Medicare and Myeloma FAQ

Medicare Basics

Q: Who is eligible to enroll in Medicare?

Medicare is a federal health insurance program for people aged 65 or older, some younger people with a disability, and people with End-Stage Renal Disease (ESRD).

Q: What’s the difference between Medicare and Medicare Advantage?

Medicare is composed of several different programs.  Traditional Medicare is composed of Parts A and B. Part A is hospital insurance, which covers inpatient stays at the hospital, care in a skilled nursing facility, hospice services and some home health services.  Part B is medical insurance, which covers doctors’ services, outpatient services at the hospital, medical supplies and preventive services.  Most people aged 65 and above, and those with disabilities, are enrolled in Parts A and B automatically.  Under traditional Medicare, the federal government pays health care providers directly for their services. Part D is the prescription drug program, which is optional and includes many different plan options. 

Some Medicare beneficiaries choose to enroll in a Medicare Advantage plan, under Part C. Medicare Advantage plans are private health insurance plans that replace traditional Medicare coverage.  There are many types of plans, which cover hospital and doctor services; most offer drug coverage as well.  Under Medicare Advantage plans, the health plan pays health care providers, not the federal government.  Some people pick Medicare Advantage plans because they offer benefits like vision or dental not covered under traditional Medicare.  Others may pick a Medicare Advantage plan so they can stick with a particular plan network (for example, if they had a Blue Cross Blue Shield plan before retirement, and want to keep the same sort of plan afterwards).  

The thing to remember is that Medicare Advantage plans are like a traditional health insurance plan in that each plan is different – in terms of costs, health care providers included in network, drugs covered on the formulary, etc.  If you are interested in selecting a Medicare Advantage plan, please be sure to research the details closely so that you can be sure that your doctors are in network, that your drugs are on the formulary and that you understand all of the deductible, co-pay and co-insurance policies. 

Q: What is supplemental coverage (Medigap)?

Medicare supplemental coverage or Medigap insurance is a private insurance plan that can help to pay some of the costs that traditional Medicare doesn’t cover, like co-payments, co-insurance and deductibles.  You pay a monthly premium to the private plan, which is separate from the Part B premium.  To enroll in a Medigap plan, you must be enrolled in traditional Medicare; Medigap plans don’t work with Medicare Advantage plans.  More information on how to compare Medigap plans is available here

Q: What does Medicare cost?

The amount that you will pay for your Medicare coverage depends on your income and what health services you use.  But, in general:

  • Part A (hospital insurance): Most people get Part A without paying a premium.  There will be co-pays and co-insurance for the services you use.
  • Part B (medical insurance): You will have to pay a premium for Part B, which varies based on your income from two years before. Enrollees pay premiums in 2013 based on their income in 2011. Most people pay $104.90 per month in 2013, but the premium can go up to $335.70 per month for people with incomes m above $214,000 in 2011. There is also a $147 deductible for Part B in 2013.
  • Part D (drug coverage):  If you enroll in a Part D plan, then you will face a monthly premium, yearly deductible and co-payments/co-insurance.  Your actual costs will vary depending on the plan you choose, the drugs you choose, whether the drugs are on the formulary and whether the pharmacy is in-network.  No Medicare drug plan may have a deductible more than $325 in 2013. It is very important that you examine the coverage policies of the particular Part D plan that you wish to enroll in so that you can minimize costs. 
  • Part C (Medicare Advantage):  If you enroll in a Medicare Advantage plan, then this will replace the enrollment in Parts A, B and D.  You will be responsible for monthly premiums, an annual deductible, and co-pays/co-insurance for your services and drugs, which will vary by plan.  It is very important that you study the particular Medicare Advantage plan that you wish to enroll in so that you can be sure that it covers the drugs and services that you need.

Q: Where can I learn more about Medicare?

The website for Medicare beneficiaries is www.medicare.gov and it has lots of resources to compare plans and learn more about the various benefits.  If you are a Medicare beneficiary and want to learn more about your current plan, you can visit www.mymedicare.gov.   There is an FAQ section here: https://questions.medicare.gov/.  You can also call 1-800-MEDICARE.

Q: What does Medicare fraud look like and what should I do if I suspect fraud is being committed?

Medicare fraud can take many forms and this list isn’t exhaustive. Fraud includes someone using your social security number or Medicare identification number to bill for medical services that you never received.  For example, if a health care provider billed Medicare for procedures, tests, or other services that were not performed or ordered for you. Perhaps a physician you never met submits a claim that he or she examined you in their office or bills twice for the same procedure. To learn more about types of Medicare fraud, visit www.stopmedicarefraud.gov.  

You can help prevent fraud by keeping your social security number and Medicare identification number private and report if you believe that someone is using your numbers. This is a form of identity theft. Also, pay attention to your explanation of benefits and summaries. If you don’t recognize a doctor’s name or believe the services listed were not performed as described, this could be fraud. You should call your provider and ask them to clarify the billing. And you can report fraud by calling the Senior Medicare Patrol Resource Center at 1-877-808-2468.

To eliminate waste, fraud and abuse of Medicare funds, the ACA enacted tough new rules and sentences for criminals, implemented enhanced screening technologies to identify suspicious claims or billing patterns, and created new procedures for providers before being allowed to participate in Medicare.

Medicare Part D – Prescription Drug Coverage

Q. How does Medicare Part D Coverage work?

Medicare enrollees have the option of purchasing a Medicare Part D plan.  There are many different plans for people to choose between, and it is important to ensure that the plan you pick covers the drugs you use.  Medicare.gov has a tool where you can enter your zip code and the drugs you have been prescribed, and it will compare various plans for you.  The tool is available here.

Q: How will closing the Medicare Part D donut hole help me pay for my prescription drugs?

Before the passage of the Affordable Care Act (ACA), you paid 100% of your drug costs until you reached a $310 deductible. At that point, Part D paid 75% of the cost of the drugs and you were responsible for 25%.  When Part D spent $2800, you reached the donut hole, or gap in coverage, and you were 100% responsible for the cost of the drugs until you spent $4550 out of pocket. Once you reached that amount, Part D paid for about 95% of your drug costs. Hence, before ACA, Medicare beneficiaries had to pay almost $5000 out of pocket before having full coverage for the cost of their drugs once they reached the donut hole.

Over time, ACA closes the donut hole and by 2020, that coverage gap will no longer exist. In 2013, when you reach the donut hole, Medicare will cover 52.5% of the cost of the drugs until you pay $4550 out of pocket and then Part D covers 95% of the cost. Previously, you were 100% responsible for the cost of drugs in the donut hole and this year, you only have to pay 47%. Between now and 2020, the percentage Medicare pays continues to increase until there is no donut hole. In 2020, Medicare will pay 75% of the cost of drugs until you reach the out of pocket limit and then Part D pays 95%. These changes to Medicare Part D will help you afford the cost of prescriptions.

Please note that the cap on out of pocket spending has remained the same and yes, Medicare will not pay 95% of the cost of the drugs until you reach that limit. However, now Medicare will cover more of the cost while you’re in the donut hole.  This means that the amount you pay out of pocket won’t reach the cap or will at least be spread out over a longer period of time making drugs more affordable for you.

Medicare Coverage for Myeloma Treatments

Stem Cell Transplants – Medicare covers a single Autologous stem cell transplantation (AuSCT) only for Durie-Salmon Stage II or III patients that fit the following requirements:

  • Newly diagnosed or responsive multiple myeloma. This includes those patients with previously untreated disease, those with at least a partial response to prior chemotherapy (defined as a 50% decrease either in measurable paraprotein [serum and/or urine] or in bone marrow infiltration, sustained for at least 1 month), and those in responsive relapse; and,
  • Adequate cardiac, renal, pulmonary, and hepatic function.

Many people wonder whether Medicare will cover a single AuSCT if the patient has previously had a transplant paid for by private insurance.  Experts say that Medicare does typically cover the single transplant in this case. 

Allogeneic hematopoietic stem cell transplantation (HSCT) is not covered as treatment for multiple myeloma nor is tandem autologous stem cell transplants, because Medicare finds “insufficient data exist to establish definite conclusions regarding the efficacy” of these treatments for multiple myeloma. 

Myeloma Drugs – Medicare Advantage and Part D drug plans determine which drugs are included on their formularies and what cost-sharing (co-payments and co-insurance) they apply.  It is critically important to research your plan to understand how your drugs are covered. 

Medicare and the Affordable Care Act

Q: How does ACA improve my access to preventive screening for cancer and other diseases?

ACA eliminates all co-pays for any preventive screening services and covers 100% of the cost. This means that screening tests such as mammography, colonoscopy, diabetes, heart disease and more are completely free.

Q: How does the ACA help me live a healthier lifestyle?

If you are new to Medicare, your “Welcome to Medicare” preventive visit is now covered without cost sharing during your first 12 months of Part B coverage. This exam is a one-time review of your health as well as education and counseling about preventive services and other care. If you’ve had Part B for longer than 12 months, you can get a yearly wellness visit to develop or update a personalized prevention plan based on your current health and risk factors.

Q. What’s the truth about the “death panels” or other policies that could stop me from receiving care?

The Affordable Care Act does not include “death panels” or other groups that could say that you are no longer eligible for care.  There is no policy that people older than 70 must stop receiving cancer treatment.  Before 2000, there was an age limit on receiving a stem cell transplant for multiple myeloma, but that policy is no longer active.

For more information please contact Meghan Buzby mbuzby@myeloma.org or Aimee Martin amartin@myeloma.org.

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