by Leah deRoulet, MSW

   Recently I’ve had a few patients who wanted to come in and discuss their confusion about all of the Medicare plans since they had to make decisions whether or not to actually accept Medicare as their health insurance plan or stay on the plan they currently had.  Patients who have been granted Social Security Disability and are on it for 24 months receive a letter from the Social Security Administration informing them that will be eligible for Medicare on a certain date, and that they have approximately 30 days from the date of the letter to let the government know if they plan to accept Medicare, and what parts of Medicare they wish to enroll in.  So, although the Prescription Drug coverage, Part D is the one that confuses people the most, all of the other plans except Part A are still confusing.  Here’s a quick run through of Medicare, and then we will talk primarily about Part D in the next post

   Medicare is composed of 4 parts: A, B, C and D.  Part A covers hospital costs, home care services, hospice care, and some Skilled Nursing Home care, generally no more than 30 days.  Part A is also free - no charge at all.  Everyone gets it, even if they opt not to use it because they are retaining their private pay insurance or are covered on a spouse’s plan.  There is a significant deductible for hospital admissions: currently it is $972.00, and this amount changes every year on January 1st.  If a person re-enters the hospital within 30 days of a previous admission, there is no deductible charge for the second admission.  However, if he were to re-enter the hospital on the 31st day after a previous admission, another deductible charge would ensue.  If the Medicare recipient accepts Plan B and then purchases a Medicare supplement policy, sometimes referred to as Medigap coverage, all hospital deductible charges are paid by the Medigap supplemental insurance plan.  We will talk more about this when we discuss Part B.

   Part B covers all outpatient services, including chemotherapy, CT scans, PET scans, X-rays, physician services in clinics, and some oral chemotherapy drugs.  There is a lot to understand about Medicare Part B.  Co-pays are often required when visiting a physician’s office, and these are not covered by the Medigap policy.  Medicare payments are also a bit confusing.  Medicare has approved amounts that they have researched, and except for some minor changes for geographical differences in the US, they have pretty much determined how much they will approve for any covered service.  This is then stated on the Explanation of Benefits, or EOB, that participants receive from Medicare for any charge submitted by a provider, and is referred to as the “approved”’ amount.  Medicare then pays 80% of the approved amount, leaving a 20% balance for the patient to pay.  If the Supplemental insurance is purchased, the 20% balance is paid by the Medigap plan.  If the providers agree to accept the approved amount as their payment in total, this is referred to as “Accepting Medicare assignment”.  To simplify this information, let’s assume that the physician sends in a bill for his services on any given day for $150.00.  Medicare approves $100.00, but pays only $80.00, leaving a $20.00 balance to be paid by the supplemental insurance, and another $50.00 by the patient if the provider does not accept Medicare assignment.  Most larger clinics and outpatient cancer centers do accept Medicare assignment, but I always caution patients to ask if the provider does take assignment, because while some amounts may be small, think of the amount a person could be charged if their PET scan was billed at $,4000.00 and Medicare only approved $3,000.00 and then paid 80% of that.  The balance due for the patient would be $1,000.00.  So, you can see that purchasing a good, solid Medicare supplement policy is very important — so is always asking if their provider accepts assignment!  The Medicare Part B Plan is not free; there is a monthly charge of $96.00 this year, deducted automatically from the person’s Social Security check, whether it be for disability, where the recipients tend to be young in age, or for standard Social Security benefits, where the recipients are generally 65 or older.  This charge for Part B also increases yearly on January 1, and tends to almost equal the cost of living raise in the total monthly amount awarded to the recipient.  It does seem as though you can’t get ahead no matter what!  For older folks, there is a wide and varied number of Supplement plans to choose from, and many of these also cover Part D, the prescription drug plan as well.  The younger disability recipients do not have as many choices, unfortunately.  For example, a widely used supplemental plan that also has good Part D plans to choose from is AARP.  AARP does not cover Disability Social Security recipients, and there are many other plans that do not as well.

   Most people require some assistance to choose the best plan for their needs.  If folks are computer literate, as I know all of the OncTalk readers are, they can go to WWW.Medicare.gov or WWW.SSA.gov sites and choose from the side bars the plans that are listed in detail as to their coverage benefits.  It is very helpful to know the drugs you consistently take so that you can look to see what is covered.  Remember that is likely that not all of your medications will be covered, but you want to get as close as you can to covering the majority of these medications.  We know that lots of these medications will change as treatment progresses, but I also suspect that more and more of the oral chemo drugs will be covered under Medicare B in the future.  Finally, if this is all too much to try to do yourself, and because these plans are different from state to state, you can call your state’s Insurance Commissioner to ask if they have a listing of the Medicare Supplement plans for both Disability and/or standard Social Security recipients, and if there are people who either volunteer or are paid to assist folks in determining the best plan for the person who needs to make a decision.  It is also important to remember that if you decide not to take Medicare Part B or D to notify Medicare in time that you are not taking these options for the time being because you are covered by other insurance, either your own or your spouse’s.  If you do not do so, and it is not actually placed in the computer, you may be subject to a fine that accrues yearly, is cumulative, and raises the cost of the Medicare Part B when you decide to take it.  Some low income folks may be eligible for Supplemental insurance and Part D coverage through Medicaid, and most of the time, persons are asked if they require financial assistance because they cannot afford the Part B premium, or the Supplemental Medigap insurance for Part B and D.  This penalty issue can be a huge burden for folks who did not respond in time to the original eligibility letter, so please do pay attention to the time frame requested by Medicare.

  
   This brings us to Part C, which is simple.  It is called the Medicare Advantage plan, and is really the HMO plan.  HMO’s have their own oddities.  The largest ones in Seattle, for instance, are Group Health and Secure Horizons.  Both require that the person utilize only the providers approved by the HMO, and if they need to go out of the “Network” of HMO providers, they must get preauthorization if the HMO provider cannot perform the service needed by the patient.  In addition, there are still co-pays required by the HMO for every visit, and Secure Horizons, as an example, requires a $20.00 co-pay for every radiation treatment, and if a patient has a normal run of radiation of six weeks or so, they will pay $600.00-$800.00 in co-pays alone.  For many people, Part C is a good answer because the medications are covered, the Part B supplement is covered, and the list of preferred providers is extensive and may already include the oncologist the patient is seeing.  It certainly deserves consideration in the decision making process!

    That’s enough for now.  We’ll move to part D next.

Till next time,

Leah