More than two-thirds of Medicare beneficiaries have multiple chronic conditions, such as cancer, diabetes, heart disease, kidney disease and lung disease.
Although original Medicare and Medicare Advantage have always provided coverage for these conditions, some plans now offer additional benefits. What’s more, Special Needs Plans, designed for Medicare Advantage enrollees who have a chronic condition, are growing in number.
Open enrollment runs from Oct. 15 to Dec. 7, so it’s a good time to assess your medical and drug coverage needs. If you have a chronic condition, consider these options.
Insulin savings program expands
One in every 3 Medicare beneficiaries have diabetes, and 3.3 million beneficiaries use one or more types of insulin, according to the Centers for Medicare and Medicaid Services (CMS). The Part D Senior Savings Model, which became available this year, provides insulin with no more than a $35 copayment for each month’s supply through participating Part D prescription drug plans and Medicare Advantage plans with drug coverage. More than 2,100 Part D and Medicare Advantage plans will participate in the program in 2022, an increase of over 500.
Keep in mind, you’ll have to check a plan’s benefits before signing up, because some Part D and Medicare Advantage plans don’t participate in the insulin savings program and some types of insulin aren’t covered, says Laura Friedman, vice president of regulatory affairs at the American Diabetes Association.
When choosing a plan, be sure to compare the costs of all your medications, not just the insulin.
“While an individual’s insulin may be less expensive with the program, in some cases their other medications might turn out to be more expensive,” Friedman says. “So we encourage everyone to determine their total medication cost before switching to a new plan.” To compare the total cost of premiums and copayments for your medications and the plans available in your area, visit Medicare.gov.
Extra benefits for Medicare Advantage enrollees
Since 2019, some Medicare Advantage plans have offered extra health-related benefits — coverage of over-the-counter medications, in-home support services, nutrition counseling and transportation to medical appointments — to people with chronic conditions. Last year the benefits expanded to include nonmedical services, such as meal delivery, transportation to the grocery store and even pest control.
“We’ve seen a lot of expansion in the number of plans that offer these benefits and the breadth of their offerings,” says Tom Kornfield, senior consultant at Avalere, a health care consulting firm.
Now, 19 percent of Medicare Advantage plans offer supplemental benefits to people who are chronically ill, according to the CMS. Next year, 25 percent will offer these benefits. The benefits may sound generous, but they can be limited.
“They vary dramatically, and they can be very different than they sound,” says Casey Schwarz, senior counsel for education and federal policy at the Medicare Rights Center. A Center for Medicare Advocacy study found that one plan limited in-home support services to 12 visits a year and another plan covered a home health aide who could assist with the activities of daily living for only four four-hour shifts after a patient is discharged from the hospital. The number of trips to doctor appointments or the store included in a plan also is usually restricted.
Before you sign up for a plan that offers special benefits, find out whether you qualify. The way an insurer determines whether a person has a chronic condition can vary.
“It may be as simple as someone answering a questionnaire when they’re enrolling. Or a plan may screen claims data and then put people into the category that applies to them,” says Christine Leo, vice president of Medicare product at Cigna.
You can find basic information about these benefits when comparing plans through the Medicare Plan Finder, but you may need to read the plan’s Summary of Benefits or Evidence of Coverage on the company’s website. You can also call the plan's customer service number or get help from your State Health Insurance Assistance Program (SHIP).
Special Needs Plans offer extras
A type of Medicare Advantage plan called a Special Needs Plan (SNP) provides coverage for certain groups of people, such as those who are enrolled in both Medicare and Medicaid and those who have chronic conditions. A chronic condition SNP offers coverage to those who have diabetes, end-stage renal disease, heart disease, chronic obstructive pulmonary disease (COPD) and other illnesses.
These plans must provide prescription drug coverage, and they usually offer extra benefits, such as lower copayments for specialists and medications. Many don’t charge an additional premium aside from the usual Part B premium.
SNPs also may provide a care coordinator who can answer your questions, help you monitor your condition, get the right prescriptions, schedule preventive services and ensure that you keep your doctor appointments. If you have traditional Medicare, your doctor can coordinate your medical care, but not all physicians provide this service. Medicare is trying to expand chronic care management services by providing additional reimbursement to clinicians who offer them.
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“There has been tremendous growth in Special Needs Plans over the past five years,” says Gretchen Jacobson, vice president of Medicare at the Commonwealth Fund. This year there are 214 plans for people with chronic conditions, up from 171 plans in 2020, according to the CMS. There will be 283 chronic condition plans in 2022.
Nearly 400,000 people are enrolled in chronic condition plans, and that number is expected to rise next year. The most common plan is designed for people who have cardiovascular disorders, chronic heart failure and/or diabetes.
An SNP for people with diabetes may provide nutrition counseling, meal delivery and low-cost insulin, and the prices may be even less expensive than the insulin savings program, says Christine Leo of Cigna, which has chronic condition SNPs for consumers with diabetes. These plans offer access to doctors who specialize in diabetes, and they may charge low or no copayments for visits to a primary care physician and specialists.
“The benefits of having a chronic condition Special Needs Plan include access to hospitals and medical professionals who specialize in the condition or disease and low or no out-of-pocket costs for visits to primary care physicians and specialists,” says Alex Furman, vice president of Medicare duals strategy at Anthem, which offers several kinds of SNPs.
Anthem’s SNPs for people with end-stage renal disease offer reduced cost-sharing for services and supplies for dialysis and coverage for medications that are specific to kidney conditions as well as others. “These plans also connect members with specialists for no copay and a dedicated kidney care team that provides 24/7 telephone access and in-home visits,” he says.
The availability of SNPs for chronic conditions varies by location. In North Carolina, for example, some counties don’t have plans for people with chronic conditions, says Melinda Munden, director of the Seniors' Health Insurance Information Program in North Carolina. Even if a plan covers a chronic condition in your area, it may not cover your condition.
Ask your doctors or other providers if they participate in SNPs. Munden’s mother-in-law, who has end-stage renal disease, found out about a plan through her dialysis center. You can also search for a plan by using the Medicare Plan Finder. Search for a Medicare Advantage plan and click on Special Needs Plans in the “filter by” section. Your local SHIP may also be able to help you find a plan in your area.
If a plan is available in your county, be sure your medications and providers are covered, including the hospital you’d like to use, Munden says. Most SNPs are health maintenance organizations (HMOs) and some are preferred provider organizations (PPOs), so it’s important to find out whether your doctors, specialists and other services, such as a dialysis center, are included in the plan’s network. With a PPO, you can use out-of-network providers but will have higher copayments. With an HMO, you may not have coverage for out-of-network providers except in emergencies.
How to Get The Coverage You Need
These benefits can help people with chronic conditions, but it’s important to check your overall coverage during open enrollment.
“You should focus on the whole picture, not just the bells and whistles,” says David Lipschutz, associate director for the Center for Medicare Advocacy. “What does the provider network look like? What is the cost-sharing and the maximum out-of-pocket amount? Are my drugs in the formulary?” Consider the following before making a decision.
- Be sure you can see your doctors. If you’re choosing between original Medicare and Medicare Advantage, keep in mind that original Medicare gives you the flexibility to use any provider or hospital that accepts Medicare. You don’t need a referral from a primary care provider, as you do with many Medicare Advantage plans. This may be particularly important if you want to see an expert who is not in a Medicare Advantage plan’s network.
Find out your plan’s rules for appealing to get coverage for an out-of-network provider. “You generally have to show that such coverage is not available in the network,” Lipschutz says.
- Consider your out-of-pocket costs. In 2022 the average Medicare Advantage premium will be $19 a month, in addition to the Part B premium, and most plans include prescription drug coverage. On the other hand, with traditional Medicare you’ll need to get a separate Part D plan (premiums will average $33 a month in 2022) and, possibly, Medigap coverage to help cover Medicare’s deductibles and copayments.
With traditional Medicare and a Medigap plan, you may have few out-of-pocket costs other than the Part B deductible. But if you have a Medicare Advantage plan, your out-of-pocket costs will increase as you use more medical services. This year, Medicare Advantage plans have an out-of-pocket spending limit for medical expenses, not counting premiums, of $7,550 for in-network services and $11,300 for covered in-network and out-of-network services combined.
- Think twice before switching from original Medicare to a Medicare Advantage plan. If you change your mind and want to switch back to original Medicare, you may have a difficult time getting a Medigap plan unless you’ve moved out of a plan’s service area or meet other requirements.
If more than six months has passed since you enrolled in Part B of Medicare, Medigap insurers in most states can charge more or deny coverage for preexisting conditions. People with chronic conditions may have an especially difficult time getting new coverage.
Ask your local SHIP about your state’s rules. Certain states, such as New York and Massachusetts, don’t allow Medigap insurers to charge more or turn people down because of preexisting conditions.
Kimberly Lankford is a contributing writer who covers personal finance and Medicare. She previously wrote for Kiplinger's Personal Finance Magazine, and her articles have also appeared in U.S. News & World Report, The Washington Post and the Boston Globe. She received the personal finance Best in Business award from the Society of American Business Editors and Writers.