Susan B. Sloane, BS, RPh, CDE, has been a registered pharmacist for more than 20 years and a Certified Diabetes Educator for more than 15 years. Her two sons were diagnosed with diabetes, and since then, she has been dedicated to promoting wellness and optimal outcomes as a patient advocate, information expert, educator, and corporate partner.
So you've reached the golden age of 65, and now you can reap the benefits of Medicare. But you're unsure about what that means and how to make the system work for you.
Like any other insurance benefit, you—the consumer—need to do some homework.
The website www.medicare.gov can help answer many of your questions. I also recommend getting an advocate to help you decide which plan is best for you. An advocate could be your daughter, son, husband, wife, or a trusted healthcare professional. This person is another set of eyes and ears for you, and they can help you ask the right questions and find the answers you need.
That said, you need to start somewhere! Here are eight common questions (and answers) about Medicare to get you up to speed.
1. How do I get Medicare?
When you turn 65, you will get a Medicare card in the mail. (Or, you may be eligible for Medicare before age 65 if you are disabled.) This card is for Medicare part A and B. These benefits are not totally free for the majority of people, and they have a standard monthly fee of $115.40.
- Part A generally covers doctor and hospital visits to some extent.
- Part B covers things like diabetes supplies with some sort of deductible. Some individuals with higher incomes pay more than the standard fee for Medicare Part B, while others who have very low income levels may not have to pay premiums at all. For Medicare Part B, there are penalties for not enrolling during the enrollment period, which is January 1 to March 31. There are some exceptions to this rule. If you are covered under a group health plan from your employer, you will not have a late penalty fee when you do sign up. Most people do get automatically enrolled in part B when they become eligible; check the federal website to see where you fit in.
2. How can Part B help with the costs of my diabetes supplies?
Diabetes testing supplies can be quite costly, so this benefit is a great help. You are usually entitled to a three-month supply at a time. Make sure your doctor writes this quantity on the prescription, along with the diagnosis code and how many times you test per day. Without this information, your prescription may not be billed correctly to Medicare. In general, you can use your neighborhood pharmacy or choose a mail-order supplier who will mail your supplies directly to you if you like.
It is also extremely important to know which type of meter you use/want and make that clear on the prescription. In other words, don’t have your doctor write blood glucose monitor on the prescription; this can leave you with a monitor you may not like.
3. What is Medicare Part C?
Medicare Part C allows you to choose to receive all of your healthcare services, such as doctor visits and prescriptions, through one provider. These plans are called Medicare Advantage Plans, and they may help lower your costs for medical services or add extra benefits for you that you may not currently have.
You must have Parts A and B to enroll in Part C.
4. What is Medicare Part D?
Medicare Part D is a bit more complex. It's an option that allows you to receive drug coverage subsidized by the government.
- You may not need a Part D plan, as many people over 65 stay in the work force these days and have employer drug coverage.
- If you turn 65 and are not eligible for social security, you will automatically get enrolled in a Part D program for Medicare.
If you choose to participate in a Part D plan, the enrollment period is from November 15 to December 31 each year. Drug coverage begins January 1 when you sign up for a Part D plan. If you sign up for a Part D plan after the enrollment period is up, you have to pay a penalty fee, so pay particular attention to meeting the enrollment deadline.
When you choose a Part D Medicare plan, make a list of medications you take. You can then go to the Medicare website and plug the drugs in to compare different plans according to monthly fees and the cost of the medications.
5. What about the time period when I'm not covered?
With Medicare Part D, there is generally a deductible, as well as a period of time referred to as the "dreaded doughnut hole" where you must pay for drugs out of pocket.
In response to the problems surrounding this coverage gap, Medicare has launched a discount program designed to help close the Medicare coverage gap. According to Medicare.gov, "In 2016, once you and your plan have spent $3,310 on covered drugs, you're in the coverage gap." The website goes into more helpful details:
"Once you reach the coverage gap in 2016, you'll pay no more than 45% of the plan's cost for covered brand-name prescription drugs. You get these savings if you buy your prescriptions at a pharmacy or order them through the mail. Some plans may offer higher savings in the coverage gap. The discount will come off of the price that your plans has set with the pharmacy for that specific drug. Although you'll pay no more than 45% of the price for the brand-name drug in 2016, 95% of the price—what you pay plus the 50% manufacturer discount payment—will count as out-of-pocket costs which will help you get out of the coverage gap. What the drug plan pays toward the drug cost (5% of the price) and what the drug plan pays toward the dispensing fee (55% of the fee) aren't counted toward your out-of-pocket spending."
This is just the first of several discounts that the federal government has allotted for Medicare patients, and the discounts will only get larger. By the year 2020, seniors who reach the gap can expect to pay only 25 percent of the cost of both brand name and generic drugs.
For you, planning for this doughnut hole may mean getting help through your local ADA, getting samples from your doctor (always ask), or looking at drug company patient assistant programs.
6. What are flexible spending accounts (FSA)?
FSA accounts only pay for over-the-counter medications with a prescription—this took effect January 1, 2011. These changes will not affect items like insulin and prenatal vitamins. In 2013, changes took place so you are now able to put $2,500 per year in your FSA account.
How your FSA card “identifies” over-the-counter medications that are accompanied by a prescription is still a bit unclear. Some pharmacies can “fill” your over-the-counter prescriptions so you get a computer-generated receipt will an Rx number that can be scanned at the point of sale at the cash register. This may cause you extra work and even potentially extra costs, as your doctor may not provide prescriptions for vitamins and other over-the-counter items without an office visit. Check your plan and talk to your doctor and pharmacist about any concerns you may have.
7. What about generic drugs?
As more generic drug approvals enter the pipeline, the opportunity for saving money on prescriptions is ever-growing, and the savings are significant.
Generic drugs are subject to Food and Drug Administration (FDA) scrutiny and are safe and effective. The FDA serves as a watchdog agency to make sure that drug approvals are done with proper evaluations in place. We can feel confident in the quality of generic drugs that are marketed today.
8. What if I can't pay for my medical supplies or prescriptions?
For those needing additional state or federal aid, there are many helpful programs available. For more information on these programs, you can contact the Health Resources and Services Administration (HRSA) by visiting their website or calling 1-800-400-2742.
Remember, if you are struggling financially, you are not alone. Help is out there. You should reach out to your doctor, Certified Diabetes Educator, social worker, or close family and friends to get the support you need. Together, we can be stronger and healthier.
It is not acceptable to risk your health by skipping medication your doctor prescribes. If you are having difficulty paying for medication, assistance is available at the state and federal level. Drug companies also have several patient assistance programs in place; just check their websites.