Dear Addy: Transition to Medicare

Dear Addy,

I have severe hemophilia B and take several prescription drugs for break through bleeds and medical procedures. Can I continue to take these drugs when I am retired in 18 months and on Medicare? If not, what would my options be? How would I ever afford the 20% co-pays? I have money saved to get my wife and I through our retirement years, but not enough to pay crazy amounts of money for co-pays. I hope your answer is not the same one as the one provided by my hematologist – to work for as long as I can!

Signed,

Ready to Retire


Dear Ready to Retire,

That’s a great question! Medicare, unfortunately, entails some complex decision-making for people approaching retirement. It’s fantastic that you are tackling these issues in advance, and I’m happy to point you to some resources.

Medicare

You are right that Medicare by itself does not provide enough coverage for your clotting factor. Clotting factors are covered under Medicare Part B. In original Medicare, Part B comes with 20% coinsurance – which is obviously out of reach for most anyone who uses hemophilia medications!

That’s why supplemental coverage (e.g., Medigap) is so essential for people with hemophilia who enroll in traditional Medicare, Medigap plans are supplemental policies, sold by private health insurers, that fill the gaps in Part B (and in Part A hospital coverage).

What Medigap policies AREWhat Medigap policies AREN’T/DON’T do
Supplemental policies (sold by private health insurance carriers) that supplement original Medicare A and BAre not compatible with Medicare Advantage, employer, or union plans
Offer the only way to get comprehensive hospital and outpatient coverage within original Medicare, including near-100% coverage of Part B drugs (including bleeding disorder injectables)Don’t cover couples (if both spouses are eligible for Medicare, each may need to subscribe to a Medigap plan)
Come in 10 standardized plan designs, identified by letterDon’t cover dental, vision, hearing, long-term care
Guaranteed issue during your initial window of eligibility*Generally, don’t cover Part D prescription drugs

It’s important to sign up for Medigap coverage during your initial window of eligibility (i.e. when you first enroll in Medicare), because once you’re outside that window, Medigap insurers in most states can turn you down or charge you more based on your health status.

(It’s also important to sign up for Medicare Part D drug coverage during this initial window of eligibility. Part D does NOT cover clotting factor but covers other medications that you may be taking now, or may expect to take as you age.)

You’ve probably heard about an alternative route to get senior health coverage, Medicare Advantage (also known as Medicare Part C). Medicare Advantage plans are private insurance policies that combine Part A, B, and D coverage and add some additional benefits. But Medicare Advantage plans limit you to narrow networks of providers, and do come with high out-of-pocket costs. Medigap supplements are NOT available to enrollees in Medicare Advantage plans, so you CANNOT count on Medigap to help with OOP costs if you opt into Medicare Advantage.

Here’s a chart comparing Original Medicare with Medicare Advantage:

CoverageOriginal Medicare covers hospital services and medical/outpatient care, including bleeding disorders injectables.Medicare Advantage plans have to cover all services covered by original Medicare, and may also cover additional services (vision, hearing, dental)
OOP costs; supplemental coverageThere is no limit on how much you may have to pay out-of-pocket (OOP) under original Medicare, unless you add supplemental Medigap coverage. People with bleeding disorders will need supplemental Medigap coverage (unless they qualify for Medicaid by virtue of their income).Medicare Advantage plans include a yearly limit on patient OOP costs, but that limit may be high. Medicare Advantage enrollees are NOT eligible to purchase supplemental Medigap coverage.
Prescription drugsOriginal Medicare does not cover most drugs (though it does cover bleeding disorders injectables). Enrollees in Original Medicare must buy a separate Part D plan to get coverage for drugs they buy at a drugstore.Most Medicare Advantage plans include Part D drug coverage.
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