MEDICARE OPEN ENROLLMENT-What COPD Patients Need to Know

This article was written by Jamie Sullivan, MPH and reviewed by David Mannino, MD, Ruth Tal-Singer, PhD, Byron Thomashow, MD, Stephanie Williams, BS, RRT, and Barbara Yawn, MD

Not much about the fall of 2020 feels routine but some things go on as usual and that means the open Medicare enrollment season. You may be reading this and say "I am not on Medicare" or "I’m happy enough with my coverage," and be tempted to click on to the next article, but if you have health insurance, regardless of the type or how happy you are with your current coverage, open enrollment review of your insurance plan should still be on your to-do list!

Why should you care about open enrollment? Many details about a given insurance plan can change from year to year, so just because you are happy now, you need to review your coverages in the assigned “open enrollment” time (for Medicare that is October 15, 2020 - December 7, 2020) to make sure that the doctors in your network, the out-of-pocket costs of care and the medications covered haven’t changed for the coming year.

Most of the issues we are going to cover in this blog are about Medicare. If you have a private plan from your employer or are enrolled in a Medicaid Managed Care Organization plan make sure to check the dates of your open enrollment. If you purchased insurance from a state or federal exchange (sometimes called Obamacare Plans), or if you need to purchase insurance for next year, your open enrollment period is from November 1, 2020 - December 15, 2020.

On October 22, 2020 The COPD Foundation hosted a webinar with the Medicare Rights Center that reviewed Medicare Open Enrollment in-depth. If you missed the presentation, we encourage you to view it here - https://attendee.gotowebinar.com/recording/2946706966072053776.

We are also doing a survey to better understand how you make insurance decisions and what type of information and support you would find helpful. Please consider sharing your thoughts at https://www.surveymonkey.com/r/MedicareInsightsCOPDFoundation

Let’s review some of the highlights about how Medicare works for COPD care.

How is COPD related care paid for in Medicare?

It is easy to get confused about which type of Medicare pays for different parts of your COPD care so let’s break it down. This is for people enrolled in TRADITIONAL Medicare, Part A, Part B, and Part D. If you are enrolled in a Medicare Advantage Plan (Part C), then all your care is paid for by that one plan.

• PART A= Hospital INPATIENT Care
• PART B= OUTPATIENT CARE in Hospitals and Doctor’s Offices + Medical Devices and Some Drugs
• PART D= Prescription Drugs from the Pharmacy
• SUPPLEMENT (MEDIGAP)= Pays for some out-of-pocket costs for care under Part A and Part B

The picture details more specific information for common types of COPD care.

Some COPD Treatments Are Covered Under Medicare Part B

Some people with COPD may be prescribed oxygen and some are prescribed medicine that is given by a nebulizer. Both of these treatments rely on a piece of “durable medical equipment” and are paid for by Medicare Part B. This means if you do not have a Supplement Plan you will likely be responsible for 20% of the costs for the oxygen and nebulizer treatment, rather than a set copay like you might see when picking up your inhalers at the pharmacy (Part D). There is one exception. The medicine called Lonhala Magnair is a nebulized daily medicine, but it is paid for by Part D because it was developed and approved with a specific handheld nebulizer device, so it is treated the same as your other inhalers.

If you choose Medicare Advantage, make sure to look at each policy to determine what you will have to pay for durable medical equipment. Many Medicare Advantage Plans will charge a 20% coinsurance (fee) for durable medical equipment. On Medicare.Gov after you have searched for plans in your area, you can find info by clicking on "Plan Details" and scrolling down until you see "other services" and then "Durable Medical Equipment."

Medicare Supplement Plans have monthly premiums that can often seem more than you can pay, but if you are prescribed treatments covered by Part B, expect to take part in pulmonary rehabilitation or are considering assessment for some of the newer treatments that require hospital care such as the valves that go into your breathing tubes (endobronchial valves) or the surgery that removes large unusable areas of your lung (lung volume reduction surgery) that both have lots of follow up outpatient care, it’s important to compare your costs. Just one month of a nebulized daily COPD medicine could cost around $247 per month or the costs of a special breathing device like a non-invasive ventilator device (NIV) could end up costing between $175-$300 per month without a Supplement Plan.

Only a Few States Guarantee You a Supplement Plan After Initial Enrollment Period

As with all things related to healthcare, each person’s needs are different, and this information is just a guide to show why it is so important to do your homework. Each state will offer different options for Medicare Advantage, Medicare Part D and Medicare Supplement Plans. For example - only 4 states guarantee that you can get a Supplement Plan after your initial eligibility period (the first time you sign up for Medicare). In other states, insurance companies can deny you coverage if you have a pre-existing condition like COPD, so it is important to consider this during your initial enrollment period.

Medicare Part D AND Medicare Advantage Plans Can Change Which Treatments They Cover and How Much They Cost Every Year!

Each year, plans will set their formularies (those are the approved groups of medicines) that will be covered or paid for in part by the insurance and how much your copay will be for each medicine. Sometimes, a plan might decide to stop coverage for one of your inhalers all together, meaning if you want to stay on that medicine you would be have to pay the full price for it. It is important to check each year, even if you are taking a generic inhaler since some plans actually charge more or do not pay for the one generic daily medicine given for COPD. You can enter each medicine you take and the dose in www.medicare.gov to compare costs You can do this for Medicare Advantage Plans and for Medicare Part D plans.

Top Takeaways

• Do your homework, even if you aren’t on Medicare—check your insurance plan!
• Decide what is most important to you (total premium costs, total out-of-pocket costs, the network (groups of doctors, services and hospitals) covered, protecting against unexpected expenses, etc)
• Have your list of medicines and services you typically use ready and dive into www.medicare.gov or the site for your insurance options if not Medicare to see what you will pay for each plan
• Remember that not all COPD medicines and treatments are covered under Medicare Part D
• Consider the costs of Medicare Part B treatments when deciding if you will enroll in Medicare Advantage or buy a Supplement Plan