Medicare Part A & B & D and Texas questions....

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RobinB29

New member
Okay, so my husband is getting out of the Army, I have had Tricare for the last ten years and I know nothing of regular insurance....I have Medicare Part A and am Part B eligible. My questions are as follows:

1. Can someone tell me how Medicare Part B works in terms of seeing CF docs? I will be living in the Dallas, Texas area.
2. What is Medicare Part D and do I need it?
3. Are there additional coverage programs I would be eligible for that would help and if anyone can tell me about those that would be helpful.
4. I have heard some pretty disparaging things about Medicare coverage for Kalydeco, I have two copies of the Delta F508 and I was hoping to get on it next year when the FDA approves the VX-809, does anyone have any experience getting Medicare to cover this drug in Texas? I have found forms online that discuss how Kalydeco is covered for CF folks in Texas but it's all so confusing to me.
5. Can anyone give me a rough estimate of copays and deductibles? I am hospitalized 1-2 times per year, I have a port and require monthly port access for flushing, 1-4 ER visits per year and take Zenpep, Pulmozyme, Xopenex, Nexium, Plaquinel, Buspar, TOBI and Cayston (every other month alternating).

I know it's a lot of questions but I figured here would be the best place to ask. I am very scared about us getting out and I know my husband will have some type of civilian health insurance plan through his new job but I am just trying to cover all our bases and see if I should go ahead and enroll in Medicare Part B before the enrollment period is up in December.
 
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triples15

Super Moderator
Hi Robin! I think I can help a little.... I live in Texas (recently moved here though) and I have Medicare A & B. I also have private insurance through my husbands employer, so my Medicare is secondary. I did have Medicare as my primary for a short while at one point though.

1. So, just because I'm not sure what you're familiar with I'm gonna sum up Medicare. Part A is hospital coverage (so inpatient stuff), part B is medical (doctor's visits/tests etc), Part D is prescription coverage. So Part B will pay 80/20 on your CF appointments. So they pay 80% and you pay the remaining 20%. Medicare negotiates super low rates for everything with hospitals, so usually your 20% isn't a ton. The only problem I have seen is that there are things they don't cover, and I can't quite pin down how/what they considered "covered services". I've had things that I just assumed were covered, only to have Medicare deny it.

2. Oops, covered this under number one, but Part D is prescription coverage. If there will be any period of time where you ONLY have Medicare (ie. aren't covered under your hubby's new employer or he doesn't have employment yet) then YES you will need a Part D. Regular Medicare (Part B) only pays for Pulmozyme, no other prescriptions, and even then you are left with a 20% copay.

There is a really cool tool on medicare.gov that lets you look at Part D plans. You can enter all of your medications and dosages etc, and it shows you what plans would cover you the best. The Part D premiums are usually pretty reasonable, and would be MORE than worth it if you have no other coverage for prescriptions.

3. So the Part B premium is currently $104 per month. It will go up a few dollars next year, as it does every year. The Part D plans vary in price, depending on what coverage you choose. When I was looking they were as low as $30 per month, going up to over $100 if my memory serves. There IS something Medicare calls "Extra Help". If you qualify financially they help you with your premiums and copays. I've never qualified, but it's something worth looking into. I can't remember what the income guidelines are like to qualify though. Sorry!

4. I have not heard anything regarding Medicare covering Kalydeco. I think there's a chance you are thinking of MedicAID coverage of Kalydeco, that has been in the news A LOT, as some states have been very resistant to paying for it. Medicare is run by the federal government, whereas the state governments are running Medicaid coverage. So for example, if Medicare covered Kalydeco for Nebraskans, it would also cover it for Texans (and every other state for that matter) because it is a federal program. I'm not sure if there is any Medicare coverage for it at all right now though, unless it's covered by Part B and I'm not aware. Hmm, that's a good question and I'll have to look into it.

5. Hmmm, an estimate would be tough, but I'll try! ;)

So for example, let's say your bill for a routine CF appt. is $1,000. Medicare will immediately knock that down, due to their contractual agreements with hospital. So let's say it's knocked down to $550, because that's all Medicare has agreed to pay for that service. Okay, now Medicare will pay their 80% of the $550, so they'll pay $440, leaving you with the remaining 20% which would be $110.

As far as the prescription copays, like I said previously, you'd have to have a Part D to have any prescriptions other than Pulmozyme covered. Go to the medicare.gov site and you should be able to get a decent estimate of what your copay for each medication your on would be.

Good luck to you, I know how overwhelming insurance changes are! Ugh. Let me know if you have follow-up questions on anything I've said. I know sometimes I'm not super clear!

Take care and good luck to you,

Autumn 34 w/cf
 
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triples15

Super Moderator
Me again, just reread your post and want to answer #5 a little better regarding copays and deductible. You will not pay a copay when you go for CF (or other) appointments. They just bill Medicare and you pay your 20% after. The Part B deductible is super low, some random amount just under $200. I want to say it's $187. So after you meet that deductible they pay the 80%.
 
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RobinB29

New member
Thank you so much!

This helps A LOT! It does get very confusing but I feel like I'm getting it now and I can research the drug plans to find the best one. :)
 
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Rigsby

New member
What happens if I have private insurance and Medicare Part A and B? Which one is billed first? Would the Medicare pay my private insurance copay if it's under 20%?
 
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triples15

Super Moderator
Hi Rigsby!

I also have private insurance (Blue Cross) AND Medicare parts A & B. There are specific criteria in deciding which insurance is primary. I know that if your private insurance is through an employer (either of your own, or of a spouse or parent), and the company employees more than 100 people, then that insurance is primary. In my case, my private insurance is through my husband's employer, and they employ over 100 people, so Blue Cross is my primary. if they employed less than 100, Medicare would be my primary. On the other hand, if you private insurance is a COBRA policy, Medicare is your primary. It also depends on other factors such as your age (over 65), and your reason for having Medicare(disability, age, black lung).

If I were you I would go to http://www.medicare.gov/supplement-...ance/who-pays-first/which-insurance-pays.html and look for your specific circumstance. If that's super confusing then come back and tell me and I'll help you look, based on your situation and what your private insurance is.

To answer your other question, that gets a little confusing....;) If Medicare is your secondary, they will be sent the bill after your primary pays whatever they are going to pay. Medicare then still looks at that bill as a whole and determines what their 20% would have been had your primary not paid anything. If the amount they (Medicare) would have paid is greater than what your private insurance paid, they will pay the difference.

That sounds clear as mud, right??

Let me know if I can help more, or you need me to try and clarify.

Take care,

Autumn 34 w/CF
 
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