Blog

July 1, 2024

By Anne Dabbs, 
NCAN TN Support Group Leader, NET Patient
and
Tom Wilson,
NCAN WI Support Group Leader, NET Advocate

Remember back to the first paycheck you ever received and your surprise at seeing an amount less than what you were anticipating… all due to a line item called FICA. Your parents or your employer probably gave you a simplified explanation of your contributions to the Federal Insurance Contributions Act which was appropriate at that time. Perhaps now, as you are inching closer to retirement age, it is important to have a refresher course. This US Federal payroll tax has been earning you credits to qualify for Social Security programs which provide Medicare and Social Security benefits for retirees, children, and people with disabilities.

A Brief History of Medicare
· 1965 – Medicare introduced for those 65+
· 1972 – Medicare expanded for those under 65 with disabilities
· 1980’s – Rise in the introduction of expensive specialty drugs
· 2006 – Part D (Medicare drug plan) introduced to help offset cost of drugs
· 2024/2025 – enhancements to Part D (coverage cap, etc).

75% of Medicare recipients spend more than 10% of their income on health.
Many can’t/couldn’t afford drugs and therefore walk away from the pharmacy counter or take fewer than prescribed.

One third haven’t taken their medication in the past year due to cost.

Medicare is constantly evolving. These incremental changes have almost always been beneficial for Medicare recipients.

This month we want to share basic Medicare facts which will serve as a primer for ready reference as you either sign up for Medicare or anticipate a change in your selections during the annual open enrollment period each year. It is especially important to be aware of basic definitions, options, and changes for those of us living with a chronic disease like NETs.

Basic, Original Medicare consists of 2 parts: Part A (Hospital insurance) and Part B (Medical insurance). Most people sign up for both Parts when they are first eligible (at age 65), but there are options to delay this coverage. Make sure you understand the possibility of a gap in coverage, a recurring penalty, and/or underwriting restraints. We recommend meeting with an independent Medicare health insurance agent before making your decision.

Part A typically does not require a premium payment. There is an annual deductible.

Part B does require a monthly premium payment which is typically subtracted from your Social Security Retirement Check before it is deposited into your bank account. In 2024, this premium was $174.70 monthly. There is an annual deductible of $240 (2024). After the deductible is met there is a cost share of 80/20 which means that once you have paid your deductible, Medicare will cover 80% of your healthcare costs and you will be responsible for 20%.
Since Part B only covers 80% of the costs for non-hospital expenditures (doctor visits, labs, scans, etc), Medigap Supplemental Plans were also introduced in 1966. Since that time, Medigap has expanded and evolved. Medigap Plans cover the 20% of medical expenses not covered under Part B (drugs excluded). Medigap plans are sold by private insurance companies and became regulated in 1980. In 1990, Medigap plans began to offer standardized coverage. These plans do incur a premium payment which typically increase annually. There are no preapprovals with Medigap. If Medicare pays for it, Medigap automatically pays the balance of 20%. Medicare submits the claim to your Gap plan automatically. You don’t need to file anything.

The so-called Part C of Medicare evolved out of a decision in 1997 to allow private insurance plans to be an alternative for beneficiaries. The original name of ‘Part C’ was ‘Medicare+ Choice’. Today it is known as Medicare Advantage which is a confusing misnomer that many recipients confuse with traditional Medicare and mistakenly purchase it thinking they have Medicare. It was established by the Balanced Budget Act of 1997 and later rebranded to Medicare Advantage under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. A premium payment is often incurred for Medicare Advantage Plans, and typically are at least the same amount as Part B or more depending upon the plan you choose. The deductible, out of pocket maximums, and cost shares will vary. Medicare Advantage plans are noted for frequent and ongoing preapproval requirements and denials of service.

Part D of Medicare serves the purpose to help offset the cost of prescription drugs for individuals enrolled in Traditional Medicare (Parts A and B). Part D usually requires a premium payment which will vary upon the plan you choose. In 2024, there were major changes occurring to the rules and regulations for Part D Plans. More are coming in 2025 and beyond.

In summary, an enrollee has two main plan options for selecting Medicare Health Insurance Coverage.

Original Medicare which includes Parts A and B. In addition, you must determine if you want a Supplemental Medigap Plan and/or a Part D Prescription Drug Plan. These are both highly recommended for those with NETs.

OR

Medicare Advantage Plan Part C which is equal to Parts A and B and you must determine if you also want a Part D Prescription Drug Plan (if your Part C plan does not include prescription drug coverage). Medigap Supplemental Plans are not available for Medicare Advantage Plans enrollees.
You can sign up for Medicare during a seven-month initial enrollment period around the time you turn 65. A general enrollment period is from January 1-June 30 each year, but coverage will not begin until July 1 and you may face late enrollment penalties. Every year there is an Open Enrollment period from October 15-December 7, during which time you can make changes to your coverage.

Prior to the Open Enrollment Period, in September every year a Medicare Plan enrollee receives an Annual Notice of Change (ANOC). This information from your existing plan includes any changes in coverage, costs and more that will be effective from the following January. It is the enrollee’s responsibility to review their coverage each year to determine if their current plan continues to meet their healthcare needs.

As a Medicare enrollee with a chronic illness such as Neuroendocrine Cancer, it is important to be well informed and advised about all options available and possible contradictions as you select your Medicare coverage Plans. Items to be clarified may include:

· Avoiding an underwriting process for coverage
· Freedom to travel to see nets specialists and receive treatments that may not be local to you without penalty. Medicare Advantage plans which provide ‘narrow networks’ of providers may not offer you access to NETs specialists. You should obtain confirmation that you will have access to larger medical facilities which support our rare disease
· Coverage of our specialized scans and treatments (gallium scans, PRRT, etc.).
· Disclosure of cost shares, hidden costs, and surprise out-of-pocket costs for all drugs and treatments. Approval process (if any).
· Delays and denials are a form of cost saving actions undertaken by some plans whose premiums are almost too good to be true. Delays and denials can be hazardous to a patient with a rare, incurable disease such as ours.
· Availability of Medicare Saving Programs and Extra help Programs
· A more than basic understanding of the primary differences between Original Medicare Plans and Medicare Advantage Plans

Understanding Medicare is crucial for managing your health, especially when dealing with a complex chronic condition like Neuroendocrine Cancer. This guide aims to simplify the intricacies of Medicare, helping you make informed decisions about your healthcare coverage.

We understand that navigating Medicare can be overwhelming, particularly when specific needs and treatments must be considered. By staying informed and utilizing resources available through reputable sources, you can ensure that you choose the best coverage for your unique situation. Always remember, we are HERE for you. Reach out to us for any questions or support you need in navigating your NETs journey. Together, we are zebra strong.

*The above information was compiled by using the links below as well as helpful resources for better understanding Medicare. The information contained here is not a specific recommendation for any choice for any patient. Our recommendation is to avail yourself of comparisons and expectations for the best Medicare program for your individual needs. Again, it is highly recommended to consult with an independent Medicare health insurance agent in your area before deciding on coverage.

GOVERNMENT SITES

Medicare.gov
CMS.gov (centers for Medicare and Medicaid Services)
HHS.gov (health and human services)
Healthcare.gov
USA.gov
Shiphelp.org

COMMERCIAL AND ADVOCACY WEBSITES and videos with additional information

Medicareinteractive.com
Boomerbenefits.com
Gohealth.com
Healthline.com
Nasi.org

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