Navigating the medical world as cancer patients is a difficult and stressful experience, often made more exhausting by insurance and prescription drug providers. While some of our members have health insurance through private insurance companies, many others deal with the federal Medicare system and its daunting regulations and guidelines.
Questions about Medicare coverage come up frequently for both new and existing members. Often people have questions about what’s covered, who’s eligible for what, how Medicare coverage works for those on disability and a host of other issues related to Medicare Part D prescription coverage. Due to the enormity of the issues and the often individualistic nature of the questions, we will only be able to provide an overview.
Please see Financial Aid page to learn more about Medicare, and to see a more thorough guide to online resources.
First, it’s worth reviewing some basics about Medicare coverage. The Medicare Insurance Program is available to
- People age 65 or older.
- People under age 65 with certain disabilities.
- People of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant).
Medicare Parts A & B:
||This pays for care in hospitals as an inpatient, critical access hospitals (small facilities that give limited outpatient and inpatient services to people in rural areas), skilled nursing facilities (not custodial or long-term care), hospice care, and some home health care. Most people do not have to pay for Part A.
||This part pays for doctors’ services, outpatient hospital care, and some other medical services that Part A doesn’t cover, such as the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary. Most people pay monthly for Part B.
You can choose different ways to get the services covered by Medicare. Depending on where you live, you may have different choices. In most cases, when you first get Medicare, you are in the Original Medicare Plan. You may want to consider a Medicare Prescription Drug Plan to add drug coverage. Or, you may want to consider a Medicare Advantage Plan (like an HMO or PPO) that provides all your Part A, Part B, and often Part D coverage. You make a choice when you are first eligible for Medicare. Each year you can review your health and prescription needs and switch to a different plan in the fall.
Medicare Coverage and Disability
You are automatically enrolled in Medicare after you receive disability benefits for two years. The 24 months begins from the month you were entitled to receive Disability, not the month when you received your first check. If you qualify for disability retroactively, you may be entitled to Medicare immediately. It is important to know your qualifying date at the time you receive your disability approval.
Social Security disability benefits are available under two programs:
- The Social Security disability insurance (SSDI) program pays benefits to you and certain family members if you worked long enough and paid Social Security taxes.
- The Supplemental Security Income (SSI) program pays benefits to disabled adults and children who have limited income and resources
Note that SSI benefits also are payable to people 65 and older without disabilities who meet the financial limits.
Medicare Prescription Drug Coverage Under Medicare, prescription drug coverage is now provided under Medicare Part D. First, you need to decide whether to:
- Stay with original Medicare (which covers your doctor, hospital, and some other services) and enroll in what is called a stand-alone Part D plan or Prescription Drug Plan (PDP). Hundreds of plans are available and vary state-to-state. You can use Medicare.gov’s prescription plan finder to evaluate which plan is right for you.
- Enroll in a private health insurance plan that has contracted with Medicare to provide the full range of Medicare covered health care, including drug benefits.
This second option is known as Medicare Advantage (previously known as Medicare+Choice). Medicare Advantage plans may be health maintenance organizations (HMOs), preferred provider organizations (PPOs), or private fee-forservice plans. There are also some Medicare Advantage plans designed for people with special needs, such as long-term care needs. The Part D drug benefit offered with a Medicare Advantage plan is known as a Medicare Advantage Prescription Drug plan or MA-PD.
The Annual Enrollment Period for Part D runs from November 15 to December 31. During this period people with Medicare can enroll in a plan or change their enrollment from one plan to another. Plans and coverage under these plans may differ in each state and may change each year. It is advisable to review your options each year as your medications may change and new plans may be available. State Health Insurance Assistance Program (SHIP) counselors can provide individualized counseling and help you assess what drug plan—if any—might be best for you given your situation (www.healthassistancepartner ship.org/ship-locator/).
The Coverage Gap or “Doughnut Hole” under Part D
The “Doughnut Hole” is the gap in coverage when an enrollee must pay 100 percent of the discounted price. It is the period after spending exceeds the initial coverage limit and before costs reach the “True Out of Pocket” cost or TrOOP limit. Your total drug costs include what you and the plan pay for your prescriptions. If these are greater than $2,510 per year, you will hit the “coverage gap,” or “doughnut hole”. During this period, you will pay 100 percent of your drug costs until your out-of-pocket costs reach $4,050 (or your total drug costs hit $5,726.25). After that, you will pay 5 percent of the costs, and the plan will pay 95 percent.
If you qualify for extra help with costs, you will not have a coverage gap. You will continue to pay reduced or no copays or co-insurance for each prescription. Depending on how much income you have, your co-pays or co-insurance may get even lower when your total drug costs (what you and your plan pay for your drugs) reach $5,726.25.
Medicare Part D vs. Medicare Part B
Medicare Part B pays for certain oral anti-cancer drugs if that drug has the same active ingredients as a non-self administrable drug. The injectable and oral drug must have the same chemical and generic name, and be approved for the same indications. Acknowledging recent advances in drug technology, Medicare now allows for coverage of certain oral anti-cancer drugs, called Prodrugs, which have the same active ingredients in the body as injectable anti-cancer drugs. The oral drug may have a different chemical composition from the injectable drug at the outset, but once metabolized the oral drug has the same chemical composition as the injectable drug. This broader interpretation permits coverage of alternative forms of administration of the same drug. The seven oral cancer drugs covered by Medicare Part B do not include any medications for GIST. Medications that are covered under Part B are paid 80 percent by Medicare and 20 percent by the patient.