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Expanded Medicare Benefits Available for People With Chronic Conditions

Options for people with diabetes, heart, kidney, other long-term diseases

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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 provide coverage for these conditions, some plans now offer additional benefits. And special needs plans (SNPs) designed for Medicare Advantage enrollees with chronic conditions are growing in number.

Open enrollment runs Oct. 15 to Dec. 7, so that’s a good time to assess your medical and drug coverage needs. If you have a chronic condition, consider these options.

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Savings for patients who need insulin

The opportunity: One in every 3 Medicare beneficiaries has diabetes, and 3.3 million beneficiaries use one or more types of insulin, according to the Centers for Medicare and Medicaid Services (CMS). The Inflation Reduction Act capped Part D and Medicare Advantage copays for insulin at $35 a month as of Jan. 1, 2023. For insulin through an external pump, which Part B covers, the cap took effect July 1, 2023.

The caveat: Not every Part D plan covers every insulin, so make sure your plan covers the type you take. The timing of the Inflation Reduction Act, signed in August 2022, made finding that information more complicated in 2023, but the problem will be resolved when you shop for 2024 plans.

The Medicare Plan Finder for 2023 plans doesn’t include the $35 monthly cap when estimating annual drug costs because insurers had already set their premiums and copays. If you take insulin, call 800-MEDICARE (800-633-4227) or contact your State Health Insurance Assistance Program (SHIP) for help choosing a 2023 plan. For 2023 coverage for people who use insulin, Medicare is extending the deadline to add, drop or change Part D coverage until Dec. 31 because of the Plan Finder problems.

When choosing a Part D plan, be sure to compare costs of all your medications, not just insulin.

Extra benefits for Medicare Advantage enrollees

Since 2019, some Medicare Advantage plans have offered extra health-related benefits for those with chronic conditions, including coverage of over-the-counter medications, in-home support services, nutrition counseling and transportation to medical appointments. In 2020, plans added nonmedical services, such as a grocery allowance, home modifications, meal delivery, transportation for nonmedical needs and even pest control.

These benefits are officially called special supplemental benefits for the chronically ill (SSBCI). Some are available through flex cards, prepaid debit cards that Medicare Advantage plans sometimes offer to cover extra expenses.

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“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 health care consulting.

The benefits may sound generous, but they can be limited.

“They vary dramatically and can be very different than they sound,” says Casey Schwarz, senior counsel for education and federal policy at the Medicare Rights Center. For example, a Center for Medicare Advocacy study found some plans that limited in-home support services to 12 visits a year or covered only four four-hour shifts after a patient is discharged from the hospital. They also restrict the number of trips to doctor appointments or the grocery store.

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 for details.

Special needs plans offer extras for chronic conditions

Special needs plans are types of Medicare Advantage plan that offer specialized coverage, including:

  • Chronic condition special needs plans (C-SNPs). For people with chronic conditions including chronic obstructive pulmonary disease (COPD); dementia; diabetes; end-stage renal disease, also called kidney failure; and heart disease.
  • Dual eligible special needs plans (D-SNPs). For people who qualify for both Medicare and Medicaid.
  • Institutional special needs plans (I-SNPs). For people who live in care facilities such as nursing homes or who require institution-level nursing care at home.
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SNP enrollment increased 24 percent from 2022 to 2023, according to KFF, formerly known as the Kaiser Family Foundation. These plans must provide prescription drug coverage, and they may provide lower copayments for specialists and medications related to the condition. Many plans don’t charge an additional premium aside from the usual Part B premium.

Special needs plans also may provide a care coordinator who can answer your questions and help you get the right prescriptions, keep your doctor appointments, monitor your condition and schedule preventive services.

“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.

Sample SNP coverage for diabetes

  • Access to diabetes specialists
  • Low-cost insulin
  • Meal delivery
  • No or low copayments for primary care physicians and specialists
  • Nutrition counseling  

Sample SNP coverage for end-stage renal disease

  • Dedicated kidney care team for 24-7 phone access and home visits
  • Kidney-specific medications
  • Reduced cost sharing for dialysis services and supplies 

The availability of SNPs for chronic conditions varies by location. Ask if your doctor participates in a special needs plan or check with your SHIP.

You can also use the Medicare Plan Finder to search for SNPs in your area. Type in your zip code and click on Medicare Advantage plan. Click view all filters and then Chronic Condition Special Needs Plans.

Before choosing a plan, find out whether your doctors, specialists and other services, such as a dialysis center, are included in the plan’s network and if you will have coverage if you go out of network. With a preferred provider organization (PPO), you can use out-of-network providers but will have higher copayments. With a health maintenance organization (HMO), you may not have coverage for out-of-network providers except in emergencies.​

How to get the coverage you need

While SNPs and some other plans offer extra benefits for chronic conditions, check your overall coverage during open enrollment and also when choosing between original Medicare and Medicare Advantage. Consider the following before making a decision.

Be sure you can see your own doctors. If you’re choosing between original Medicare and Medicare Advantage, keep in mind that original Medicare gives you 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 for people with chronic conditions who may want to see an expert outside of their plan’s network.

Compare out-of-pocket costs. In 2023, the average premium is $18 a month for a Medicare Advantage plan in addition to the Part B premium. Most plans include prescription drug coverage.

The plans’ out-of-pocket costs increase as you use more medical services. In 2023, Medicare Advantage plans have an out-of-pocket spending limit for medical expenses, not counting premiums, of $8,300 for in-network services and $12,450 for covered in-network and out-of-network services combined. 

For original Medicare, you’ll need to get a separate Part D plan — premiums average $31.50 a month in 2023 — and Medigap coverage or its equivalent to help cover Medicare’s deductibles and copayments. But with original Medicare and a Medigap plan, you may have few out-of-pocket costs other than the Part B deductible. 

Think twice before switching from original Medicare to a Medicare Advantage plan. If you have Medicare Advantage but 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 passed since you enrolled in Medicare Part B, 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. These rules vary by state — contact your SHIP for details.

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