One of the few things I looked forward to when I approached 65 was becoming Medicare eligible. Before becoming eligible for Medicare, I found a high deductible plan that I could afford as a self-employed person. Since I’m a really healthy person, it worked fine until I broke my ankle and needed surgery and a hospitalization. Then the high deductible kicked in and I found myself with thousands of dollars in medical expenses. Especially for older people who are self employed and for those whose employer doesn’t provide adequate (or any) insurance, Medicare provides good coverage with minimal out-of-pocket expenses.
Medicare, passed by Congress in 1965, is a national health insurance program for the elderly (OMG, do I fit that category?) and the disabled. It was designed when medical care was quite different than it is now. One of the biggest differences has been the explosion of medications to treat a myriad of ailments. Many of these drugs are lifesavers and we are all better off for them. But, these medications can be quite expensive. Medicare, in its original form, didn’t cover most drug costs. As the years marched on and more drugs came on the market, Medicare recipients were going broke trying to pay for their prescriptions.
To remedy that situation, Congress passed the Medicare Modernization Act in 2003, adding both Medicare Advantage (managed care) plans and Part D Medicare, prescription drug coverage. The new law took effect in 2006. I won’t go into Medicare Advantage Plans here, but Part D attempted to address prescription drugs’ problematic high costs. Unfortunately, the law does not allow Medicare to negotiate with pharmaceutical companies on costs (the VA, another Federal program, is allowed to do this). The drug plans, though overseen by CMS (Centers for Medicare and Medicaid Services), are independent. They decide on costs and change their formularies regularly.
So, let’s get back to why I’m singing the blues. When I signed up for Medicare a couple of years ago, I had a lot of choices to make. Did I want regular Medicare (yes I did) or a Medicare Advantage Plan? In regular Medicare, I was automatically enrolled in Part A, hospitalization. Part B is for doctor visits and the monthly premium is deducted from my Social Security payment. As to Part D, drug coverage, I had many options including plans with an annual deductible and plans with a range of monthly premiums. At the medicare.gov site, you can put in your personal information plus the drugs you regularly take and get a list of all the plans in your area that cover those drugs. Medicare.gov also provides information on what your monthly premiums and co-pays for those drugs will be in each plan.
As a healthy senior, older person, whatever they’re calling me these days, I wasn’t taking any regular medications, but I decided to sign up for a Part D plan for two reasons: 1. Insurance is about hedging your bets and I could afford the monthly premium; 2. You pay a penalty if you don’t have creditable coverage (i.e., as good as Medicare’s) and you wait until you need Part D rather than signing up right away. So, I thought, let me sign up now. You never know what the future holds. I looked for an inexpensive plan with no deductible that covered the one drug I occasionally take for sleep.
That first fall, a few months after I was Medicare-eligible, my Part D plan must have sent me a notice of a rate hike but I didn’t see it. So, as of January 1, my monthly premium almost doubled — now not so affordable. Open enrollment, for a few months in the fall, allows you to switch plans. But since I didn’t see the rate hike notice, I was locked into that rate and plan for a year.
Then that summer I went through a bad period of no sleep and my usual medication stopped working. A friend turned me on to her sleep drug of choice. I asked my doctor. for a prescription but, when I went to the pharmacy, I was told that, even though the new drug was an older medication and a generic, my plan didn’t cover it and it cost over $5 a pill. I bit the bullet and bought a few. The following fall, during open enrollment, I switched to a lower premium plan that covered both my old sleep medication and the new one I wanted to use.
A month after my new plan went into effect, I went to my optometrist and was diagnosed with a sty. He prescribed the only generic eye drop to treat it, but my pharmacy told me that my co-pay would be $47! It turns out that my plan has it classed as a tier 3 generic (there are several tiers, tier 1 being the least expensive). I called the plan and they said that Medicare determines the tiers.
I have subsequently found out a few things: a brand name can be cheaper than a generic (always check) and Medicare does not determine the tiers. Each plan does. There are appeals (both expedited and regular) that you can, and should, pursue whenever a plan classes a drug out of reach or denies coverage for a prescribed drug. The other thing I found out from the Medicare Rights Center (see below) is that the problems I experienced, both non-coverage and an unaffordable tier, are the most common Part D problems that people call the Center for help with.
So what’s a girl to do? First, read everything your plan sends you. Second, don’t believe what your plan tells you and never take no for an answer: appeal, appeal, appeal. Third, be a savvy consumer and understand, as best as possible, the rules.
And, finally, know where you can get help:
(1) Your local State Office for Aging. The staff can help you pick a plan and help with any problems you’re having with your plan. They can also give you information about what programs are available to help pay for Part B and Part D premiums. I am currently training with my local office as a volunteer with the Health Insurance Information, Counseling and Assistance Program (HIICAP) so I can help others navigate the complexities of Medicare.
(2) The Medicare Rights Center: medicarerights.org. The Center is a national non-profit consumer services organization, based in New York City, that works to ensure access to affordable health care for older adults and people with disabilities through counseling and advocacy, educational programs, and public policy initiatives. Their consumer helpline (1-800-333-4114) is staffed by knowledgeable people who can help with any problems you are having. Their website (www.medicareinteractive.org) is chock full of information, including videos, to help you understand your rights in Medicare. Join them in advocating to make Part D simpler and easier for consumers.
Many thanks to the Center’s staff for being extremely generous with their time and expertise about Part D for this article.
Laura Kaplan is a life-long women’s health activist and the author of The Story of Jane. She is a former NWHN board member.