Seniors Living With Diabetes What Medicare Pays For

by | Nov 10, 2014 | Blog, Finance & Planning

Almost 27 million Americans age 65 and older – more than one-fourth of that age group – have Type 2 diabetes, according to the Centers for Disease Control. The overall national rate has doubled since 1995.

Medicare Options

Medicare is the national health insurance program for people age 65 or older, people under age 65 with disabilities and people with End-Stage Renal Disease (ESRD). Below is information regarding Medicare Part A, Part B, Part D, Medicare Advantage and Medigap. For more information, you may call 1-800–MEDICARE (1-800-633-4227) or visit www.medicare.gov.

Medicare Part A

  • Medicare Part A (hospital insurance) provides coverage for in-patient hospital stays, care in critical access hospitals, skilled nursing facilities, hospice care, and some home health care.
  • Most people do not have to pay a premium for Medicare Part A, because they or a spouse paid Medicare taxes while working. If you do not qualify for premium-free Part A, you may be able to purchase the coverage. Call your local Social Security office, or 1-800-772-1213, for more information about buying Medicare Part A coverage.

Medicare Part B

  • Medicare Part B (medical insurance) provides coverage for doctors’ services, outpatient hospital care and some medically necessary services not covered by Part A (including some physical and occupational therapy services and some home health care).
  • Medicare Part B also covers some diabetes-specific supplies and services, including blood glucose testing monitors, blood glucose test strips, lancet devices, lancets, glucose control solutions, medical nutrition therapy and diabetes self-management training. Some beneficiaries may also qualify for coverage of therapeutic shoes.
  • Medicare Part B also covers some preventive care, including a “Welcome to Medicare” physical for new enrollees, diagnostic screenings for diabetes and cardiovascular disease, and glaucoma tests.
  • A one-time “Welcome to Medicare” physical exam is covered within the first 12 months of Part B coverage. Beginning January 1, 2011, Medicare Part B will also cover an “Annual Wellness Visit” which will include the creation (or update) of a personalized prevention plan and be available every 12 months after the first 12 months of Part B coverage or after receiving a Welcome to Medicare physical exam.

How Much Does It Cost?

  • Unfortunately, Medicare Part B is not free. All Medicare enrollees who elect Part B coverage must pay a monthly premium. This premium can change from year to year. The Social Security Administration can verify the exact amount of your monthly premium. They can be reached at 1-800-772-1213.
  • Additionally, if you enroll in Medicare Part B, you will have to meet a deductible first before Medicare will begin to pay its share. After that, Medicare will pay 80% of the Medicare-approved cost of your medically necessary supplies and services. For some preventive services, the deductible and/or coinsurance will be waived.
  • You do not have to enroll in Medicare Part B. However, if you decline to enroll when you are first eligible, and then decide to sign up later, you may have to pay extra for the coverage. Your monthly premium may increase by 10% for each 12 month period that you could have had Part B but did not sign up for it. You may have to pay this late enrollment penalty for as long as you have Part B, unless you meet certain conditions. Please call 1-800-MEDICARE (1-800-633-4227) for more information.

Medicare Advantage

  • Some beneficiaries choose Medicare Advantage plans instead of Medicare Part A and/or B (the “Original Medicare Plan”).
  • Medicare Advantage plans are private health insurance plans that are a part of the Medicare program. Beneficiaries receive their health care services through the private plan, and Medicare pays the plan a set amount of money each month for each beneficiary’s care, regardless of whether or not the person actually uses any health care services.
  • Medicare Advantage plans can charge different out of pocket costs and have different rules for how beneficiaries access services, such as if you must go to only doctors, facilities or suppliers that belong to the plan for non-emergency care.
  • Because Medicare Advantage plans are private insurance plans, they come in all shapes and sizes. Out of pocket costs vary depending on the plan. Most plans offer prescription drug coverage and many offer extra benefits that are not covered under Parts A & B.
  • People who have Medicare Part A & B are eligible for Medicare Advantage if they live in a region where Medicare Advantage is available. To find out if you can sign up for a Medicare Advantage plan, visit www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227).

Medicare Part D

  • Medicare Part D is the prescription drug program available to all Medicare beneficiaries. Under Part D, you will have a variety of coverage options to help you pay for your prescriptions. Each Part D drug plan is run by a private company, and they will all look a little different from each other but they must all meet standards set by the federal government.
  • Part D coverage is optional and you are not required to sign up for it. If you chose not to join a Medicare drug plan when you are first eligible, and you don’t have other creditable prescription drug coverage, you may have to pay a late enrollment penalty if you decide to sign up in the future.
  • In addition to providing prescription drug coverage, Medicare Part D ensures coverage for supplies necessary to inject insulin, including syringes, needles, alcohol swabs, and gauze.

How much does it cost?

  • Most Medicare drug plans charge a monthly premium that varies by plan (separate from the Part B premium you may already be paying), plus some out-of-pocket expenses for your medications. Some drug plans also have a deductible.
  • Most Medicare drug plans have a coverage gap (also called a donut hole). This means after you and your drug plan have spent a certain amount of money, you are responsible for paying all of the costs out of pocket up to a yearly limit. In 2010, if you have Medicare prescription drug coverage and have to pay for your drugs in the coverage gap, you will get a one-time tax free $250 rebate check from Medicare to help pay for your prescriptions.
  • Starting in 2011, if you have high prescription drug costs that put you in the coverage gap, you will get a 50% discount on covered brand-name drugs while you are in the coverage gap. Additional savings will occur each year for people in the coverage gap through 2020, when the gap will effectively be closed.

Choosing a plan requires a little homework before enrolling. Here are some things you can do to help you decide:

  • Every fall, Medicare will mail you the Medicare & You handbook, containing information about Part D plans available in your area. If you do not receive this booklet, contact Medicare at 1-800-MEDICARE (1-800-633-4227).
  • If you think you might want to enroll in a Part D plan, start by making a list of the medications you currently take, including their names, your dosage, how much it costs each time you fill the prescription, and how often you fill the prescription. If Medicare does not consider your current coverage to be “creditable coverage,” you will need to decide whether to keep it and risk having to pay a late enrollment penalty later if you decide to join Part D, or to cancel it and enroll in Part D now.
  • Compare Part D plans to see how well they will serve your needs. You may wish to make a chart for yourself comparing the monthly premium, deductible, copay amount, and coinsurance percentage for all of the plans you are interested in. Make sure that the plan formularies include all of the drugs you take, and that the pharmacies you like to use are included in the plan network.

Medigap (Medicare Supplement Insurance)

A Medigap policy, sold by private insurance companies, can help pay some of the health care costs (“gaps”) that Original Medicare doesn’t cover, like copayments, coinsurance, and deductibles. Some Medigap policies also offer coverage for services that Original Medicare doesn’t cover, like coverage for medical care when you travel outside the U.S.

Every Medigap policy must follow federal and state laws designed to protect you, and it must be clearly identified as “Medicare Supplement Insurance.” In 2010, Medigap insurance companies can sell you only a “standardized” Medigap policy identified in most states by letters (Plans A through N).

All standardized plans must offer the same basic benefits but some offer additional benefits, so you can choose which one meets your needs. (Note: In Massachusetts, Minnesota, and Wisconsin, Medigap policies are standardized in a different way.)

For more information, please consult “Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare” at: (www.medicare.gov/Publications/Pubs/pdf/02110.pdf ). You can also call your state’s department of insurance to get more information. Both the guide and the phone number for your state insurance office can be found online atwww.medicare.gov or by calling 1-800-MEDICARE (1-800-633-4227).

Medicare and Health Reform

On March 23, 2010, President Obama signed into the law the Affordable Care Act which strengthens Medicare and includes provisions that will reduce fraud and close the gap in Medicare prescription drug coverage known as the donut hole. The reforms will not be implemented all at once but rather in stages.

Portions of the law have already taken effect while other regulations will be implemented through 2014 and beyond. Some benefits of the law directly related to Medicare are:

  • Starting in 2010, if you have Medicare prescription drug coverage and have to pay for your drugs in the coverage gap, you will get a one-time, tax free $250 rebate check from Medicare. Medicare will automatically send you a check if you are in the coverage gap. You do not need to provide any personal information like your Medicare, Social Security, or bank account numbers to get the rebate check.
  • Starting in 2011, if you have high prescription drug costs that put you in the coverage gap, you will get a 50% discount on covered brand-name drugs while in the coverage gap. Additional savings will occur each year for people in the coverage gap through 2020, when the gap will effectively be closed.
  • Starting in 2011, Medicare beneficiaries will be able to receive some free preventive care services and a free new annual wellness visit to develop (or update) a personal prevention plan based on your current health needs.
  • If you are in a Medicare Advantage plan, you will still receive guaranteed Medicare benefits but, beginning in 2014, the new law will ensure that at least 85% of every dollar these plans receive is spent on health care instead of insurance company profits and administrative costs.

For more information please go to: www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227). Additionally, look for more details in your Medicare and You handbook which Medicare mails to beneficiaries in the fall and which is also available at: www.medicare.gov.Some information on this fact sheet is from www.healthcare.gov.