Ask the Medicare Specialist
QUESTION:
From Donna: The Patient Assistant Programs are great for Diabetics who are taking insulin and other expensive drugs. However, they won’t pay for insulin for those of us who have pumps. I have an Advantage Plan and must pay 20% of the retail cost. Can you explain why that is and why the Assistance Programs won’t help me?
ANSWER:
I actually confirmed that two of the best Patient Assistance Programs will provide insulin for use in pumps. So that’s great news for people like you Donna. Let’s quickly review the programs she is speaking of. Due to space restraints let me keep this simple. I recently discovered that several drug manufacturers have made many of the most commonly prescribed brand name diabetes drugs available for free to anyone whose income is at or below 400% of the Federal Poverty Level, $51,000 for a single person and $69,000 for a married couple. Insulins Humalog, Humulin, Novolog, Novolin, Levemir, Tresiba, and Basaglar. Noninsulin injections Ozempic, Victoza, and Trulicity. Oral diabetes meds Jardiance and Januvia are all available at no cost. For those who want more details, go to our website, read last week’s column, and watch my latest webcast on this topic. If you have questions or would like an application for these Patient Assistance Programs call or email us with that request. Insulin pumps and the insulin that goes in them is actually a Medicare Part B medical benefit, not a Part D prescription benefit like it is for those who inject or take their medications orally. This is a good thing for those who have original Medicare and a Supplement because Medicare pays their 80% and then the Supplement, including the most popular plans, G, and N, pay the other 20%. There isn’t a need to apply for the Patient Assistance Programs since insulin would already be no cost.
However, those on Advantage Plans HMO’s and PPO’s aren’t provided those same level of benefits when it comes to Insulin that goes in a pump. Those who use pumps and don’t qualify for the Patient Assistance Programs could end up paying significant out of pocket expenses. We have close to 4,000 clients on Advantage Plans and there are several reasons to choose one. The best in my opinion is the low cost, from $0. We almost never recommend Advantage plans that cost over $60/month. The logic of going with an HMO or PPO is the possibility of saving $5,000 to $10,000 or more in premiums over a five- or 10-year period. Those who stay relatively healthy can indeed do just that. However, Advantage Plans aren’t without risks, one of which is the possibility of paying thousands for medical services and reaching what is known as the Maximum Out of Pocket (MOOP), which represents the most one could be billed in a calendar year. Those range from $3,400 to as much as $6,700 depending on the company and plan. I estimate close to 50% of all available plans in the Western PA have a MOOP on the higher end. Only two are available with a MOOP of $3,400. We prefer that our clients avoid the plans with the highest MOOP’s.
Advantage Plans are regulated to provide the same or better benefits than original Medicare. In most cases it’s much more generous for services such as Emergency Room visits, hospitalizations, outpatient surgeries, blood tests, X-Rays, Radiation Therapy, and others. They also can provide benefits original Medicare and a Supplement do not such as cosmetic dental, vision, and hearing as well as free gym memberships. However, there are areas where the coverage is only as good as Medicare for services such as Chemotherapy, infused drugs like Remicade, Skilled Nursing, and Durable Medical Equipment. Many of these services can result in large bills, often as high as one’s MOOP. Unfortunately, Insulin for pumps falls into this category.
Which leads to another risk, one that I consider the biggest those take who choose Advantage Plans, the possibility of not being able to enroll in a Supplement at a reasonable cost ever again. Someone who is going to need Chemo on a regular basis and I have met several, those who have an insulin pump, or get regular Remicade infusions are not only likely to be out of pocket $3,400 to $6,700 every year, but they probably won’t be able to get a Supplement that would eliminate these bills. That’s because, as I’ve written on numerous occasions, Supplement companies can discriminate and deny coverage to those who have certain current or preexisting medical conditions. There are some exceptions for those who are going on Medicare Part B for the first time, losing coverage from an employer or as a retirement benefit, have had an Advantage Plan less than a year, and a couple of others. Please call one of our offices or email me for more details. You can also tune into next week’s webcast where I will discuss this much further.
We are adamant about educating our clients on the pros and cons of both Advantage Plans and Supplements. I’ve met too many people to count who not only didn’t have those explained but weren’t even told about the Supplement option, enrolled in an Advantage Plan, and had a condition where they would never be able to get a Supplement the rest of their lives.
We are now able to resume face to face appointments for those who prefer them. We have taken all precautions and are following CDC and Pennsylvania guidelines. For those who are not yet comfortable meeting in person we can still provide phone and Zoom meeting consultations. And in case you weren’t aware, we never charge for our services.