Navigating Medicare With Rheumatoid Arthritisby Lene Andersen, MSW Patient Advocate
Chances are that you’ve heard of Medicare. Chances are equally as good that your knowledge about this program is pretty vague — or at best, confusing. This slideshow will give you some clarity about the different elements of Medicare with a general overview, then explore how it applies to rheumatoid arthritis (RA).
What is Medicare?
“I'm not on yet, but worry about what will happen when my current meds will not be covered, or be too expensive.” — Carole
The U.S. government provides health coverage to people who are over 65 years old, as well as those younger than 65 who need coverage due to a medical condition or disability. Currently, almost 57 million people in the United States receive Medicare benefits — 84 percent of these are seniors. The number of people receiving benefits will increase significantly as the baby boomer generation ages.
The four parts of Medicare
Medicare has four parts. Part A is for inpatient hospital care and skilled nursing facilities, and some home healthcare. Part B applies to outpatient healthcare and medical supplies. A and B are together called Original Medicare. Part C, or the Medicare Advantage Plan, is covered by private insurance and includes items not covered by A and B, such as dentists, hearing and vision care. You will have to pay part of the premium costs yourself. Prescription drug coverage is provided by Medicare Part D.
Coverage, add-ons, and fees
“Many drugs are still expensive and deter me from taking treatment that my rheumy prescribes.” — Ruth
When qualified for Medicare, you are automatically enrolled in Parts A and B, but must add the optional C and D plans yourself. Services covered by A and B are largely the same across the country, but in C and D, coverage can vary between states, even regions. Medicare doesn’t pay for everything. You pay a premium for coverage, deductibles for services and drugs, and coinsurance — similar to a co-pay.
Covering the gaps
As you can imagine, premiums, deductibles, and coinsurance can add up. This is where Medicare supplemental plans F, G, K, L, M, and N enter the picture. These are also called Medigap plans and are covered by private insurance plans. You need to be enrolled in Original Medicare in order to qualify and should keep those plans for things like hospital care. Medigap plans do not include coverage for prescription drugs. If you need help with your meds, enroll in a stand-alone Medicare drug plan.
Enrollment in Medicare varies across three different groups. If you are younger than 65 and receive Social Security disability benefits, you will automatically be enrolled in Medicare 24 months after benefits started. If you receive Social Security benefits (not disability), you will automatically receive plan A and B services when you turn 65. Lastly, if you are employed and not on Social Security, you need to sign up online. It’s generally recommended that you do so to lock in your services.
Medicare and RA
“I have had a wonderful experience with having this coverage and am very thankful.” — Janine
Medicare covers medically necessary treatments for RA. Given the systemic nature of RA and the necessity of taking medications, adding Plan D to your coverage is essential. Also, be aware of the open enrollment period. During this time (six months from activation of your Plan B and again when you turn 65) you can’t be turned down for supplement plans and do not have to answer any medical questions.
RA medications and Medicare
Which plan covers your RA meds depends on the type of drug. If it is taken by mouth and you pick it up at your own pharmacy, the medication is covered by Plan D, with you paying for deductibles and co-pays. If it is administered in a doctor’s office or clinic, such as biologic infusions, plan B covers 80 percent of the cost. Biologics cost tens of thousands of dollars a year, and even 20 percent of that can be significant. This is why getting a Medigap plan is important.
Biologics and Medicare
People respond differently to RA medications. For some, biologics may be necessary to get the condition under control. One quarter of people with RA who receive Medicare are prescribed biologics. One study found that most plans cover at least one biologic, but with the requirement of prior authorization. As well, almost all plans required an average of almost 30 percent coinsurance. Manufacturers of biologics offer financial assistance plans, but these exclude recipients of Medicare.
What about the donut hole?
The donut hole concept refers to a gap in Medicare coverage. There is a maximum limit for prescription medication coverage. When you reach that — which can happen quickly with RA medications, especially biologics — there is a gap between the maximum limits and the point when you reach Medicare’s level for catastrophic coverage. In 2018, this kicked in at $5,000. At this stage, you pay significantly less for prescription drugs.
Other treatments for RA
RA is a complex disease that can require a number of other treatments in addition to medication. Surgery, physical therapy, and more may be partially covered under Original Medicare. Again, some of these treatments — especially surgery — can be extremely expensive and Medigap plans can help you cope with that. The security of having backup financial help can be offset by the requirements of using the services and providers within a particular network.
You are entitled to maintenance care by a skilled health professional, such as a nurse or physical therapist. To qualify for coverage, it must be prescribed by a doctor and it’s required that you are home bound. Denials of coverage still happen, however. Your doctor may be able to help prevent this by being very specific about the benefits of the service. As well, advocacy organizations may be able to step in.
Extra financial assistance
Even with Medigap plans, you may still be required to pay more than you are able. If you have very limited funds, you may qualify for Medicare Extra Help. You can also apply for financial assistance programs offered by nonprofit organizations. If you receive Social Security disability benefits, but Medicare hasn’t yet kicked in, these organizations could be helpful for you. In such a case, you may also be able to get help from pharmaceutical assistance programs.
Making sense of it all
Making sense of Medicare, supplemental plans, and shopping for insurance can be extremely complicated. But you don’t have to do it alone. A number of government services, including Medicare itself, has help centers to assist you. 65 Incorporated may also be useful. Founded by a Medicare expert, it provides unbiased advice without pressure to sign up for a particular insurance company. With patience and a bit of research, you will be able to find a plan that’s right for you.