Choosing the Right Medicare Program When You Have Cancer
The good news is that you’re eligible for Medicare. Choosing a Medicare plan, however, can be very challenging. Because costs are so high, it’s especially important for people with cancer to understand how plans cover care and treatment.
The Medicare Landscape
Medicare coverage, provided by the government, includes Parts A and B, which pay a large portion of the costs of inpatient care (visits that require hospital admission) and outpatient care (such as doctor visits and lab tests) For most people, there is no premium for Part A, while Part B costs $130 per month on average. Part D, purchased separately, covers prescription drugs and costs $12.40 to $77.40, depending on your income.
For Medicare Part A, the inpatient deductible for hospital admissions will be $1,364 in 2019. Once your total payments equal this amount, you will not have to pay if you are hospitalized again. For Part B, patients must first pay an annual deductible of $185. After that, Medicare pays for 80% of all costs of any outpatient care you receive and you must pay the remaining 20%. (Many people with Medicare buy supplemental insurance, also called Medigap insurance, to cover their out-of-pocket costs under Part B.) The premiums for Part D vary widely and increase for those with higher incomes. The annual deductible cannot be more than $415; however, the amount you pay (through co-pay and co-insurance) for your prescription drugs also vary widely. Once you spend $5,100 out of your own pocket, you’re considered to have catastrophic coverage, and the amount you pay for your drugs will decrease.
If you meet certain income qualifications, there are programs that can help pay your Medicare premiums. See the Official US government website or call 1-800-MEDICARE (800-633-4227) to learn more.
Medicare Advantage Plans
The alternative to Original Medicare is to enroll in a Medicare Advantage plan. About one-third of people eligible for Medicare choose this option. These plans are offered by private insurance companies and cover Parts A and B; most of the time, they also cover Part D. Enrollees must stay enrolled in Parts A and B while enrolled in a Medicare Advantage plan. They must pay the Part B premium as well as the monthly premiums of their Advantage plan, which can range from $0 to $350 or more. The average is about $38 per month.
Each Advantage plan has its own summary of benefits, which will tell you what your co-pays will be for various healthcare services. Your plan will offer all the same services as Original Medicare, such as doctor visits, surgeries, lab work and so on. You might pay $10 to see a primary care doctor. Specialists will often be more: a $50 specialist co-pay is quite common. Diagnostic imaging, hospital stays and surgeries may have higher co-pays.
For 2019, there are an average of 24 different Advantage plans from which to choose, depending on your state of residence. Most plans have an HMO or PPO network of providers. Most Medicare HMO plans do not cover anything out of network except emergencies. In PPO networks, seeing a provider outside the network will be partially covered but it will cost you much more than if you stay within the network.
Unlike Original Medicare, Advantage plans may cover lifestyle support services, including home meal delivery, transportation to and from medical appointments, home health aides and home safety fixtures (like handrails and ramps). They often offer minor benefits for routine dental, vision or hearing, and some even include gym memberships. Advantage plans also offer the convenience of having both medical and Part D drug coverage in one plan.
It’s important to know the rules that generally apply to Advantage plans:
- Prior authorization for certain procedures is common, especially in Advantage HMO plans.
- You must obtain a referral from your primary care physician before seeing a specialist on many HMO plans.
- You are responsible for cost-sharing expenses or co-pays for treatment. Some cancer services under Medicare Advantage plans require you to pay up to 20% of the cost of your treatment. You will pay this until you reach the plan’s out-of-pocket maximum. That maximum can be as high as $6,700 per calendar year within the network and even higher out-of-network. One you reach the out-of-pocket maximum, the plan will pay 100% of your treatments for the remainder of the calendar year. Original Medicare does not have out-of-pocket maximums for Parts A or B.
- As of 2019, Advantage plans may require step therapy for part B medications. This means patients will have to try a less expensive drug before a more expensive one is covered, even if the cheaper drug is less effective.
You can enroll in Original Medicare or an Advantage plan during the Initial Enrollment Period when you first turn 65. After that, you may enroll or dis-enroll only during certain times of year. Once you enroll in Medicare Advantage, you have the option of trying it for 3 months and switching to another plan or Original Medicare. After the initial 3 months, you must stay enrolled in the plan for the rest of the calendar year. The Annual Election Period in the fall is the most common time to change your Medicare Advantage plan. This period runs from October 15th to December 7th each year. Pre-existing conditions are covered under Medicare plans, though there may be a waiting period for Medigap insurance.
Concerns about Medicare Advantage Plans and Cancer Coverage
- The HHS Office of the Inspector General (OIG) recently found that Medicare Advantage plans deny care—inappropriately—at relatively high rates. It may be that prior authorization rules are a reason that sicker Medicare Advantage patients are more likely to dis-enroll in their plans than healthier people.
- Four in 5 Medicare Advantage enrollees are in plans that require prior authorization for some services, including for Part B drugs, hospital and skilled nursing facility stays, lab tests, home health and medical equipment.
- Step therapy requirements can mean that patients are denied access to new and better medications until they have tried a less expensive drug. For cancer patients, this can mean delays in using the best treatments to treat their cancer, side effects and treatments.
- If you plan to travel, you will need to contact your Advantage plan to find out if/which benefits are available out-of-state. If your plan does not offer out-of-state coverage, the same firm may offer another plan that does, or you may need to find a similar plan offered by another firm in your area. If you decide to switch to a different plan, however, you will need to wait until the annual Medicare Open Enrollment period (October 15 to December 7). You can also use the annual Medicare Advantage Open Enrollment period (January 1 to March 31) to switch to a different Medicare Advantage plan or switch to traditional Medicare.
Making decisions regarding which Medicare plan is right for you can be complicated and confusing. Cancer patients often find that original Medicare is their best option for covering treatment costs. However, there are resources available to help you decide, such as:
The Official US government website or call 1-800-MEDICARE (800-633-4227). This site has a section that explains how to get help from your state paying your Medicare premiums. In some cases, Medicare Savings Programs may also pay Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) deductibles, coinsurance, and copayments if you meet certain conditions. These conditions are listed below under "How do I apply for Medicare Savings Programs?" If you meet certain income and resource limits, you may qualify for Extra Help from Medicare to pay the costs of Medicare prescription drug coverage.
Medicare Help: Compare various insurance options to see which one suits your needs best. MedicareHelp.org offers comprehensive information on Medicare, Medicare Advantage, Medicare Part D and their providers.
The Henry Kaiser Health Foundation: Provides an overview of Medicare and Medicare Advantage.
Local Help for Health Insurance: Find local help to apply for health insurance. People and groups in the community offer free assistance with both the application process and picking and enrolling in a plan.
State Health Insurance Assistance Programs: Offers assistance for Medicare-eligible individuals, their families, and caregivers through objective outreach, counseling and training to make informed health insurance decisions that optimize access to care and benefits.
-- Ellen Miller Sonet, MBA, JD
Chief Strategy and Policy Officer, CancerCare