Medicare Coverage of COPD

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Medicare is a national health insurance program that covers people aged 65 and older and people with certain disabilities. It is a different program than Medicaid, which is a program that assists people with low incomes with the costs of healthcare.

It is estimated that 1 in every 9 Medicare beneficiaries suffer from COPD. Health.com reported that it is was the fourth leading cause of death in the United States. While smoking is the leading cause of COPD, a small percentage of individuals develop the condition due to other air pollution.

Finding Medicare with COPD

Original Medicare has two parts which cover hospital benefits and outpatient medical benefits. There is also a voluntary drug program to help out with the costs of outpatient prescription medications. In general, most medical care which is medically necessary will be covered by Medicare. This includes lung disorders like Chronic Obstructive Pulmonary Disease (COPD), emphysema and asthma.

Let’s look at how the different parts of Medicare cover treatment of COPD:

Original Medicare

Medicare Part A provides inpatient hospital benefits. If you are hospitalized for COPD or any other breathing disorder, Part A will pay for your hospital room and bed, skilled nursing facility care, short-term home health care immediately after a hospital stay, and hospice benefits. You are responsible for paying the Part A deductible, which is $1340 in 2018. Should you have a hospital stay that lasts longer than 6 days, you will also begin to pay a daily copay. Medicare’s benefits run out after 150 consecutive days in the hospital.

Medicare Part B provides outpatient medical coverage. This includes preventive care, doctor visits, lab-work, durable medical equipment, oxygen, emergency care, chemotherapy, radiation, surgeries and dialysis among other things. Part B’s smoking cessation benefit is designed to help you prevent your COPD symptoms from getting worse. COPD patients can qualify for up to 8 sessions per year and nicotine patches may also be covered as part of this care.

For people with COPD, Part B is important in that it provides coverage for pulmonary rehabilitative care that helps you breathe more easily. It can also provide coverage for certain medication delivered in a doctor’s office or clinical setting or medications that are used in a nebulizer. Part B can also provide oxygen under the DME benefit as well as the related supplies like tubing, masks, and cannulas. You must use a supplier that is part of Medicare competitive bidding program. These suppliers can be found using the search engine on Medicare’s website. Your cost-sharing responsibility under Part B is a small annual deductible and then Medicare pays 80% and you pay the other 20%. There is no cap on the total that you might spend in any given year, so many beneficiaries purchase Medigap plans to help them pay for deductibles and coinsurance on both Part A and Part B.

Medigap plans pay after Medicare and allow you see any doctor in the nation that accepts Medicare, so they provide great freedom of access to your own providers. There are ten standardized Medigap plan options to choose from in most states. Beneficiaries can choose from comprehensive coverage plans or plans like Plan N that cost less because you agree to do more of the cost-sharing.

You can compare plan options here.

Medicare Part D

Part D is the newest part of Medicare, having just rolled out in 2006. It is an optional program to provide retail prescription drugs. There are a number of medications commonly prescribed for COPD such as bronchodilators and inhaled steroids. These kinds of medications fall under Part D. Unlike Original Medicare, which you sign up for at the Social Security office, Part D plans are sold by private insurance companies. Each company has its own formulary list of medications, but the Medicare program requires all plans to offer at least two medications in each therapeutic class.

Part D premiums vary widely between carriers. You must live in the plan’s service area and be enrolled in either Part A or Part B to be eligible for a plan. Although Medicare itself does not offer these plans, they do monitor your enrollment. Failure to enroll in a plan during your initial enrollment period for Medicare may result in a late penalty being assessed later if you did not have any other creditable coverage. Speak with a Medicare insurance broker who can help you enroll during the proper election periods so that you can make the most of your benefits and avoid any unnecessary delays in coverage or penalties.

Danielle Roberts is the co-founder of Boomer Benefits where she and her team help thousands of baby boomers with navigating their Medicare choices every year.

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  • Excellent article! Medicare and insurance always feels so complicated, so it is nice to see an article where they really break it down- One small thing to add is that in some instances individuals can qualify for Medicaid and Medicare!
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