INFORMATION ABOUT MEDICARE A GUIDE FOR PEOPLE WITH RELAPSING MULTIPLE SCLEROSIS

Transcription

1 INFORMATION ABOUT MEDICARE A GUIDE FOR PEOPLE WITH RELAPSING MULTIPLE SCLEROSIS

2 HOW TO CHOOSE A MEDICARE PLAN If you are living with relapsing multiple sclerosis (RMS), you have a lot to think about. One concern you may have is how to pay for your treatment. Many people with RMS qualify for Medicare. You may know of Medicare as the federal health insurance program for people 65 years or older. But did you know that Medicare can also cover younger people who become disabled due to conditions like RMS? Medicare may be able to cover the cost of your trips to the doctor and hospital. It may also cover many of your prescriptions. There are many different Medicare plans. Choosing the right plan is a big decision. Here are some things to consider: You may need more than 1 plan (1 for your prescription and 1 for your doctor visits) There are set times to enroll in Medicare. Find out when you need to sign up You may be able to get help paying for your RMS care from your state or other resources This booklet can help you learn about Medicare. It may help you make insurance choices that may be right for your care. Remember to talk to your doctor if you have questions about your healthcare. The Above MS program from Biogen is here to help The Above MS program can help answer your questions about Medicare. This free program from Biogen is here for you with tips, tools, and inspiration for your multiple sclerosis (MS) even if you re not on a Biogen therapy. Contact Above MS from Biogen at Call , Monday through Friday, 8:30 am to 8 pm ET 2 INFORMATION ABOUT MEDICARE

3 TABLE OF CONTENTS WHAT IS MEDICARE? WHEN CAN I SIGN UP FOR MEDICARE? HOW DO I SIGN UP FOR MEDICARE AND WHAT CAN I EXPECT?...10 THE MEDICARE DRUG (PART D) STANDARD BENEFIT COMPARING MEDICARE DRUG (PART D) PLANS FOR YOUR RMS CARE THE MEDICARE DRUG (PART D) EXTRA HELP BENEFIT WHAT ARE MEDICARE SAVINGS PROGRAMS? WHAT SHOULD I CONSIDER WHEN CHOOSING A MEDICARE PLAN? WHO CAN HELP ME REVIEW MY PLAN OPTIONS? WHERE CAN I LEARN MORE ABOUT MEDICARE? HOW CAN ABOVE MS HELP? INFORMATION ABOUT MEDICARE

4 WHAT IS MEDICARE? Medicare is an optional insurance plan offered by the government. You may be able to get Medicare if you Are age 65 or older Are disabled but younger than age 65 Have permanent kidney failure (called end-stage renal disease) How is Medicare different than Medicaid? Medicare Run solely by the federal government. Coverage is based on your age or health. Medicaid Run by the federal government and your state. Helps low-income people and families. Only available to people with certain incomes. Sometimes Medicare and Medicaid work together to help low-income people who qualify for Medicare. If you have RMS and can no longer work, you may qualify for Medicare. If you have questions, call MEDICARE ( ) or go to Medicare has 4 parts: Part A: Hospital Insurance Part B: Medical Insurance Part C: Medicare Advantage Part D: Medicare Prescription Drugs Parts A and B are known as Original Medicare. Part C offers optional plans you can buy. A Part C plan provides more coverage than Parts A and B alone. Part D covers drug costs. 4 INFORMATION ABOUT MEDICARE

5 PART A AND PART B: ORIGINAL MEDICARE Part A (hospital insurance) covers Hospital visits Nursing homes Hospice Some home healthcare services Part B (medical insurance) covers Doctor visits Visits to infusion or hospital clinics for treatments you receive from your doctor Some home healthcare services Medical equipment Wellness services Lab tests Preventive screenings You can sign up when you are close to age 65. What you need to know about Part A and Part B You do not choose a Part A and Part B plan. They are assigned to you by the government. If you are younger than age 65 and disabled, you are automatically enrolled in Part A and Part B. You will receive your Medicare card in the mail. RMS treatments that are infused at a doctor s office or clinic are usually covered under Part B. For added help with your Part A and Part B Medicare options, Contact Above MS from Biogen at Call , Monday through Friday, 8:30 am to 8 pm ET 5 INFORMATION ABOUT MEDICARE

6 PART C: MEDICARE ADVANTAGE Part C is another way to get Medicare coverage. A Part C plan is also called a Medicare Advantage (MA) plan. A Part C plan covers everything in Part A (hospital insurance) and Part B (medical insurance). Here is what else you should know about Part C These plans are offered by private companies. The government regulates these plans Having a Medicare Advantage plan is just an option. You do not have to buy a Medicare Advantage plan if you don t want to Most plans also include prescription coverage. These plans are called Medicare Advantage Prescription Drug plans (MA-PDs) Some plans may offer extra coverage. This can include dental, vision, or other health programs If you have Medicare Advantage, you cannot buy a Medigap policy (see page 13) What kinds of Medicare Advantage plans are there? There are many different kinds of Medicare Advantage plans. Some allow you to visit only in-network doctors and hospitals. Others may allow you to see doctors outside of your network. Out-of-network visits will usually cost you more. You also may need a referral to see a specialist with this type of plan. Is a Medicare Advantage plan right for my RMS care? A Medicare Advantage plan may offer you more services than what Part A and Part B will cover. If you need vision coverage, you may want a Medicare Advantage plan. A Medicare Advantage plan may cost you less over the year. Be sure to compare plans to see if a Medicare Advantage plan is right for you. To learn more, go to or contact Above MS by calling , Monday through Friday, 8:30 AM to 8 PM ET. 6 INFORMATION ABOUT MEDICARE

7 PART D: MEDICARE DRUG PLAN Part D covers medicines prescribed by your doctor. These are drugs you take yourself. They may include but are not limited to Pills that you swallow (oral). Injections you give yourself. Inhaled treatments. What you need to know about a Medicare drug (Part D) plan for your RMS care Even if you do not take many prescriptions, you should consider a Part D plan. Your doctor may need to prescribe treatment during the year There are many Part D plans. Do your research to choose the best plan for your RMS care You can compare Part D plans at You can also contact Above MS from Biogen at or call , Monday through Friday, 8:30 am to 8 pm ET When can I sign up for a Part D plan? You can sign up for a Part D drug plan if 1) You have only Part A and/or Part B OR 2) You have a Medicare Advantage (Part C) plan that does not offer drug coverage Either a Medicare Advantage (Part C) plan or a Medicare drug (Part D) plan can help you pay for your RMS medicines. Compare the costs on these plans before choosing one. 7 INFORMATION ABOUT MEDICARE

8 WHEN CAN I SIGN UP FOR MEDICARE? Medicare has certain times to enroll each year. This depends on your age and if you had Medicare in the past. INITIAL ENROLLMENT PERIOD when you turn age 65. GENERAL ENROLLMENT PERIOD if you did not sign up when you turned age 65. SPECIAL ENROLLMENT PERIOD if you or your spouse are still working. You can sign up 3 months before the month you turn age 65 or up to 3 months after the month you turn age 65 When you enroll, you will be asked if you want to sign up for Part A and Part B. If you do not sign up for Part B at this time, you may have to pay more, unless you qualify for a Special Enrollment Period Each year, from January 1 to March 31, you have the chance to sign up if you did not enroll at age 65 Your coverage will start on July 1 You may have to pay more for signing up this way The Special Enrollment Period allows you to sign up for Part A and/ or Part B if you did not do so when you were first able There are no certain dates You can still sign up for Part A and/or Part B if you have a health plan through your job If you lose your health plan at your job, you can sign up for Part A and/or Part B. You would do this during the 8 months after coverage ends 8 INFORMATION ABOUT MEDICARE

9 OPEN ENROLLMENT ALLOWS YOU TO MAKE CHANGES TO YOUR PLANS EACH YEAR Each year, between October 15 and December 7, you may make changes to your health or drug plan for the next year. This is called Open Enrollment. Even if you have just enrolled in Medicare during one of the other enrollment periods, you will need to choose your plan for the next year during this period. Open Enrollment lets you review your plan benefits. There are different options. You can keep your current plan. You can also compare plans to find one with better coverage. Make sure the plan you choose covers the health services and medicines you will need next year. Medicare offers an online tool to compare plans in your area. Go to You can also contact Medicare at MEDICARE ( ). You can review plans as early as October 1. Once you pick a plan, your coverage will begin on January 1. Oct 2017 Nov 2017 Dec 2017 Jan 2018 October 15, 2017 Open Enrollment begins December 7, 2017 Open Enrollment ends January 1, 2018 Coverage begins If you get Extra Help or are dual eligible (see page 17), you can change plans at any time. You do not have to wait for the Open Enrollment period. 9 INFORMATION ABOUT MEDICARE

10 HOW DO I SIGN UP FOR MEDICARE AND WHAT CAN I EXPECT? How do I sign up for Medicare? Unless you are disabled, you will not be enrolled in Medicare unless you sign up. It will not be done for you. You can sign up for Medicare 2 ways: 1 2 Call the Social Security office at Sign up online at If you are disabled, you will be enrolled in Part A and Part B without having to sign up You will be enrolled by the 25th month of receiving disability benefits through Social Security You will get your Medicare card in the mail (see below) You also get a yellow notice in the mail about your Part D drug plan, that will tell you how to review or change it How do I know if I qualify as disabled? If you have worked in the past, but cannot now because of your RMS, you may qualify as disabled. You need to apply with Social Security. For more information, call Social Security at go to MEDICARE HEALTH INSURANCE NAME OF BENIFICIARY JOHN DOE MEDICARE ( ) MEDICARE CLAIM NUMBER JOHN DOE A IS ENTITLED TO HOSPITAL (PART A) MEDICAL (PART B) SIGN HERE SEX MALE EFFECTIVE DATE Your red, white, and blue card will come in the mail. This card shows that you have Part A, Part B, or both. It also shows the date your coverage starts. If you are eligible for Medicare, it is important to sign up for a Medicare plan. Contact Social Security at You can also contact Above MS from Biogen at , Monday through Friday, 8:30 am to 8 pm ET, if you have any questions. 10 INFORMATION ABOUT MEDICARE

11 THE MEDICARE DRUG (PART D) STANDARD BENEFIT If you have a prescription plan with Medicare and you do not get Extra Help (see page 16), you likely have the Standard Benefit. There are typically out-of-pocket costs that go along with this type of benefit: Monthly premiums Annual deductible Copays or coinsurance Your copay may change with the amount of money you spend on prescriptions during the year (see below). People who have the Standard Benefit may also have a coverage gap. This gap is called the donut hole (see page 12). In 2018, the Standard Benefit is as follows: Initial Coverage Coverage Gap a Catastrophic Coverage You pay an annual deductible. + You pay 25% of drug costs. + You pay 35%. Manufacturer pays 50%. Plan pays 15%. + You pay a small copay or coinsurance the rest of the year. You pay $3.35, $8.35, or 5% (whichever is greater). a These costs are for brand-name medicines. If you get generic medicines, you pay 44% of drug costs and the plan pays 56%. 11 INFORMATION ABOUT MEDICARE

12 WHAT IS THE PART D COVERAGE GAP? If you have the Standard Benefit for Part D, you may have a coverage gap, or donut hole. Here is how it works: Initial Coverage You pay an annual deductible. You pay 25% of drug costs. + Coverage Gap a You pay 35%. Manufacturer You pay a + pays 50%. small copay or coinsurance the rest of the year. Plan pays 15%. Catastrophic Coverage + You pay $3,750 You pay $1,250 You pay $3.35, $8.35, or 5% (whichever is greater). a These costs are for brand-name medicines. If you get generic medicines, you pay 44% of drug costs and the plan pays 56%. At the end of the gap, you will pay a much smaller copay or coinsurance for your RMS medicine for the rest of the year. You may be able to get help paying for your medicines in the coverage gap from Pharmaceutical companies. National and community charitable programs. Your state pharmaceutical assistance program. The Centers for Medicare & Medicaid Services provide a summary of these programs at 12 INFORMATION ABOUT MEDICARE

13 HOW CAN A MEDIGAP POLICY HELP PAY FOR MY MEDICINES? If you have Part A and Part B as well as the Part D Standard Benefit, you may want a Medigap policy. This is also called Medicare Supplemental Insurance. It can help pay for Copays and coinsurance for your RMS treatments Copays and coinsurance for other medicines Coinsurance or deductibles for visits to hospitals, neurologists, and other specialists What you need to know about Medigap You must have Part A and Part B to get Medigap You cannot get Medigap if you have Medicare Advantage (Part C) A Medigap policy charges a monthly premium There are many types of Medigap policies Costs vary and rise as you get older You can buy Medigap for 6 months after the month you turn 65. If you wait, you may not be able to get Medigap or it may cost more. For more information or to find Medigap policies in your area Call MEDICARE ( ) Go to Medigap may help you pay for your RMS treatment and care that is not covered by your Medicare plan. 13 INFORMATION ABOUT MEDICARE

14 COMPARING MEDICARE DRUG (PART D) PLANS FOR YOUR RMS CARE When it comes time to select a Part D plan, there are many things to consider. You may think about Finding a plan that has the coverage for your RMS medicines Yearly deductible costs Monthly premiums and copays If you have the Standard Benefit (see pages 11 and 12) and are on a prescription RMS medication, you likely will enter the coverage gap. The cost of your medicines will determine when you enter and go through the coverage gap. It is important to plan for when that will happen and how much your Part D plan will cost. To understand the difference in the total costs between 2 types of Part D plans, see page 15 for what you would have to pay if you had: 12 months of premiums A deductible. (Some plans do not have a deductible) Copays for 12 months of 4 prescriptions per month. This includes a 3 drugs to treat conditions other than your RMS, such as bladder issues, anxiety, or fatigue 1 specialty drug to treat your RMS. It likely has a high copay a The example does not include an infused treatment for your RMS that you may receive at a doctor s office. This treatment would be covered under Medicare Part B (medical insurance). 14 INFORMATION ABOUT MEDICARE

15 WHAT YOU MAY PAY Total $7,580 Total $7,209 March-December Copay $3,800 ($380 per month) $3,300 ($330 per month) February Copay Catastrophic Met $790 $1,100 January Copay $2,510 Coverage Gap $2,200 Deductible 12 months of premium $0 $480 ($40 per month) $405 $204 ($17 per month) PLAN X PLAN Y The above example of Plan X and Plan Y shows the following: Plan X has a higher monthly premium ($40 per month) and no deductible Plan Y has a lower monthly premium ($17 per month) and a $405 deductible (maximum allowed for 2018) Patients in both plans enter the coverage gap in January Patients in both plans reach catastrophic coverage in February The monthly copays are different Over 1 year, Plan Y would cost you $371 less than Plan X. That is why it is important to estimate the yearly costs for a deductible, premiums, and copays before selecting a plan that is right for you. You can compare plan costs for your medicines at 15 INFORMATION ABOUT MEDICARE

16 THE MEDICARE DRUG (PART D) EXTRA HELP BENEFIT Extra Help is a benefit from the government that helps pay for Part D costs. You may be able to get Extra Help if you OR Have low income. Are disabled and receiving Medicare. What can Extra Help do for me? Extra Help can help you afford medicines and treatments by offering $0 or a small initial deductible and monthly premiums. Lower out-of-pocket costs for brand-name prescriptions. No coverage gap (see page 12). The chance to change plans at any time. Any changes you make will take place on the first day of the next month. 16 INFORMATION ABOUT MEDICARE

17 DO I QUALIFY FOR EXTRA HELP? You may qualify for Extra Help if you are disabled or have a low income. You will get Extra Help automatically with no need for paperwork if you Already have full Medicaid coverage (dual eligible, see below) Get help from Medicaid to pay for Part B Get Supplemental Security Income benefits If you get Extra Help automatically, Medicare will mail you a purple letter. What can I do if I think I need Extra Help but have not gotten a purple letter? If you think you may need Extra Help, you can apply any time at Social Security: What does it mean to be dual eligible? If you qualify for both Medicare and Medicaid, you are dual eligible. As discussed earlier, Medicaid is a program funded by the federal and state government that helps pay for medical costs. You may be eligible for Medicaid if you have low income and meet other requirements set by your state. Extra Help can make it easier to afford your RMS treatments. If you get Extra Help, or are dual eligible, you may change plans at any time. 17 INFORMATION ABOUT MEDICARE

18 WHAT ARE MEDICARE SAVINGS PROGRAMS? Medicare Savings Programs are state programs that help you pay for Medicare premiums Part A and Part B deductibles Resources Part A and Part B coinsurance Part A and Part B copays for your RMS care Depending on your income and resources, you may qualify for one of these programs: Stocks Qualified Medicare Beneficiary Program Specified Low-Income Medicare Beneficiary Program Qualified Individual Program Money in the bank Bonds Qualified Disabled and Working Individuals Program Some people who qualify for a Medicare Savings Program automatically get Extra Help to pay for Part D prescriptions. How do I know if I qualify for a Medicare Savings Program? First, you must have or be eligible for Part A Second, your income must be below a certain limit Third, your resources must be below a certain limit Each Medicare Savings Program has different income and resource limits. For information on the resource limits, go to and search Medicare Savings Programs. Call your state Medicaid office to see if you quality for a Medicare Savings Program. Even if you have a slightly higher income and more resources than the limits for a Medicare Savings Program, you may still qualify. You can apply through your state Medicaid office. 18 INFORMATION ABOUT MEDICARE

19 WHAT SHOULD I CONSIDER WHEN CHOOSING A MEDICARE PLAN? If you need more insurance than Part A and Part B, you may choose to enroll in a Medicare Advantage (Part C) plan with drug coverage. OR Medicare drug (Part D) plan. Be sure to look for a Part C plan or Part D plan with enough coverage for your RMS treatment and care from your neurologist. Before you choose a plan, talk with your doctor about your medical and prescription needs for next year. Will you have to change your RMS medicine? Will you need additional services? What if my RMS treatment is not covered by my Medicare plan? If your doctor wants you to have an RMS treatment that is not covered, he or she may be able to work with your plan. This is called a medical exception or an appeal. Above MS may also be able to help. Contact Above MS to learn more about your Medicare plan choices. They can tell you if your RMS treatment is covered and help you learn about your options. 19 INFORMATION ABOUT MEDICARE

20 QUESTIONS TO THINK ABOUT WHEN YOU REVIEW PLANS Is my current RMS treatment covered? Are other prescriptions covered? What are the copays, coinsurance, and deductibles for my doctor visits? For my medicines? Note: These costs will change based on the plan you choose. It will also change if you receive Extra Help (see page 16). If I do not get Extra Help, is there a Medigap policy in my area? (see page 13) What is the premium? How much does it cover for my prescriptions? What is my out-of-pocket limit? Once my deductible is met, how much will I pay for coinsurance? Is my doctor in the plan s network? Will I be able to keep seeing the same doctor? When choosing a Medicare plan, consider Your current RMS treatment plan Your other medicines Costs You can find out if your medicines are covered and compare the costs of plans at 20 INFORMATION ABOUT MEDICARE

21 WHO CAN HELP ME REVIEW MY PLAN OPTIONS? There are many tools and resources that can help you review Medicare plans. Medicare MEDICARE ( ). Your State Health Insurance Program (SHIP) Call MEDICARE for the phone number of your local SHIP office. Above MS , Monday through Friday, 8:30 am to 8 pm ET WHERE CAN I LEARN MORE ABOUT MEDICARE? To learn more about Medicare, you can visit the following websites: Centers for Medicare & Medicaid Services: Multiple Sclerosis Association of America: (search Medicare ) National Multiple Sclerosis Society: Support/Insurance-and-Financial-Information/Health-Insurance/Medicare Social Security: Above MS: or call , Monday through Friday, 8:30 am until 8 pm ET 21 INFORMATION ABOUT MEDICARE

22 HOW CAN ABOVE MS HELP? Above MS TM offers Support Coordinators who can help you choose a Medicare plan. They can help you learn about the plans in your area and the benefits they may offer. Above MS is a free program from Biogen committed to helping people living with multiple sclerosis (MS) and provides extra support services for patients, such as Financial and Insurance Support to help try to identify the best financial assistance solution for you with insurance counseling, benefit investigation, navigation of the Prior Authorization process assistance, and our $0 Copay Program (if you are eligible). Support Coordinators who offer general MS information, one-on-one MS support over the phone, additional injection training information, insurance and financial assistance support. Peer Community that helps you connect with others living with MS, share personal experiences, and listen to concerns to help stay positive and motivated. Nurse Educators who provide additional support through one-onone guidance to you and your care partner with injection technique and who can respond to questions you may have. They are available by phone 24/7. Please keep in mind that your doctor is always your primary resource when it comes to your MS and your treatment. 22 INFORMATION ABOUT MEDICARE

23 The Above MS program from Biogen is here for you The Above MS program can help answer your questions about Medicare. This free program from Biogen is here for you with tips, tools, and inspiration for your MS even if you re not on a Biogen therapy. Contact Above MS at Call Monday through Friday, 8:30 am to 8 pm ET. 23 INFORMATION ABOUT MEDICARE

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