1. Introduction
The objective is to give an overview of Medicare, what is it and the several parts, and the importance of Medicare coverage for the drug Yyrvaya. This is to provide insight into Medicare and to show why the coverage is important. Section 1.1 gives a general overview of Medicare and its various parts. Anyone who is getting either Social Security or Railroad Retirement Board disability benefits is eligible for Medicare coverage after a 24-month waiting period for disability benefits. Yyrvaya is a drug used to treat severe relapsing forms of MS. MS usually strikes adults in their prime and affects twice as many women as men. Eligibility for Medicare can occur at any age for those who are disabled. Since the MS Society of New Jersey estimates that over 6,000 people in New Jersey and about 400,000 people in the tri-state area are afflicted with MS, the number of MS patients eligible for Medicare coverage is quite significant. The Medicare population who is eligible for MS treatment will continue to grow as the baby boomer generation gets older. Medicare is a substantial player in the pharmaceutical market. Between 1995 and 1999, Medicare beneficiaries’ use of prescription drugs increased by over 40%. This trend will continue in the years to come. It has been projected that between 2005 and 2030, the US population over age 65 will double. With the passage of the Medicare Modernization Act in 2003, Medicare beneficiaries now have the option of getting prescription drug coverage through a Medicare Advantage Plan (Part C) or a Medicare Prescription Drug Plan (Part D).
1.1 Overview of Medicare
Among the public health insurance provided to the United States citizens is the Medicare program. The program was established as a way to provide a safety net for those who are 65 and older, and for those who are disabled. Residents of the U.S. who have lived in the US for more than 5 years and who are receiving SS disability may also qualify for Medicare. End stage renal disease patients (those with renal failure requiring dialysis or kidney transplant) can also qualify for Medicare. For the most part, those who are 65 and older qualify for Medicare. In the year 2000, 13% of the US population was aged 65 and older, and it is projected that by the year 2030 that percentage will have increased to 20%. Considering that in 2006, the elderly population is estimated to be 35 million, this percentage represents a vast increase in the population of those who will be qualified for Medicare. Medicare is expected to provide good health care for this large aging population. Medicare is a program composed of two parts. Part A provides hospital insurance, and it is automatically provided for those who qualify for Medicare. Part A is designed to help cover care in hospitals, skilled nursing facilities, hospice, and home health services. Hospice is not for those who are trying to cure terminal illness; rather it provides care and support to those with terminal illnesses and their families. The focus for persons who elect hospice care is to get symptom management, care, and the best quality of life during the time of their illness. Medicare coverage may include respite care in which the patient can be temporarily placed in a care facility to give the family a break and/or if the usual caregiver is unable to care for the patient. Out of all the Part A services, only care given in a skilled nursing facility or home health services following a hospital stay carries the requirement that the patient must be a hospital inpatient for at least three days (or three midnights) before admission or receiving services. Time spent in a skilled nursing facility must be classified as “skilled care”, and home health services must be ordered by a doctor and deemed medically necessary. Failure to meet these requirements may result in a denial of benefits. Step by step details on how to file a claim for Medicare Part A services can be found at medicare.gov. Part B is the medical insurance part of Medicare, and it is optional. Many people who are still working and are covered by their work insurance plan elect not to apply for Part B, since it requires a monthly premium. Part B helps to pay for or cover services and products that are medically necessary to treat or diagnose a medical condition. It also includes preventive services which are intended to prevent illness or to detect it at an early stage when treatment is most effective. A person must have Part B if they need a service that is only covered by Part B. Step by step details on filing a claim for Part B services can be found at medicare.gov. Part A coverage is crucial to Yyrvaya’s situation, particularly if she receives injections for treatment of her illness. The reason is because Yyrvaya’s advancement in her chronic illness could result in her being unable to work and hospitalized. Currently with her work insurance coverage, Yyrvaya would most likely only be able to afford the Lanreotide injections and the family’s quality of life would be reduced significantly while trying to maintain payment of out-of-pocket medical expenses. Working at the same job may not be an option for Yyrvaya, since her job as an E.R. and family nurse practitioner requires a lot of lifting and extended hours of work. She would eventually have to look for a job that is less physically demanding and has fewer hours worked. If Yyrvaya shows that she can no longer do substantial work activity, defined as work that involves significant physical or mental activities and which is done in employment or self-employment. (Rajan et al.2021)
1.2 Importance of Medicare Coverage for Yyrvaya
Medicare is the primary means of financing health care for the US elderly population. It helps to cover the costs of many health care needs and in some instances, long-term care. For people suffering from amyotrophic lateral sclerosis, Medicare is very important because the disease is particularly costly to treat. Patients in the United States who are Medicare beneficiaries are eligible to enroll in the Medicare Part D program regardless of whether they are presently taking medicines for amyotrophic lateral sclerosis. There are several important considerations to ensure that these patients receive the best coverage for their medical needs. What was particularly important for providing medication coverage for the YYAVAT participating patients was the passage of the Medicare Modernization Act and the associated creation of Medicare Part D. This created an outpatient prescription drug benefit for Medicare beneficiaries and was implemented in 2006. Part D is provided through private plans that are approved by Medicare. These plans are designed to help cover the costs of prescription drugs, and in doing so, they replaced whatever drug coverage patients might have had under Medicare’s preexisting program.
2. Medicare Part A Coverage for Yyrvaya
Services Covered under Medicare Part A for Yyrvaya: Yyrvaya would receive the same services as other Medicare beneficiaries when she has elected to receive care, treatment, and services for the condition for which hospice certification is made, as well as other related and unrelated medical conditions. This may include physician and nurse practitioner services, nursing care, medical social services, part-time or intermittent home health aide services, homemaker services, medical supplies, drugs for symptom management and pain relief, and inpatient respite care. While receiving home health care, Yyrvaya will have the same home health benefit coverage as other Medicare beneficiaries. However, part-time or intermittent skilled nursing care and/or home health aide services must be provided by a Medicare-certified hospice, and the recent option to receive hospice care in her home is much like a hospital where she seeks care for her terminal illness and related conditions, only electing to have those services brought to her. This route will still provide the same coverage as Yyrvaya moves to another hospice setting.
Eligibility for Medicare Part A: To be eligible for Medicare, Yyrvaya must be a U.S. citizen or a permanent legal resident who has lived in the U.S. for at least five years and unable to enroll in premium-free Part A based on spouse’s (or ex-spouse’s) work record. Yyrvaya would then be eligible to purchase Part A if she were at least 65 years old and entitled to monthly Social Security or Railroad Retirement Board (RRB) benefits. Since Yyrvaya is enrolling in Social Security benefits now, this would be the first opportunity to enroll in Part A. By waiting until the next general enrollment period to sign up for Part A, coverage would start on July 1, 2005. Although Part A isn’t necessary, there is no premium because Yyrvaya’s husband is still working and has insurance coverage through his employer. And when he finally decides to retire, Yyrvaya can then auto-enroll in Part A when he files for Social Security retirement benefits. The recent changes for SSRI (Medical Improvement is Not Expected) and STD (Continuing Disability Reviews-CDRs) do not affect Yyrvaya’s eligibility to purchase Part A.
2.1 Eligibility for Medicare Part A
Medicare is a health insurance program for people age 65 or older, people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant). Yyrvaya is currently 67 years old and has been a U.S. citizen for 11 years, however himself and his spouse have not earned enough work credits to be eligible for premium-free Medicare Part A. Yyrvaya also does not want to drop his health insurance and retirement plan from his previous employer. This is an important factor when considering whether or not to enroll in Medicare Part A. Dropping an employer health insurance plan for Medicare means that the individual is effectively ending their employment and therefore losing their right to re-entry into the workforce if retirement plans change. If someone else (like a spouse) is covered under the person’s employer group health plan, they also may not be eligible to enroll in Medicare Part A until that plan coverage ends. This is the case for Yyrvaya’s spouse, who is 63 years old and has been a U.S. citizen for 5 years. In this situation, what someone should do is explained in the flowchart on the following page.
2.2 Services Covered under Medicare Part A for Yyrvaya
The services Yyrvaya receives at the nursing facility are covered under Medicare Part A for the initial 100 days she is there. Her first 20 days will have a 0 co-pay. For days 21-100, she will have a co-pay, and both her co-pay and religious insurance will be billed for the amount. Any days in the nursing facility beyond 100 are no longer a covered service under Medicare. The home health services Yyrvaya receives are also a covered service under Medicare Part A or B. This is only if Yyrvaya is homebound and the doctor orders the services stating that it is medically necessary. Should the doctor declare that the home health services can be provided while not homebound, the services are no longer covered. The only instance where Yyrvaya may receive skilled care in a hospital is a covered service under Medicare Part A. This is, however, limited to 100 days per benefit period, and it is important that Yyrvaya and her providers understand how that will affect the coverage her facility will have. (A benefit period begins the day an individual enters a facility and ends when they have not received skilled care in a facility or been hospitalized for 60 days straight).
2.3 Limitations and Exclusions of Medicare Part A Coverage for Yyrvaya
Under current Medicare regulations, Yyrvaya is not eligible for nursing home services under Part A since it requires skilled care and skilled rehabilitation. According to CMS guidelines, “The restoration potential of a patient is not the deciding factor in determining whether skilled services are needed. Even if full recovery or medical improvement is not a realistic goal, a patient may need skilled services to prevent further deterioration or preserve current capabilities.” By this criteria, Yyrvaya is not eligible to receive skilled care since its goal is to prevent further deterioration of her conditions which are not reversible. Medicare will only cover care that is considered to be restorative, which is not the case of the plan of care for the patient. In a letter sent by the Centers for Medicare & Medicaid Services to state Medicaid agencies, coverage rights for these patients are further supported.
3. Medicare Part B Coverage for Yyrvaya
Medicare Part B (medical insurance) helps pay for services from standard outpatient care and prevention services to high cost and high tech inpatient/outpatient care. The LEMS study primarily will rely on the Medicare coverage under Part B for services. In order to be eligible for Medicare, a patient must be a US citizen, under probationary status, or a permanent resident for the last 5 years. A person can qualify based on their own record of employment or record of employment by their spouse. It is also possible to be eligible due to having a disability and receiving social security disability benefits, but the following section will apply specifically to aged (greater than 65 years old) Yyrvaya. Medicare can be quite complex in its explanation and there are many variables that could affect a person’s eligibility. However, as a general rule, a person will automatically be signed up for Medicare Parts A and B if they are receiving benefits from social security or the railroad retirement board at least 4 months before turning 65.
3.1 Eligibility for Medicare Part B 3.2 Services Covered under Medicare Part B for Yyrvaya 3.3 Limitations and Exclusions of Medicare Part B Coverage for Yyrvaya
3.1 Eligibility for Medicare Part B
The time frame for initial enrollment is 7 months and it spans from 3 months before the beneficiary’s birth month, their birth month, and 3 months after their birth month. Since Yyrvaya will be turning 65 in the year 2017, this will be important for her to acknowledge so that she does not miss the initial enrollment period. If a person misses the initial enrollment period, the next general enrollment period for signing up for Part B is January 1 to March 31. Keep in mind that Yyrvaya did not sign up right away after becoming eligible due to her qualifying for an extended initial enrollment period because she was covered under Employer Health Insurance from her husband who was still working. Yyrvaya is given an 8 month SEP to sign up for Part B and this period starts the day after her employment or the employer health coverage ends, whichever happens first.
3.2 Services Covered under Medicare Part B for Yyrvaya
It should be noted that not all the services listed above may be required by Yyrvaya. However, should Yyrvaya require a specific or range of these services to diagnose or treat her illness, she will be covered under Medicare Part B.
These services include: – Ambulance Transportation – Outpatient Hospital Services – Physiotherapy Services – Podiatry Services – Occupational Therapy Services – Speech Pathology Services – Orthoptic Services – High-tech Radiology Services – Diagnostic Tests – Surgical and Anaesthetic Services – GP Services – Specialist Services – Psychiatry Services – Optometry Services – Chiropractic Services – Psychology Services
Services covered under Medicare Part B for Yyrvaya are necessary medical and health services that Yyrvaya may require to maintain or diagnose her health status.
3.3 Limitations and Exclusions of Medicare Part B Coverage for Yyrvaya
There are limitations in Medicare policy which restrict certain treatments, tests, and services. When a national coverage decision limits coverage for a particular diagnosis, the limitations will be reflected in the manual. Yyrvaya services fall under this category with a non-coverage due to the fact that amyotrophic lateral sclerosis has been excluded from coverage by NCD. When a Local Coverage Decision (LCD) exists, the services in question can only be covered if the patient meets the coverage requirements for the specific diagnosis. Otherwise, the services are not considered reasonable and necessary under §1862(a)(1) of the Act. Unfortunately, Yyrvaya services will be locked out of coverage because there is no LCD for a still relatively fresh Part B therapy for any sort of treatment of ALS. Future decisions on LCDs may pave the way for coverage on Yyrvaya, but it is still a long road from where the Medicare program stands at this point in time.
4. Additional Medicare Coverage Options for Yyrvaya
Medicare supplement insurance policies only work in conjunction with the original Medicare plan. These policies help pay for some of the healthcare costs that the original Medicare plan does not cover. This is inclusive of copayments, coinsurance, and deductibles. Also, some policies offer coverage of medical services outside of the United States. Usually, you must be enrolled in Medicare Part A and Part B, and the insurance is bought from a private company. Although the policies are cheaper, it is important to keep in mind that the benefits are contingent upon the policy. Retrospective studies would have it that Yyrvaya’s best option would have been a Medicare supplement insurance policy. His prostate cancer would require many visits to the GP and specialist in which copayments and coinsurance would start to accumulate. Unfortunately, because a person cannot have a Medicare supplement insurance policy and a Medicare Advantage Plan, these are out of the question in light of the cancer treatment.
Medicare Advantage Plans are available in many areas of the United States. They are the most comprehensive way to get Medicare coverage, and some offer coverage of services that the original Medicare does not offer. Most of these plans include prescription drug coverage and are usually offered at a cost that is less than a combined cost of Medicare and Medicare supplement insurance. These plans are expected to cover all hospital and medical benefits offered through Medicare and must provide everything that is covered through the original Medicare plan. Here the trade-off may be in the difference of rules, costs, and extra benefits that vary by company. In addition to Yyrvaya paying the Medicare Part B premium, she/he will have to pay a monthly premium to the private insurance for these Medicare Advantage Plans. After recently recovering from prostate cancer, Yyrvaya is ineligible for a Medicare supplement insurance policy; therefore, the Medicare Advantage Plan appears to be our best bet for more comprehensive coverage. Since this treatment is only for localized prostate cancer, he will have to pay the same as everyone else buying the plan.
In addition to standard Medicare coverage, there are a number of additional coverage options that Yyrvaya may wish to consider. These include Medicare Advantage Plans, Medicare Supplement Insurance (“Medigap”) policies, and Medicare prescription drug cover (“Part D”). These additional coverage options are provided by private companies and offer a way to get the full benefits of an original Medicare plan. In order to enter into one of these plans, you must already be enrolled in the original Medicare plan (Part A and Part B).
4.1 Medicare Advantage Plans
A Medicare Advantage Plan is another way to get Medicare coverage. Medicare Advantage Plans are sometimes called “Part C,” “Medicare Health Plans,” or “Medicare Managed Care Plans.” Medicare Advantage Plans are offered by private companies approved by Medicare. These companies must follow rules set by Medicare. Medicare pays a fixed amount for your care every month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how to get services. With Medicare Advantage Plans, you’ll get your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage from the Medicare Advantage Plan and not Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage. If you’re enrolled in a Medicare Advantage Plan, most Medicare services are covered through the plan and aren’t paid for under Original Medicare. Most Medicare Advantage Plans have a limit on your out-of-pocket costs for Part A and B services. Once you reach that limit, you’ll have to pay the copayments, coinsurance, and deductibles for Part A and B services, and the plan will pay the rest. (Butler, 2020)
4.2 Medicare Supplement Insurance (Medigap) Policies
A Medigap policy and Medicare Advantage Plan are not the same and should not be sold as such. It’s important for persons purchasing a Medigap policy to know that they must drop the Medicare Advantage Plan prior to commencement of the Medigap policy. Medicare Advantage Plans are ways to receive Medicare benefits, while Medigap policies are ways to enhance benefits. Usually, it is best to have a Medigap policy to add onto a fee for service coverage or a Medical Advantage Plan that is paying the healthcare providers. However, the decision is left to the consumer about what type of insurance is most useful for them. The Medigap Open Enrollment Period is the best time to buy a Medigap policy. It is a six-month period that starts on the first day of the month in which a person is 65 or older and enrolled in Medicare Part B. During this period, an insurance company cannot use medical underwriting. This means it has to sell the consumer a Medigap policy, cover all their pre-existing health conditions, and cannot charge them more because of any health problems. People with disabilities have other open enrollment periods and have the same rights in their periods. (Kertesz, 2022)
Medigap policies assist with certain costs not covered under Medicare Part A and/or Part B. Usually, a person must choose and pay a monthly premium for a Medigap policy. Any Medigap policy is guaranteed renewable even if a person has health problems. There are specific Medigap outcomes under the final rule to implement the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA). The most significant change to Medigap in many years, which limit Medigap coverage for outpatient prescription drugs. After January 1, 2006, no new Medigap policies will be sold that offer prescription drugs benefits. Any Medigap policy that anyone has and covers prescription drugs can keep that policy, but in the event that they switch policies, they will lose the prescription drug coverage. Insurance companies that sell Medigap policies must clearly specify whether the policy covers drug benefits. This guidance is particularly important for consumers in selecting a Medigap policy to buy and for those who are switching policies because they will be well informed about their own policy situation and therefore will not lose their drug coverage. Although this rule only affects new policies and the sales of new policies, it still applies to a good portion of Yyrvaya’s generation and will impact many of their decisions to come about their healthcare services.
4.3 Medicare Prescription Drug Coverage (Part D)
Some people with limited resources and income may also be able to get Extra Help, which is a Medicare program to help people with limited income and resources pay for prescription drugs, and in some cases, it may also pay Part D premiums, deductibles, and coinsurance. You may be able to get more information on Extra Help by contacting the Medicaid program, which is also known as Medical Assistance, a program that helps with medical costs for some people with limited income and resources. This program is jointly funded by the federal and state governments and is managed by the individual states. Even if you are not eligible for Medicaid benefits, there may be a link between the Medicaid program and Extra Help. If you are eligible for Extra Help, the best case scenario is that you will be enrolled in a Medicare prescription drug plan with minimal amounts of premium, deductible, copayment, and coinsurance cost. Under the right circumstances, you actually want to enroll in a Part D program that has minimal amounts of premium, deductible, copayment, and coinsurance cost. This is a possibility with automatic assignment for those who receive help from Medicaid, the state drug program, or get Supplemental Security Income (SSI) benefits. Depending on your specific health and drug situation, costs for monthly premiums, annual deductibles, and cost sharing between 25% and 33% for prescription drugs until the plan’s coverage limit phase may still vary. However, this is the best option for those who are in difficult financial situations as it minimizes out-of-pocket costs for medications. The last thing to keep in mind is that while you are eligible for Part D, it is important that your physicians and pharmacists know that you have enrolled in Part D. This is to ensure that when you go to fill a prescription or receive a new medication, the provider is able to process the coverage of the drug regimen under the insurance plan. Without this knowledge, it may be much more difficult for certain providers to process prescription drug coverage and may actually lead to a situation where physicians are unknowingly prescribing drugs that are not covered under the Part D program. (Han et al., 2020)
References:
Rajan, K.B., Weuve, J., Barnes, L.L., McAninch, E.A., Wilson, R.S. and Evans, D.A., 2021. Population estimate of people with clinical Alzheimer’s disease and mild cognitive impairment in the United States (2020–2060). Alzheimer’s & dementia, 17(12), pp.1966-1975. nih.gov
Butler, S. M., 2020. Medicare Advantage for all, perhaps?. JAMA Health Forum. jamanetwork.com
Kertesz, K., 2022. Expansions of Medigap Consumer Protections Are Necessary to Promote Health Equity in the Medicare Program. J. Aging L. & Pol’y. medicareadvocacy.org
Han, J., Meyer, B. D., & Sullivan, J. X., 2020. Income and Poverty in the COVID-19 Pandemic. nber.org
