Senior Life: Medicare

Have you ever wondered what is covered under the different parts of Medicare?  Your Lewis Drug Pharmacists know that Medicare can be confusing and that choosing a plan that is best for you may be a challenge.  The following will help explain the different parts of Medicare along with a few tips to keep in mind when evaluating your current prescription drug plan or selecting a new plan this Fall. 

• Medicare Part A: Hospital Insurance (Inpatient care) that helps cover:
  • Skilled nursing facility care (That is not custodial/long-term)
  • Hospice care
  • Home health care
• Medicare Part B: Medical Insurance that helps cover:
  • Outpatient care
  • Home health care
  • Durable medical equipment (wheelchairs, walkers, etc)
  • Many preventive services (screenings, some vaccines, and a yearly wellness exam)
• Medicare Part C: Medicare Advantage Plans
  • Sold by private companies, alternative to original Medicare for health and drug coverage
    • Bundle that includes Part A, B, and often D
    • May offer additional benefits that original Medicare does not 
      • Examples: Vision, dental, and hearing services
• Medicare Part D: Prescription Drug Insurance that also helps cover some vaccines (shingles, tetanus, and more)

Medicare Prescription Drug Coverage 

• Prescription drug coverage is a benefit that is optional, but available to anyone with Medicare

• You may receive a late enrollment penalty if you do not enroll when you are first eligible

• Plans vary in what medications are covered and their cost
  • Medicare.gov has a helpful tool to search for Medicare Part D or Advantage Plans
• Prescription drug coverage can be obtained through a Prescription Drug Plan (PDP, Part D) or a Medicare Advantage Plan (Part C)
• Part C: Similar to a Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO) that offers prescription drug coverage (Also referred to as MA-PDs)
• Part D: Adds drug coverage to original Medicare (Parts A and B)
  • There is an annual deductible which is the amount you are responsible for each year before your drug plan will pay its share for your medications. The amount can vary by plan and some do not have one. In 2022 no Medicare drug plan could have a deductible over $480. In 2023 this will increase to $505. 
  • Copays and coinsurance is the amount you will pay for covered medications after you meet the deductible. Coinsurance may change throughout the year based on changes in your total medication expenses. This also changes based on the tier your medications are assigned to. 
    • Once you and your drug plan spend a combined total of $4,660 on medications you will enter the coverage gap (“donut hole”). In the coverage gap, you will not pay more than 25% of the cost of your medications until you reach the $7,400 out-of-pocket maximum. This amount includes your deductible. 
    • Patients who get extra assistance with paying for their Part D plan will not have a coverage gap. 
    • After the coverage gap is met, you then enter catastrophic coverage for the rest of the year. This means you will pay a small coinsurance percentage or copay for medications that are covered. 

When can I sign up for Medicare prescription drug coverage? 

• When you turn 65
• If you are newly eligible for Medicare due to a disability (<65 years old) 
• Already eligible for Medicare due to a disability and are 65 years old
• If you don’t have Medicare Part A and enrolled in Part B during the Part B General Enrollment Period which is January 1st to March 31st (Eligible for a Medicare PDP from April 1st to June 30th)
• If you have Medicare Part A and enrolled in Part B during the Part B General Enrollment Period which is January 1st to March 31st (Eligible for a Medicare Advantage Plan from April 1st to June 30th)

When can I make changes to my current prescription drug coverage?

Open enrollment period runs from October 15th through December 7th each year

• Changes that can be made during the annual open enrollment period include: 

• Change from Original  Medicare plan to an Advantage plan and vice versa
• Change to a different Medicare Advantage Plan
• Change from a Medicare Advantage Plan without drug coverage to one with it, and vice versa
• Join or change Medicare drug plans
• You also may enroll in Medicare Part D (prescription drug) if you didn’t when you were first eligible or you may cancel your prescription drug coverage completely

Medicare Advantage Plan Open Enrollment is from January 1st to March 31st 

• Changes that can be made during this enrollment period include:

• Switch from one Medicare Advantage Plan (with or without drug coverage) to another
• Cancel your Medicare Advantage Plan and return to Original Medicare (Can then join a PDP, if desired)

• Changes that cannot be made: 
  • Change from Original Medicare to a Medicare Advantage Plan
  • Join a Medicare PDP if enrolled in Original Medicare
  • Switch from one PDP to another if in Original Medicare

Who can help me evaluate and sign up for a Medicare Part D plan? 

• Pharmacists
• Insurance agents
• State organizations 
  • South Dakota has a program called Senior Health Information and Insurance Education (SHIINE) which is federally funded
    • Located in Eastern, Western, and Central South Dakota
    • Provides free, unbiased, and confidential information to Medicare recipients
    • Visit their website at http://shiine.net/home.html for more information
  • Iowa has a program called Senior Health Insurance Information Program (SHIIP) that is offered through the state 
    • They have several locations with trained, certified volunteers to assist with answering Medicare questions
    • This is a free service and you can visit their website here to find a location near you https://shiip.iowa.gov/about 
  • Minnesota has a Senior LinkAge Line that can be called to help compare plans and choose one that fits your needs
    • For more information, visit their site at https://mn.gov/senior-linkage-line/older-adults/medicare/ 

What immunizations are covered by Medicare? 

• Medicare Part B covers the annual influenza immunization along with pneumonia, COVID-19, and hepatitis B immunizations. 
• Medicare Part D covers other vaccines such as those that provide protection against shingles and tetanus, diphtheria, and pertussis (Tdap). 

Medicare Part B is considered medical insurance. However, under some conditions, it covers some outpatient prescription medications and supplies. These are often medications you would receive at a clinic or hospital.  For these medications, patients pay 20% of the amount approved by Medicare and the deductible applies. In an outpatient setting, the co-pay is also 20%. If medications are not covered by Part B in a hospital outpatient setting, the patient will pay 100% unless they have Part D or other prescription drug coverage where the amount paid depends on the plan’s coverage. You can check your Part D medication formulary to see what medications are covered in the outpatient setting. 

Medicare Part B covered medications include: 

• Insulin used with an insulin pump
• Nebulized medications used with a nebulizer machine
• Diabetic testing supplies including meters, strips, lancets, etc.
• Injectable and infused medications
• Injectable osteoporosis medications
• Blood clotting factors
• End-Stage Renal Disease medications
• Transplant medications

References: 

CMS.gov- Announcement of Calendar Year (CY) 2023 Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies. https://www.cms.gov/files/document/2023-announcement.pdf. July 30, 2022.

Medicare.gov-The Official U.S. Government Site for Medicare. https://www.medicare.gov/. July 30, 2022. 

Minnesota’s Senior Linkage Line. https://mn.gov/senior-linkage-line/older-adults/medicare/. July 30, 2022.

Senior Health Information and Insurance Education. http://shiine.net/home.html.  July 30, 2022.

SHIIP Iowa’s Medicare Resource. https://shiip.iowa.gov/about. July 30, 2022.