Get the Medicare Coverage You Need for a Chronic Condition

Courtesy Medicare.gov

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If you have a chronic condition, you may be tempted to sign up for a Medicare Advantage plan during open enrollment, which runs from Oct. 15 to Dec. 7. Many plans are offering additional health-related benefits, such as transportation to medical appointments, nutrition counseling and in-home support services.

One-quarter of Medicare Advantage plans are providing supplemental benefits for people who are chronically ill, up from 19 percent in 2021, according to the Centers for Medicare and Medicaid Services (CMS). In addition, the number of Special Needs Plans (SNPs), which provide benefits for Medicare Advantage enrollees with specific chronic conditions, is growing.

While the new benefits are appealing, it’s important to understand a plan’s overall coverage before signing up. You’ll want to make sure you can see the doctors who have expertise in your condition and that you can go to the hospital of your choice. Original Medicare offers this flexibility.

“People with serious illnesses may approach their health care differently than people who are generally in good health,” says Tricia Neuman, executive director of the Kaiser Family Foundation’s Program on Medicare Policy. “They begin to establish a relationship with a specialist and seek treatment in places that specialize in the type of illness they have.”

Your health care needs and Medicare options can change from year to year, so it’s a good idea to compare Medicare Advantage and Part D prescription drug plans during open enrollment. Visit Medicare.gov to find out more about the coverage and costs for the plans available in your area. You can also get help from your State Health Insurance Assistance Program (SHIP).

Here are some benefits to consider if you have one of the following conditions.

Diabetes

• If you use insulin, find out whether the Medicare Advantage or Part D plan you’re considering participates in the Part D Senior Savings Model, which caps the copayment for certain types of insulin at $35 or less for a 30-day supply. Keep in mind, not all plans participate and not all types of insulin are included. Also, if you’re enrolled in the Extra Help financial assistance program, you aren’t eligible for the benefit, says Jo Paul, senior technical adviser for the Seniors' Health Insurance Information Program, the North Carolina SHIP.
  
  
• Choose a pharmacy or medical supply company that accepts payment from Medicare for such supplies as glucose monitors and test strips. “That will save you money in the long term,” says Laura Friedman, vice president of regulatory affairs at the American Diabetes Association. If a pharmacy or company accepts payment from Medicare, Part B of Medicare will cover most of the cost of your supplies. If you have original Medicare, you’ll only be responsible for a 20 percent copayment, which could be covered by a Medigap policy or a retiree plan. You can search for medical equipment and suppliers by ZIP code at Medicare.gov.
  
  
• Many Medicare Advantage plans have provider networks, so if you're considering one of them, make sure your endocrinologist and other doctors are covered. If they are, find out if the plan provides special benefits for people with diabetes. Some plans offer low or no cost sharing for visits to an endocrinologist, over-the-counter drug benefits, and additional podiatry visits and vision screenings, says Christine Leo, vice president of Medicare products at Cigna.
  
  
• Find out if there’s a diabetes SNP available for Medicare Advantage enrollees in your area. These plans aren’t available everywhere, but they may offer additional specialized benefits. For example, Anthem’s diabetes plan typically includes blood glucose and insulin management tools, nutrition counseling, a fitness program, and routine podiatry and wound care. A patient’s primary care doctor works with an endocrinologist to coordinate care.
  
  
• Check a plan’s medical and drug coverage. “Look into all of the coverage options and costs for your medications and diabetes management technologies,” says Friedman.

For more information, see Medicare Coverage of Diabetes Supplies, Services & Prevention Programs.

Kidney failure

• If you have kidney failure — also known as end-stage renal disease — and you need regular dialysis or have had a kidney transplant, you may qualify for Medicare before you turn 65. If you live in one of the 20 states that doesn’t guarantee access to Medigap supplemental insurance for people who have kidney failure and are under age 65, you may want to enroll in a Medicare Advantage plan. “These plans have an annual out-of-pocket maximum,” says Holly Bode, vice president of government affairs at the American Kidney Fund. “This cap on out-of-pocket expenses is particularly important for patients who don’t have guaranteed access to Medigap.”
  
  
• Medicare Advantage plans may offer additional benefits, such as a care coordinator, vision and dental coverage, and transportation to and from dialysis appointments. There are SNPs for people with kidney failure as well. Some plans, such as Anthem’s chronic condition SNP for end-stage renal disease, include a kidney care team that provides 24/7 telephone access and in-home visits.
  
  
• If you’re interested in a Medicare Advantage plan, make sure your nephrologist and dialysis provider are covered. Also, find out which kidney transplant centers are included in the plan’s network.
  
  
• If you travel frequently to a second home or to visit family members, find out how dialysis providers would be covered in the other location.
  
  
• Be sure to calculate your out-of-pocket costs for all of your health care needs, including other medical conditions, says Bode.
  
  
• Keep in mind, a Medigap policy or a retiree or employer health plan can help cover your deductibles and copayments if you have original Medicare. Outpatient dialysis is covered under Part B, which has a 20 percent copayment unless you have a Medigap policy or another supplemental plan.

For more information, see Medicare Coverage of Kidney Dialysis and Kidney Transplant Services.

Cancer

• There won't be any SNPs for cancer in 2022, but some Medicare Advantage plans offer extra coverage, such as transportation to chemotherapy or radiation therapy appointments. “You’re often asked not to drive to those appointments, so transportation may be an important benefit for people who have cancer,” says Leo.
  
  Find out what the plan you’re interested in covers. The type of transportation service offered varies from plan to plan, and it could have limits in terms of the number of trips offered and the distance you can travel, says Anna Howard of the American Cancer Society’s Cancer Action Network.
  
  
• Make sure your oncologist, other doctors and the hospitals you want to use are covered by your plan. Having the flexibility to choose your own doctor can be particularly important with cancer. “Cancer is not just one disease, and oncologists may have different subspecialties,” says Howard. “Cancer treatment can vary and can consist of surgery, chemotherapy and/or radiation. Each of these treatments may be handled by different providers.”
  
  
• Keep in mind, some academic medical centers that offer advanced treatments may not be included in a Medicare Advantage plan’s network. For instance, Memorial Sloan Kettering Cancer Center in New York City is not included in many Medicare Advantage plans, says David Lipschutz, associate director of the Center for Medicare Advocacy.
  
  
• With a Medicare Advantage plan, you may have to obtain approval, known as prior authorization, before you have surgery or imaging procedures, says Howard.
  
  
• Make sure you understand your plan’s medication coverage and check the benefits every year, whether you have original Medicare with a stand-alone Part D plan or coverage through Medicare Advantage. A 2019 study by the Kaiser Family Foundation found that the out-of-pocket costs for several specialty cancer medications exceeded $8,000 for the year even with Part D coverage.

Part B of Medicare covers most chemotherapy drugs given in a doctor’s office, leaving you with a 20 percent copayment unless you have a Medicare supplement policy or other supplemental coverage, such as a retiree or employer plan, to fill in the gaps.

• People who have original Medicare and purchase a Medigap policy or other supplemental coverage may be able to keep their out-of-pocket costs low. They may only need to pay the Part B deductible regardless of the number of medical services they receive (not including medication costs).

For more information, see Medicare Coverage of Cancer Treatment Services.

Heart failure and cardiovascular disorders

• If you’re considering a Medicare Advantage plan, find out if there are any SNPs in your area. Some of the most common plans focus on cardiovascular disorders and heart failure. Anthem’s Heart SNPs, for example, help people manage congestive heart failure through medications, fluid retention control, nutrition counseling and an exercise program. Members receive a personalized care plan from a team that includes a nurse practitioner, primary care physician, nutritionist, registered dietitian and exercise coach, says Alex Furman, vice president of Medicare duals strategy at Anthem.

Some plans include additional benefits, such as cardiac rehabilitation, medication management, nutrition counseling, classes and materials, and a smoking cessation program, Furman says.

• Check a Medicare Advantage plan’s Evidence of Coverage for details about any extra benefits you might qualify for. Aetna is participating in a CMS program called the Value Based Insurance Design model, which allows insurers to provide extra benefits within some of their regular Medicare Advantage plans. Aetna is offering benefits for people with congestive heart failure, including no copayments for cardiology visits and certain heart medications. The insurer is expanding the number of plans that will offer these benefits in 2022.

Many Medicare Advantage plans offer special benefits for people with heart conditions, such as a blood pressure cuff for members with high blood pressure, healthy eating programs, nutrition counseling and exercise programs. Some plans even help cover the cost of tai chi classes for people with heart conditions, says Melinda Munden, director of the SHIP in North Carolina. A plan affiliated with the Cleveland Clinic offers an app that allows patients with congestive heart failure to check in with a clinician and get quick care when necessary.

• Find out if your cardiologist, other doctors and hospital are covered by the Medicare Advantage plan you’re considering. If you need complex surgery and want to go to an out-of-network hospital, you may have some coverage but higher copayments if your plan is a preferred provider organization (PPO). Plans that are health maintenance organizations (HMOs) may not offer any coverage. If you can’t get a certain treatment in network, some insurers will cover out-of-network services that they consider to be medically necessary. But this authorization can be difficult to get and may take several weeks. Stick with original Medicare if you want the flexibility to choose any doctor or hospital that accepts Medicare.
  
  
• Make sure your heart medications are covered by the plan you’re interested in, whether it’s original Medicare with Part D prescription drug coverage or a Medicare Advantage plan with drug coverage. Visit Medicare’s Plan Finder and type in your drugs and dosages to estimate your total annual costs for the plans available in your area.

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.

More on Medicare

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• The big choice: original Medicare vs. Medicare Advantage
• How to sign up: a guide to Medicare enrollment