If you’re one of the millions of Americans living with a chronic medical condition, selecting the Medicare plan can be intimidating.
Maybe you’ve finally settled into a routine with your medical professionals and services and don’t want to upset that balance. Or maybe you’re hoping the transition to Medicare can help you find the care team, lifestyle changes, or facilities that will help you make the strides you need to improve your quality of life.
Regardless, living with chronic illness or recurring medical conditions can introduce a new, distinct set of variables in the hunt for a good Medicare plan. But, you’re far from alone; the Centers for Disease Control (CDC) estimate six in 10 Americans lives with at least one chronic disease and it’s likely this number increases as people age. CDC statistics from a 2015 journal article estimated more than ⅔ of Americans age 65 and older had two or more chronic conditions.
While you likely have several criteria to evaluate your options for managing chronic conditions with Medicare, we’ve also rounded up some key points to consider.
1. Original Medicare and Medicare Advantage Cover Chronic Conditions
One of the biggest Medicare choices you’ll face upfront will be whether to have Original Medicare or to select a private network via Medicare Advantage. While both have pros and cons, it may be comforting to know that both cover chronic conditions.
Legally, Medicare and Medicare Advantage plans must cover treatments for chronic conditions regardless of their “restoration potential,” meaning treatments should be covered even if there isn’t a cure. Treatment may include outpatient or rehab services that aim to help a person maintain, slow, or improve the symptoms of their condition.
Original Medicare and Medicare Advantage also can’t charge you or deny you coverage based on “pre-existing conditions” (and chronic illness would definitely be considered a pre-existing condition).
2. Original Medicare Coverage for Chronic Conditions Doesn’t Change
Medicare Parts A and B treat chronic conditions much the same as other types of care. The same co-pays and deductibles apply, the same limits cover outpatient and inpatient treatments, and the same processes govern chronic care. This means nothing about your Medicare coverage changes; no need to worry about networks or prior authorizations for the kinds of care you need. However, the 20 percent part B coinsurance fee can be steep, and it adds up for conditions that need frequent treatment.
The Centers for Medicare and Medicaid Services (CMS) also advocates for Medicare beneficiaries with chronic conditions to establish a chronic care management (CCM) plan that serves to coordinate care between several doctors or medical networks. While this isn’t a specially paid-for benefit, CMS notes that maintaining a CCM can help make your care less expensive by ensuring your providers are all in the loop and can give you a better quality of life with fewer trips to the emergency room and less duplication of care.
3. Consider Your Medicare Advantage Network of Covered Providers
Medicare Advantage plans tend to be less expensive than if you enroll in Original Medicare and get a Medigap plan with a Plan D drug plan. However, Medicare Advantage plans require their enrollees to use their designated medical network and get prior authorizations to receive many kinds of care.
So, if there’s a provider or facility you like, you’ll need to make sure your Advantage plan covers their services. If your Advantage plan is a PPO network, you may still be able to visit your favorite provider or facility but you’ll be subject to more expensive, out-of-pocket costs for any covered services.
4. Medicare Advantage May Cover More Chronic Care Treatments
Medicare Advantage plans have doubled the number of “special needs plans,” or SNPs, over the last half-decade. SNPs pair a standardized CCM with a Medicare Advantage provider’s network, making it easier to pair people with a chronic condition like diabetes or kidney disease, to more common treatments available to them.
5. Consider Getting or Switching to a Supplemental Plan
While Original Medicare will cover many services associated with a chronic illness, you may still have to contend with out-of-pocket costs due to the gaps in Original Medicare. In other words, treating your chronic condition may become quite costly especially if you’re making frequent visits to the doctor. You can opt for a Medicare Advantage plan, but the pay-as-you-go nature of that system may have you spending just as much on your care. On the other hand, a Supplemental plan will cover many of the gaps in Original Medicare, significantly decreasing your out-of-pocket costs on covered services.
6. Getting a Supplemental Plan After Open Enrollment May Not be Possible
Should you choose a Medicare Supplement plan, you’ll have to be mindful of when you enroll. Medicare Supplement companies can’t discriminate against enrollees based on their health during the six months after they enroll in Medicare Part B. However, if someone decides to enroll in Supplement coverage after the first six months, the insurance carrier will require you to medically qualify. Unfortunately, depending on your chronic condition, Medicare Supplement carriers can deny coverage or charge higher premiums based on their chronic conditions.
The only exception to this rule is if you live in Connecticut, New York, Oklahoma, Vermont, and Washington where there is year-round open enrollment.
7. Stay on Top of the Annual Notice of Change
Your healthcare plan will send an Annual Notice of Change (ANOC) each year. This document details any changes in network and premium for the coming year. If you have a Supplemental plan or are just enrolled in Original Medicare, you don’t have to worry about any coverage changing, but you will want to pay attention to the new part B deductible and your new premium if you have a Supplemental plan. This will help you make changes to your budget or explore a more affordable Supplemental plan.
If you have an Advantage or Part D plan, you’ll want to take a look at any changes to your coverage as this may affect your medication costs or which providers you can continue seeing in the coming year. If you live with a chronic illness, looking through the ANOC will help you decide what to do when the Annual Enrollment Period comes around.
8. Prepare for the Annual Enrollment Period
Whether you’re a Medicare Advantage member, or have Original Medicare with a Part D plan, preparing for the Annual Enrollment Period toward the end of the year is essential. If you aren’t happy with the upcoming changes stated in your ANOC documents, the AEP is the only time you can switch coverage before your new plan terms take effect.
Remember, if you have Advantage or Part D, making annual changes to these plans is a decision that lasts for a year, not forever. So, take it a year at a time, and be sure your coverage is in lockstep with your health goals.
9. Medicare May Not Cover Everything
While Medicare will cover many services related to a chronic illness, especially if you have a Supplemental plan, it won’t cover everything. For example, if your illness progresses to the point of needing any custodial care services, you’ll likely need money set aside for those services as well as a long-term care policy. This is because Medicare doesn’t cover custodial care services.
Find Medicare Coverage for Chronic Conditions with Medicare School
When it comes to managing a chronic condition, planning ahead will save you time and money. If you’re you’re curious about Medicare coverage for chronic conditions, give us a call or schedule an appointment with a Medicare guide. Our dedicated team will lay out your Medicare options so you can make an informed decision on your coverage.
If you want to learn more about the Medicare system and what it covers, sign up for our virtual Medicare Essentials workshop today!