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[IP] Re: Medicare enrollment

I'll try to address all the Medicare questions at once (I work in a SHIP
program, which are volunteer-based programs sponsored by the federal and state
governments that help people with Medicare). First, as some of you already
pointed out, there are two routes to getting your Medicare. The first is
Original Medicare Parts A and B with an optional supplemental plan (Medigap)
and an optional stand-alone Part D prescription drug plan. This is fee for
service coverage and the insurer for Parts A and B services is the government
(CMS). They process the claims and pay the bills. Supplemental plans and drug
plans are sold by private insurers. Supplements in most states are
standardized with letters A through N and are almost always portable and can
be used anywhere in the country. For example a Plan N purchased anywhere from
any insurer has to offer the exact same benefits as any other Plan N. There
are no networks or referrals needed with this Original Medicare route. As long
as a provider takes Medicare, they have to also take all official Medigap
supplement plans.
You have certain times when you're guaranteed the ability to get one of these
Medigap plans without health screening. One such time is within six months of
starting Medicare Part B for the first time. There are certain other times,
depending on your state. There are federal "guaranteed issue" rights and then
certain states also have their own additional rights. If you don't get a
Medigap under one of these rights, you could be denied, charged more based on
your condition, or have waiting periods for pre-existing conditions. Under
this Original Medicare path, Medicare Part B typically pays 80% after a
deductible, and you pay the other 20% unless you have a supplement, in which
case it pays the 20%.B 
 DME and drugs used in conjunction with DME are covered under Part B, hence
insulin when used in a pump is Part B. If you have a supplement or other
secondary coverage that pays the 20%, you'll owe nothing. As far as I know,
there is no formulary for insulin under Part B. The key is that it has to be
medically necessary and the prescription has to specify that the insulin is
used in a pump. I know that all the national chains such as CVS, Walgreens and
Rite-Aid have national Part B billing staff who can help any local branch
store bill it the proper way.

Instead of an official Medigap supplement you can also have secondary coverage
through an employer or retiree plan, COBRA, Tricare for Life, etc. That
coverage may pay for things that Medicare doesn't, like dental, or it could be
worse than getting a Medigap and separate drug plan because it might have high
deductibles, etc. It may or may not have what is known as creditable
prescription coverage. If it does you do not need a Part D plan. If you do not
have creditable coverage then if you don't get Part D when you're first
supposed to, you will have to wait until the following year and pay a lifetime
Part D has the infamous donut hole, although that's supposed to be gone by
2020 under the ACA. Stand-alone Part D plans vary by state or even by
County.B  There is a big range of Part D plans. For instance, here there are
25 plans with monthly premiums ranging from $18/mo to $170/mo. They all have
different formularies and categorize the drugs into different tiers. There is
no standardization amongst plans as far as what tier a given drug is. If you
take any meds at all that are Part D meds, then the best way to pick a plan is
to enter your specific drugs, dosages, frequencies, etc., into the Planfinder
tool on medicare.gov. It will analyze the results and tell you what plan is
the overall lowest cost for you. It factors in premiums as well as copays,

Alternatively to the above, you can assign your Medicare over to a private
Medicare Advantage plan. These encompass Parts A and B (you still have to pay
the same premiums for Part B) and usually also include Part D bundled into it.
These are typically managed care plans such as HMOs and PPOs, meaning they
have geographically-limited provider networks, require authorizations, etc.
Advantage plans have to offer equivalent benefits to Parts A and B of original
Medicare, but can set their own deductibles and copays. These plans also have
to follow the Part D rules and they too have their own drug formularies, the
donut hole, etc. You can also see the results for your drugs under these plans
on the same medicare.gov tool. For Part B drugs such as insulin in a pump,
many of the Advantage plans charge the 20% as if you were under Original
Medicare without a Medigap supplement. That's also often true for DME such as
pump supplies. That's why for many pumpers it's often better to go the
Original Medicare and Supplement path and pay nothing for your insulin or
supplies. Also, Advantage plans are highly specific, often limited just to a
single county, so you have to check carefully and see what your options are
and what the details of each plan in your area are.
I hope this helps. I'm happy to answer any questions. Pam
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