profit.

In my case, my private insurance required me to go on Medicare at 65, and then the private insurance became a Medicare "supplement" plan, which was suboptimal. I'm in New England and I ditched the private insurance and signed up with a regional 5 star non profit plan, with zero additional premium, and the experience has been incredibly positive.

I had an implant (AMS) last month at age 68. So far I am a *very* happy camper! The hospital (a participating provider) billed $67K and my copay is $250. I worked extensively with the Medicare advantage plan and the cost estimating department in the hospital to identify the cost before the surgery. It wasn't a simple and quick answer. Medicare is incredibly complicated.

I think Medicare requires preauthorization for an implant. If the procedure is performed as outpatient, the cost of the device itself is apparently rolled into the hospital charges. My procedure was classified as "outpatient in a bed", meaning I was discharged the next day.

Do be aware that Medicare coverage can vary somewhat depending on where you live. You can get Medicare advice from your local State Health Insurance Assistance Program. Be careful: if you are actually required to enroll, including drug coverage, and you don't, you can get socked with penalties later.

Hope this helps!

[LMCatman]

My first two implants were with Humana - before I was old enough for Medicare. My second two were Medicare. My co-pays were low enough that I don't even remember them.

I believe was covered because I was "Post RP". I think their thinking (did I really say that?) is that it is similar in concept to a woman's breast reconstruction after a mastectomy. It makes her "whole". It makes us "whole".

No regrets!

Good luck man!!!

[MoMoJo]

Thanks to all who responded!

It seems like Medicare plus Plan G is most likely to cover the implant and woudl give me the greatest freedom to choose doctors wherever they are. I think I can get a great plan for no more than I am paying now to be on my wife's private insurance. I just need to nail down the nubmers and execute.

[happycamper59]

Momojo....
I recently went on Medicare, and added a Medigap (supplemental Plan G). My surgery is scheduled for next month and it looks like it will all be covered. However, I do pay about $110 per month over the Medicare cost for Medigap. But with a very small deductible, it looks like it will be worth it. The Advantage plans are pushed by the insurers because they make the most $$ on them. Sounds good to have zero premium, but it comes with a big cost to you after that, such as very high deductibles and you may not have the choice of doctors and hospitals that you do with Plan G. I would recommend Medicare and a Plan G.