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Thread: What does SRT cost / what does Medicare Pay?

  1. #1

    What does SRT cost / what does Medicare Pay?

    I currently have Florida Blue Shield Medicare Supplemental Plan F, which will cost me $222/month in 2020. Plan F pays EVERY dollar not paid by Medicare A & B. I have $0 out of pocket expenses with Plan F.

    I am being inundated with offers to connect me to a Medicare Advantage HMO or PPO with monthly premiums ranging from $0 to $42 (Humana & Florida Blue are particularly aggressive!). Those Advantage Plans provide basic Dental and Rx coverage that is somewhat comparable to the coverage I have now which will cost me $133/month in 2020. The annual Maximum out of pocket expense for the HMO is $5,000 and $5,900 for a regional PPO plan.

    All my current doctors/clinics/hospitals are part of both Florida Blue and Humana Advantage networks as is my dentist and pharmacy. The sales people are telling me I can keep my doctors, I won't need specialist referrals, and nothing will be different if I choose one of their HMO or PPO plans AND I will save between $213 and $355 / month on premiums (Plan F, Rx, Dental). And, they give me one vision exam a year and $100 per year for eye glasses.

    That all seems like a pretty good deal ...

    HOWEVER, IF I do need SRT in 2020 the HMO/PPO plans require I pay 20% of the cost of the 33-Radiation sessions plus the setup CT and RO expenses. The financial adviser at the radiation clinic where I met with an RO told me a "typical" bill for post-RP SRT could range up to $35,000 or roughly $1,000 per session. She strongly recommended I keep my Plan F in order to fix my costs.

    What is the maximum allowable Medicare billing amount for 33-SRT treatments (66-Gy) and the CT setup and fiducial placement for a "typical" SRT series?

    I can keep my Florida Blue Plan F as long as I want but once I switch over to any other plan - I will never be able to go back to Plan F.
    DOB: July 1947
    PSA: 2.0/2004 4.0/2010 5.8/2010 4.5/2012 5.6/2013 Normal DRE
    5/18 PSA: 9.2
    6/18 PSA: 10.2 & 8.4% Free
    6/28 3T mpMRI PIRADS 3
    18 cc gland=PSD 0.57 ng/cc
    0.32 cc lesion in apical PZ with subtle T2 signal hypointensity
    mild restricted diffusion of contrast into lesion prostate unremarkable intact capsule
    7/18 4KScore 34% Probability Gleason =>7

    8/03/18 Bx: Adenocarcinoma 6 of 13 cores ONLY L lobe
    T1c / Grade II / unfavorable intermediate
    extent of G3-G4 tissue far greater than indicated by MRI
    G6 (3+3) 70% LL Base 50% L Lateral Mid 20% L Base
    G7 (3 +4) 100% LL Apex 20% L Mid 60% L Apex
    8/15/18 Clear CT scan and Bone Scan
    RALP 8/23/18 pT3a, G7 (3+4), 20% involvement, SM+ (Focal 2mm G6), EPE(Focal G6)+, PNI+, LNI-, SVI-, LVI-
    7g Tumor 20x size in MRI & biopsy report & in BOTH lobes not just L as biopsy reported

    PSA
    10/3/18 0.021
    01/4/19 0.018
    04/03/19 0.022
    06/26/19 0.028
    10/1/19 0.035

    Decipher RP = 0.47 Average Risk

  2. #2
    Top User
    Join Date
    Aug 2016
    Posts
    1,929
    My understanding is you want to keep your current plan. It is my plan as well. For you, certainly through this next phase of your treatment if you can afford it.

    The advantage plans have costly limitations to make them less expensive. I'm not saying they are bad plans, but more affordable for those who need them to be less expensive. With it comes higher risk of out of pocket expenses which is troubling for some ederly who will need more expensive services as they age.

    If you have disposable income to cover the risk of copays it is a different conversation, but as we age the risk of higher medical costs counters this position. Medicare with the supplemental Plan F (or G) is the best medical insurance deal around, imo.

    There is no good deal. Only one deal vs another.
    Last edited by Another; 10-31-2019 at 05:34 PM.
    Born 1953
    family w/PCa; grandfather, 3 brothers
    07-12-04 PSA 1.90
    07-10-06 PSA 2.02
    08-30-07 PSA 3.20
    12-01-11 PSA 5.69 Internist recommends urologist, I say no
    05-16-12 PSA 4.76 manipulate w/diet & supplements
    12-11-12 PSA 5.20, Health system changes to 3 years on testing
    03-07-16 PSA 7.20 Internist adamant on urologist
    DRE smooth, enlarged
    03-14-16 TRUS biopsy-prostatic adenocarcinoma 1%-60% across 8 of 12 samples, Gleason 3+3=6
    03-31-16 MRI pelvis w/o dye
    05-04-16 DaVinci prostatectomy, nerve sparing, Dr. Kent Adkins - recommend
    Final Path; weight 65g, lymph nodes, seminal vesicles, capsule, margin all negative, Gleason 3+4=7, Tumor volume 35%, +pT2c
    Catheter out - 16 days
    Incontinence at 6mos is minimal – no pad
    Cialis 3x/wk & Viagra on occasion
    Begin self-injection needle therapy for erections, stop after 6 due to onset of Peyronie’s
    Erections 100% - 14 months
    5-21-19 PSA <0.02, Zero Club 3.5 years

  3. #3
    I agree. If you are in great health the advantage plans are good. After a cancer diagnosis, not so good.
    YOB 1957

    DX 12/18, GS 8, 4+4 6/12 cores, LL Apex 100%, LM Apex 60%, LL Mid 50%, LMM 40%, LL Base 5%, LM <5%, Right side negative.

    3/6/19. Pathology - Grade Group 4 Intraductal Carcinoma
    T3aNO, 1 mm EPE, GS8, 21 mm uni-focal tumor involved 10% of prostate.

    7 Nodes, SV, SM, PNI, and BNI were negative.

    LVI and Cribriform pattern present.

    Decipher .86 High Risk.

    Post Surgery PSA
    3/25/19 .03. (<1 month)
    4/25/19 <.03. (2 months)
    5/25/19 <.02. (3 months)
    9/10/2019. <.02. (6 months)
    11/27/2019. <.02. T<3. (9 months)

    3 Part Modality Treatment

    2/25/19 Robotic Laparoendoscopic Single Site Surgery outpatient Cleveland Clinic,

    ADT - started 6/19, end date 6/21.

    ART - Completed 9/26/19. (78 Gy, yes, I glow in the dark)

  4. #4
    Hi OTS! A few points/observations:

    - The degree to which those approaching age 65 and older are "assailed" by providers of Medicare Advantage Plans (MAPs) is proof positive that the providers stand to make a lot of $s through their MAPs. (Hope I haven't offended Joe Namath!)

    - Re "The sales people are telling me I can keep my doctors, I won't need specialist referrals, and nothing will be different ..." Hmmm... Didn't we hear this exact verbiage back in 2013 from the Chief Promoter of The AHCA?

    - Dental & Vision are not included in any Medicare Supplemental Plans (as you are aware). This can make a MAP appealing. Most Dental Insurance Plans offered to help those on Medicare may not be worth the cost. Check with your DMD practice administrator. One may be better off setting aside $50/month to cover current and future dental expenses.

    - A very important consideration if you leave your Supplemental Plan F and switch to a MAP: What happens if you later decide to switch back to Supplemental Plan F (or other "Letter" Plan)?

    1. For certain, your monthly Plan F premium will be higher than before. Also, Plan F is about to go away. So staying in may be advantageous.

    2. If you undergo SRT or develop another illness or disease while on a MAP, you may get rejected from qualifying for a Supplemental Plan due to pre-/existing condition.

    - Re "Those Advantage Plans provide basic Dental and Rx coverage that is somewhat comparable to the coverage I have now which will cost me $133/month in 2020." PLUS your $135/month Medicare Part B Premium => $238/month (of course you still are paying the $135/mo Part B premium regardless of whether you have a MAP, Supplemental Plan or standard Medicare alone)

    - Re "IF I do need SRT in 2020 the HMO/PPO plans require I pay 20% of the cost of the 33-Radiation sessions plus the setup CT and RO expenses:" Let's say the total Medicare negotiated billings = $40,000. Does this mean you will pay $8,000 out of pocket or $5,000 (HMO) / $5,900 (PPO)? In the latter scenario, the Max OOP will cost you about $425/month when spread out over 12 months.

    A neighbor, who is a former major hospital administrator and now retired, unexpectantly underwent both HDR-BT & a Triple Bypass operation in 2019. He is on Medicare with a Supplemental (F or G) and paid close to $0 out of pocket. My guess is his total hospital, MD, Surgeon, anesthesia, physical rehab bills paid by Medicare exceeded $200K. I will get an approximate $ figure that next time we're together.

    The point is: If he only had Medicare Parts A & B, he would now owe an extraordinary amount of $!

    I am looking seriously into Supplemental F (going away soon!) or G. Currently, I have fairly comprehensive Medical, Dental & Vision coverage through my wife's insurance for $67/month with a $4,000 OOP maximum. I have had almost $0 annual medical expenses since RP. However, a single "event" can very quickly max out OOPs & co-pays. So moving to a comprehensive Supplemental Plan now may make very good sense.

    Last item re Medicare: *For those > 65* and covered by private health insurance: Be sure to check that your Prescription Coverage is deemed "Creditable" by Medicare. If it is deemed "Non Creditable," you must sign up for a Medicare Part D Rx Plan. If you do not, you will be charged 1% if the monthly premium for every month that you are >65 yo without Creditable Drug Coverage for the rest of your life!!!

    Back to OTS:

    - Apologies for not answering your specific question on the total costs of SRT! This is a government negotiated rate and the $35K for SRT is likely accurate. You did your homework well, by checking with the RT Clinic administrator. Good job and TY for sharing!

    - It is quite refreshing that you and I for once are not bickering about (+) Ms, EPEs, BCR definitions/implications or 3rd decimal values in uPSA results!!!

    Hoping that SRT remains off of the menu in 2020!

    Let us know your 2020 healthcare coverage decisions by Dec 7.

    MF
    Last edited by Michael F; 10-30-2019 at 04:41 PM.
    PSA: Oct '09 = 1.91, Oct '11 = 2.79, Dec '11 = 2.98 (PSA, Free = 0.39ng/ml, % PSA Free = 13%)
    Referred to URO MD
    Jan '12: DRE = Positive: "Left induration"
    Jan '12: Biopsy = 6 of 12 Cores were Positive: 1 = G7 (3+4) and 5 = Gleason 6
    Referred to URO Surgeon
    March '12: Robotic RP: Left: PM + EPE. MD waited in surgery for preliminary Path Report then excised substantial left adjacent tissue(s) down to negative margins and placed 2 Ti clips for SR guidance, if needed in future.
    Pathology: Gleason (3+4) pT3a pNO pMX pRO c tertiary pattern 5 / Prostate Size = 32 grams / Tumor = Bilateral: 20% / PNI: present
    3 month Post Op standard PSA = <0.1 ng/ml
    1st uPSA at 7 months Post Op = 0.018 ng/ml
    uPSA remains "stable" at 91 Months Post Op: Mean = 0.022 (22x uPSAs: Range 0.017 - 0.032) LabCorp: Ultrasensitive PSA: Roche ECLIA
    Continence = Very Good (≥ 99%)
    ED = present

  5. #5
    Top User
    Join Date
    Aug 2016
    Posts
    1,929
    While F is going away for those coming in, the replacement plan is similar except for a modest deductible. Congress decided there should be no public healthcare insurance plan that did not have a least some skin in the game meaning a deductible. So they ended the F plan eventually as an option going forward. You can keep it if you have it for now. And they replaced it with the G with a modest deductuble, $185 for 2019.

    I stuck with the F for as long as it will last. I assume I will then be allowed to migrate to the next one up, the G. G is still a very good plan. Just going to cost you an additional $185 a year in deductible, for now.

    It is conceivable the F plan may never end for those already in it, or the insurance companies will have the option to add a deductible to it up to the limit of the replacement plans current annual $185 deductible.
    Last edited by Another; 11-15-2019 at 02:41 PM.
    Born 1953
    family w/PCa; grandfather, 3 brothers
    07-12-04 PSA 1.90
    07-10-06 PSA 2.02
    08-30-07 PSA 3.20
    12-01-11 PSA 5.69 Internist recommends urologist, I say no
    05-16-12 PSA 4.76 manipulate w/diet & supplements
    12-11-12 PSA 5.20, Health system changes to 3 years on testing
    03-07-16 PSA 7.20 Internist adamant on urologist
    DRE smooth, enlarged
    03-14-16 TRUS biopsy-prostatic adenocarcinoma 1%-60% across 8 of 12 samples, Gleason 3+3=6
    03-31-16 MRI pelvis w/o dye
    05-04-16 DaVinci prostatectomy, nerve sparing, Dr. Kent Adkins - recommend
    Final Path; weight 65g, lymph nodes, seminal vesicles, capsule, margin all negative, Gleason 3+4=7, Tumor volume 35%, +pT2c
    Catheter out - 16 days
    Incontinence at 6mos is minimal – no pad
    Cialis 3x/wk & Viagra on occasion
    Begin self-injection needle therapy for erections, stop after 6 due to onset of Peyronie’s
    Erections 100% - 14 months
    5-21-19 PSA <0.02, Zero Club 3.5 years

  6. #6
    Top User garyi's Avatar
    Join Date
    Apr 2017
    Posts
    1,459
    Quote Originally Posted by Michael F View Post
    ....A few points/observations:

    - The degree to which those approaching age 65 and older are "assailed" by providers of Medicare Advantage Plans (MAPs) is proof positive that the providers stand to make a lot of $s through their MAPs. (Hope I haven't offended Joe Namath!).....


    Back to OTS:

    Hoping that SRT remains off of the menu in 2020!


    MF
    That is one fine analysis, Michael, and befitting the detailed studies performed by OTS. You must be getting close to 65

    Best of luck OTS, with your insurance coverage, and your radiation decision!
    72...LUTS for the past 7 years
    TURP 2/16,
    G3+4 discovered
    3T MRI 5/16
    MRI fusion guided biopsy 6/16
    14 cores; four G 3+3, one G3+4,
    CIPRO antibiotic = C. Diff infection 7/16
    Cured with Vanco for 14 days
    Second 3T MRI 1/17
    Worsened bulging of posterior capsule
    Oncotype DX GPS 3/17, LFP risk 63%, Likelihood of Low
    Grade Disease 81%, Likelihood of Organ Confined 80%
    RALP 7/13/17 Dr. Gonzaglo @ Univ of Miami
    G3+4 Confirmed, Organ confined
    pT2 pNO pMn/a Grade Group 2
    PSA 0.32 to .54 over 3 months
    DCFPyl PET & ercMRI Scans - 11/17
    A one inch tumor still in prostate bed = failed surgery
    All met scans clear
    SRT, 2ADT, IMGT 70.2 Gys @1.8 per, completed 5/18
    Radiation Procitis, and Ulcerative Colitis flaired after 20 years
    PSA <.006 9/18, .054 11/18, .070 12/18, .067 2/19, .078 5/19, .074 7/19, .081 9/19, .116 11/19
    We'll see....what is not known dwarfs what is thought to be fact

  7. #7
    A couple things I have learned/confirmed since my original post:

    1) MF is correct about the future cost of Florida Blue Plan F IF I were trying to signup for it now. A new Plan F member with my characteristics would pay $249/month compared to my $222/month premium as a "grandfathered" Plan F member.

    2) My orthopedic practice has been trying to convince me to do a bi-lateral knee replacement (after seven prior knee surgeries and about 20-cortisone or OrthoVisc injections). I visited them yesterday afternoon to talk more about knee replacements and the subject of Plan F -vs- HMO/PPO came up. The PA, the nurse, and the billing financial adviser all told me the same thing - No matter what the the HMO / PPO tell me - the approval process for additional knee treatments is infinitely more complicated and difficult when my secondary insurance is an HMO/PPO compared to Plan F.

    3) My dentist (new crown this aftenoon) billing told me they charge the same for insured / non-insured patients. They than looked at the insurance payout for my wife and I for 2018 & 2019 and said the amount our dental insurance paid the practice was slightly less than what I told them I pay in premiums. AND, that does not include what we paid directly to an oral surgeon for work that was not covered at all by our dental plan (simple implant of stud for a tooth that was removed / root canal).

    4) Same thing for my pharmacy - the total of what Florida Blue Medicare Rx paid them the last two years is less than the premium I paid to Florida Blue. And GoodRx or similar discounters would greatly reduce any payout I might have to make.

    I guess Plan F along with NO dental insurance ($83/month) and NO Medicare Rx supplemental ($52/month) is the new plan for 2020.

    My wife is too young for Medicare and her Florida Blue individual policy does provide excellent Rx coverage.

    Good thing I am retired and that my sailing/bike riding/pickleball leave me enough time to ponder the intricacies of being an old fart and dealing with medical expenses.
    DOB: July 1947
    PSA: 2.0/2004 4.0/2010 5.8/2010 4.5/2012 5.6/2013 Normal DRE
    5/18 PSA: 9.2
    6/18 PSA: 10.2 & 8.4% Free
    6/28 3T mpMRI PIRADS 3
    18 cc gland=PSD 0.57 ng/cc
    0.32 cc lesion in apical PZ with subtle T2 signal hypointensity
    mild restricted diffusion of contrast into lesion prostate unremarkable intact capsule
    7/18 4KScore 34% Probability Gleason =>7

    8/03/18 Bx: Adenocarcinoma 6 of 13 cores ONLY L lobe
    T1c / Grade II / unfavorable intermediate
    extent of G3-G4 tissue far greater than indicated by MRI
    G6 (3+3) 70% LL Base 50% L Lateral Mid 20% L Base
    G7 (3 +4) 100% LL Apex 20% L Mid 60% L Apex
    8/15/18 Clear CT scan and Bone Scan
    RALP 8/23/18 pT3a, G7 (3+4), 20% involvement, SM+ (Focal 2mm G6), EPE(Focal G6)+, PNI+, LNI-, SVI-, LVI-
    7g Tumor 20x size in MRI & biopsy report & in BOTH lobes not just L as biopsy reported

    PSA
    10/3/18 0.021
    01/4/19 0.018
    04/03/19 0.022
    06/26/19 0.028
    10/1/19 0.035

    Decipher RP = 0.47 Average Risk

  8. #8
    Senior User
    Join Date
    Jul 2017
    Posts
    137
    Stay away from Advantage plans, unless you will never get sick. I'm afraid there are many people who get sold a bill of goods with Advantage plans. Everything is so confusing, they like the "free" price and all the goodies. Those goodies aren't free... you give up choices. You will need pre-approval for many things, which may not be given. Not all docs will take an Advantage plan (much like an HMO).

    I know some people love them, but as I always say... there's not a problem until there's a problem. Why take the risk to save a very few sheckles.

    I think they should be illegal to sell.
    Age 63 at Dx
    PSA History
    07/10 - 0.5
    05/12 - 0.5
    08/13 - 0.9
    02/14 - 1.2
    10/15 - 1.3
    07/16 - 3.3
    12/16 - 4.4 with Free PSA 52% (low risk)
    04/17 - 5.03
    08/17 - 3.5
    09/17 - 3.2
    11/17 - <0.01
    2/18 - <0.01
    05/18 - <0.01
    08/18 - 0.01 (CPL says they don't use the "<" any more. ???)
    10/18 - 0.02
    11/18 - 0.01
    01/19 - 0.02
    05/19 - 0.02
    07/19 - <0.02
    09/19 - <0.02


    Biopsy 07/11/17 PSA 5.02 T1c, revised to T3b after RALP
    Results 07/26/17 - Gleason 4+3 = 7 (two 4+3's, five 3+3's)
    RALP at MDA Oct. 23. Confirmed Gleason 4+3

    Pathology:
    Bladder neck (microscopic) and seminal vesicle involvement + large volume of PC, clear margins
    Bone Scan and CT Abdomen, lymph nodes are clear
    Decipher test result: .78 - High Risk
    Dry after six months post surgery.
    Axumin PET and Pelvic MRI are clean 11/09/18
    Completed 35 Proton treatments at MDA 03/28/19
    Considering AdVance Sling procedure


  9. #9
    Quote Originally Posted by mikesimm View Post
    Stay away from Advantage plans, unless you will never get sick.
    Hi mikesimm! I think you have simplified this issue perfectly into a succinct nutshell! TY!

    Re:

    07/19 - <0.02
    09/19 - <0.02


    Congrats again!!! Looks like The Protons have Beamed Back your missing "<" symbol! May it be cemented to the front of all future results!

    Doubtful if a Medicare Advantage Plan would have allowed for PBT!?!?

    Stay healthy

    MF
    Last edited by Michael F; 11-14-2019 at 09:44 PM.

  10. #10
    Senior User
    Join Date
    Feb 2019
    Posts
    293
    Great thread ! Was just thinking about my prostate dx and treatment as I creep up on my 64th birthday and need to start now looking ahead at Medicare and the various plans and options. My biggest concern is primarily the prescription part (though all my treatments options are important) with the cost of Lupron and any chemo my future may hold.
    Age DX 63 dob 1955
    8/11/16 CT scan (blood/sand in urine). Prostate norm w/cent calcification.
    11/6/18 GP freq urine/retro ejact. PSA 7.1 (RX Proscar/Flomax)
    12/18 PSA 4.1 14.8% Free Proscar? MRI Lesion 1.6cm. Lymph nodes sim to 2016 CT, prostate norm size. Stage 3. PIRADS 4
    1/19 Biopsy 2/5/19 DX
    2/19 Bone/CT scans: No evid met chest/abd/pelvis
    3/2019 RALP Cath out/post-op path rpt week later:
    G9 (4+5) (65-70% + 15-20%)
    Dominant tumor: 4.3 cm apex to base, bilat.
    LNI+ (4 of 12 on R, largest 4mm, 1 of 8 on L, 9 mm)
    EPE+ (right lat., post. and L lat. aspects apex to base and at ant. mid aspect)
    Intaraductal component+, BNI-, SVI+, LVI+
    SM+ (carcinoma unifocally extends to ant. mid margin area of EPE (2mm)
    Prostate fat: neg. pT3b pN1
    5/2019 Casodex 2-weeks. uPSA 0.11
    5/24 uPSA 0.11 Lupron injection
    6/19 uPSA .02
    8/7 began 39 sessions RT 70.2 Gy (last session 10/1)
    8/23 uPSA .01 Lupron injection
    9/27 uPSA <0.01
    10/22 uPSA <0.01

 

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