Marci's Medicare AnswersMarch 2013
Dear Marci,
I am eligible for Medicare, because I have End Stage Renal Disease. Can I join a Medicare Advantage plan?
—Athena
Dear Athena,
Most people who are eligible for Medicare due to End Stage Renal Disease (ESRD) cannot join Medicare private health plans, also known as Medicare Advantage plans, and must stick with Original Medicare, the traditional fee-for-service Medicare program offered directly through the federal government. However, there are a few exceptions.
If you have ESRD, you can join a Special Needs Plan (SNP) that specifically accepts people who have ESRD, if there is one in your area. A Special Needs Plan is a type of Medicare Advantage plan that exclusively or primarily serves members who have a particular special need such as a chronic illness. Alternatively, if you have employer health coverage through the same insurance company that offers a Medicare Advantage plan, you are eligible to enroll in that company’s Medicare Advantage plan.
Keep in mind that if you developed ESRD after you joined a Medicare Advantage plan, your Medicare Advantage plan cannot disenroll you. Also, if your Medicare Advantage plan leaves Medicare and is no longer available, you have a Special Enrollment Period to join another plan in your area.
Contact 800-MEDICARE or visit the Medicare Plan Finder online at www.medicare.gov to learn more about Special Needs Plans and Medicare Advantage plans within your area. Remember, if you are in a Medicare Advantage plan, you will typically have to see doctors, hospitals and dialysis facilities that are in your plan’s network in order for your services to be covered by your plan. Make sure you’re aware of the plan’s rules and costs before making any decisions about your health care coverage.
—Marci
Dear Marci,
My pharmacist told me that my Medicare prescription drug plan will cover my drug, only if I undergo step therapy. What is step therapy?
—Bria
Dear Bria,
Step therapy is a type of coverage restriction that Medicare prescription drug plans, also known as Part D plans, place on certain drugs. If your Part D plan requires you to try step therapy, this means that you must try a similar, less expensive drug to treat your condition before the plan will cover the drug that was originally prescribed to you.
If your doctor feels that step therapy may be harmful to your health or that the cheaper drug may not be as effective as the prescribed drug, ask your doctor to help you request an exception to the plan’s coverage rules.
Step therapy is one type of coverage rule that Medicare prescription drug plans impose on certain prescription drugs. The two other types of coverage restrictions include prior authorization, which is when the plan requires you to get permission from the plan before they cover your drug, and quantity limits, which is when the plan limits the amount of a drug that will be covered over a specified period of time.
Keep in mind that coverage rules vary, depending on your plan. For more information on coverage rules and drug costs, you should contact your prescription drug plan, directly.
—Marci
Dear Marci,
I was told that I have the QMB Medicare Savings Program and that I wouldn’t have to pay anything for doctors’ office visits. Is this true?
—Sofia
Dear Sofia,
Qualified Medicare Beneficiary (QMB) is one type of Medicare Savings Program that pays for your Medicare premiums, deductibles, coinsurance and copays. Medicare Savings Programs, like QMB, help pay your Medicare costs if you have limited income.
If you have QMB, try to find a doctor who accepts both Medicare and Medicaid. These doctors are more likely to know that people with QMB cannot be billed for Medicare costs. If you have QMB and you are still charged a coinsurance or copay, let your doctor know that you have QMB. If your doctor still charges you a coinsurance or copay, click here for information that explains why charging these amounts are prohibited for individuals with QMB. It may be helpful to share this information with your doctor.
Bear in mind that Medicare Savings Program eligibility requirements vary by state. Check with your state Medicaid program or contact your State Health Insurance Assistance Program (SHIP) to learn whether or not you qualify for these programs.
—Marci
Marci's Medicare Answers is a service of the Medicare Rights Center (www.medicarerights.org), the nation’s largest independent source of information and assistance for people with Medicare. To subscribe to "Dear Marci," MRC's free educational e-newsletter, click here.
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