Tag: Medicare

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Open Enrollment is NOW

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Do you feel like you are paying too much for healthcare services and prescription drugs under your current health insurance plan? Does your insurer require you to try and fail at less costly therapies before allowing the treatment your doctor has prescribed? Is the medication your doctor prescribed denied by because it isn’t listed on your plan’s formulary?

Now may be the most important time of the year if you are dissatisfied with your health insurance coverage. We are currently in the middle of Open Enrollment season for Medicare and the Affordable Care Act (ACA) Marketplace plans. For those insured under employer plans, the end of the year is also a time when new or updated plans are often offered, allowing employees to make changes to their benefits plans.

The following are important deadlines to keep in mind for applying for or making changes to insurance coverage for 2022:

  • Medicare Open Enrollment ends December 7.
  • ACA Open Enrollment ends January 15 (coverage starts February 1).
    • Deadline for ACA coverage to start on January 1 is December 15.
  • For employer plans, check with your human resources manager.

CSI Pharmacy is here to help you navigate the system. We are experts at understanding the fine print in health insurance policies. We can help you review your options and find the plan that best meets your healthcare needs as well as your budget.

For those who are having trouble paying for healthcare coverage, here are some options that can help:

Medicare Assistance Programs – If you are unable to afford Medicare premiums, several types of State Medicare Savings Programs are available to help you pay your Medicare premiums. In some cases, they may also pay deductibles, coinsurance, copayments, and prescription drug coverage costs. Each of the programs has different eligibility criteria. There are even programs that allow individuals who delayed enrollment into either Medicare Part A or Part B to enroll outside regular enrollment periods. In some cases, qualifying for these programs automatically qualifies you to get Extra Help to pay for Medicare drug coverage.

To see if you qualify for these programs and to apply, contact your State Medicaid Program or Department of Social Services. You can also call 1-800-MEDICARE (1-800-633-4227) to get the phone number for your state’s Medicaid office.

Extra Help – If you meet certain income and resource limits, you may qualify for Extra Help in paying for your Medicare prescription drug plan premiums, deductibles, and copays. Depending on your income and state of residence, you may pay less or nothing for premiums and deductibles, and copays are capped at an affordable rate.

For additional information and to see if you qualify, see the Extra Help webpage at Medicare.gov. In some cases, you may automatically qualify if you qualify for the Medicare Savings Programs above. If you don’t automatically qualify, there is a link on the Extra Help page where you can apply.

Medicaid is a joint federal/state program that helps with medical costs for those with limited income and resources. Each state has different eligibility requirements and application processes. You can now apply for Medicaid either through the ACA Marketplace or directly with your state Medicaid agency. See this website for more information and to see if you qualify. You can also call 1-800-MEDICARE (1-800-633-4227) to get the phone number for your state’s Medicaid office.

PACE – Program of All-Inclusive Care for the Elderly (PACE) is a comprehensive healthcare program through Medicare and Medicaid that helps individuals remain in the community rather than going to a nursing home or other extended care facility. The program provides a team of healthcare professionals who work with you and your family to coordinate your care. It covers all the services this team decides you need, including drugs, provider visits, transportation, home care, hospital care, and nursing home stays when needed.

You never pay a deductible or copay for any drug or service provided. If you are covered by Medicaid, long-term care is also fully covered. If you have Medicare but not Medicaid, there is a monthly premium for long-term care and Medicare drug coverage (Part D). Enrolling in PACE, however, means you are required to use a PACE-preferred physician and the other providers associated with the plan.

PACE is only available in some states and only in some areas. To qualify, you must:

  • Be 55 or older
  • Live in the service area of a PACE organization
  • Need nursing home-level care (as certified by your state)
  • Be able to live safely in the community with help from PACE

To find out if you qualify and if there is a PACE program in your area, search for PACE plans in your state, or call 1-800-MEDICARE (1-800-633-4227) to get the phone number for your state’s Medicaid office.

Veterans Benefits – If you qualify for health benefits from the Department of Veterans Affairs (VA), you can receive both Medicare and VA benefits, but they don’t work together. Medicare doesn’t pay for any care provided at a VA facility, which is the only place VA benefits are offered. Many veterans use their VA benefits to get services not covered by Medicare, such as prescription drugs. For more about eligibility and benefits, call the VA Health Administration Center at 1-800-733-8387 or 1-877-222-8387.

ACA Marketplace – Uninsured individuals and families who do not qualify for the government-funded programs above can still get coverage, often at a discount, through the ACA Health Insurance Marketplace, also known as the Exchange. ACA plans are offered through private insurers participating in the Exchange. They all provide the same essential health benefits, and you cannot be denied based on pre-existing conditions. You can review plans and apply for coverage at Healthcare.gov. In completing the application, you can also see if you qualify for free or low-cost coverage through Medicaid, or for savings on a Marketplace plan.

Marketplace plans and insurers change every year. This year premium subsidies enacted under the COVID-related American Rescue Plan Act (ARPA) last year are still in effect for 2022. This means many Americans will qualify for lower premiums. The number of insurance companies participating has also increased, so there are more options to choose from. If you currently have a Marketplace plan, you may want to consider exploring these options to see if you can find a more affordable rate rather than allowing you current plan to auto-reenroll.

If you make changes to your health insurance coverage, be sure to notify your healthcare providers and your pharmacist so the transition to the new plan is smooth.

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Advocacy Patient stories

Disability Benefits in Danger

Andrea Williams

Andrea Williams had a panic attack when she opened her mail earlier this year. Her hands were shaking even before she tore into the envelope from the Social Security Administration (SSA). The letter inside informed her that, according to SSA, she was no longer disabled and would no longer receive disability benefits, including Social Security Disability Income (SSDI) and Medicare.

Andrea is one of thousands of American citizens who are unable to work because of severe, chronic health problems who can expect to receive these notices in the coming year. This is because SSA wants to cut $2.6 billion dollars from SSDI and its sister program Supplemental Security Income (SSI) by changing the rules they use to terminate people like Andrea, who have depended on the disability safety net for years.

Six years ago, Andrea was diagnosed with a rare, debilitating disease of the muscles called myositis. She had trouble lifting her head, she couldn’t pick up her newborn baby, she couldn’t climb stairs, she couldn’t even lift her arms enough to wash her hair. For months she went back and forth to the doctor saying, “I feel like I’m dying.” It wasn’t until she was referred to a specialist and ended up in the hospital for a week that she was finally diagnosed.

Myositis causes chronic pain, disabling weakness, and extreme fatigue. Treatment has helped Andrea, but she has lost too much muscle tissue that she will never regain. She can’t stand for any length of time, she drops things, and the brain fog from her medications makes it difficult for her to think. Her doctor told her she would never work again. When she applied for SSDI benefits in 2016, her application was accepted on the first try, which almost never happens.

“I’m scared to death,” she says. “My biggest fear is not having the medications, and I already can’t afford the doctors.”

An “Explanation of Determination” letter like the one Andrea received is a notice an SSDI or SSI recipient gets when they have been identified by SSA for “Continuing Disability Review” (CDR). This is the agency’s review process to see if beneficiaries are still medically eligible for the program. After this review, if SSA believes the person no longer meets their criteria for disability, their benefits are terminated.

A medical CDR is done at least once every three years, unless the SSA expects your medical condition to improve sooner. Those who have a medical condition that is not expected to improve undergo a CDR every seven years.

A rules change that took effect earlier this year, however, dramatically increases how often a person must undergo a CDR review. This change adds a new category for those whose condition is “likely to improve.” Hundreds of thousands of people now in less frequent CDR categories will be moved into this new category to be reviewed every two years.

This new rules change is especially disturbing because it targets people like Andrea who have chronic conditions that flare up unpredictably. Those who are approaching retirement age and those with mental illness are some of the other people this rules change aims to remove from benefits.

If you get one of these letters, the first thing you need to do is notify Social Security that you want to appeal this decision. To appeal, you need to submit a Request for Reconsideration form within 60 days of receiving the notice of denial of benefits. If you want to continue receiving benefits while your case is being decided, you will need to submit this form withing 10 days of the denial, and you need to specifically ask that benefits continue. Be aware, however, that if your case is unsuccessful, SSA can require you to return the overpaid benefits.

Andrea has followed this advice and is awaiting a response from SSA. She is hopeful that, with the support of her doctors and her patient advocate, her appeal will be granted and she will once again be able to sleep at night.  

For others like her, Andrea offers this advice:

“You have to reach out and get some help from someone like a patient advocate,” she says. “You have to have your medicine. You have to see your doctors. You can’t take no for an answer.”

CSI Pharmacy has patient advocates who can help you navigate this and other health care access challenges. We offer this service regardless of whether you are a CSI Pharmacy patient.