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Readers Ask About Concierge Medicine And Medicare; Insulin Costs And The Doughnut Hole

This week, I answered three questions related to coverage in the Medicare program, the federal health insurance program for people who are 65 or older and some who are disabled.

Q: I was recently advised by my primary care physician that he is transitioning to a “membership-based personalized health care program,” also known as concierge medicine. This program will cost me $1,760 a year. I currently am covered by Medicare, and my out-of-pocket expenses have never exceeded $100 per quarter. If I sign up with the program, how might it affect my Medicare coverage and costs?

dear michelle 570A: As long as your doctor still participates in the Medicare program — and nearly all physicians do — he can’t apply the concierge practice annual fee to services that Medicare covers, says Cristina Boccuti, a senior associate at the Program on Medicare Policy at the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.) Likewise, if you sign up for the concierge program, you’ll still be responsible for normal cost sharing for covered Medicare services as well, says Boccuti.

In addition, Medicare will not pay any of the concierge fee.

Concierge practices often say the annual fee entitles patients to continue seeing a familiar doctor, get faster access or extra perks. As long those extras aren’t services covered by Medicare, that’s OK. You may get a wellness newsletter, for example, or preventive services during your annual check-up that aren’t included in the annual wellness exam that Medicare covers.

It’s up to you whether you think that access or those extra services are worth an additional fee.

Q: I’m a health insurance counselor, and I’m working with a Medicare beneficiary who hit the doughnut hole on his Medicare Part D prescription drug plan because of the cost of his diabetes medications. Now he’s been told that because he uses an insulin pump, both the pump and the insulin are covered under Medicare Part B as durable medical equipment, and should not have bumped him into the donut hole. Will this change save him money?

A: It’s hard to know exactly what the impact will be. There are cost sharing issues either way. In a Part D drug plan, once the patient and the drug plan together spend $2,960 on prescription drugs, the patient enters the coverage gap often called the “doughnut hole” where he’s responsible for a greater share of the cost of his drugs. Once he reaches $4,700 in spending, he leaves the coverage gap and Medicare picks up nearly all remaining drug costs for the year.

But there are costs associated with Part B coverage as well. Insulin pumps and the insulin that the device uses are covered under Medicare Part B, which covers outpatient medical services and durable medical equipment. After meeting the $147 annual deductible, patients generally have to pay 20 percent of the cost of Part B care, unless they have a Medigap plan that covers those coinsurance amounts.

Depending on how much insulin someone uses and the specific drug he’s on, 20 percent coinsurance could be significant, says Dr. Robert Gabbay, chief medical director at the Joslin Diabetes Center in Boston.

As an example, a vial of insulin might cost $250, and someone might use three vials a month in their insulin pump, Gabbay says. The annual cost of that insulin would be $9,000, and the beneficiary could be responsible for $1,800 in coinsurance charges.

Insulin pumps, which are small battery-powered devices that deliver insulin through a tube inserted under the skin, are recommended by physicians for some patients whose blood sugar control isn’t optimal. The pump may cost more than $5,000 plus $100 monthly for supplies, such as the needle, tubing and adhesive. The pumps can maintain better insulin control and help the patient stay healthier, thereby helping patients and the Medicare program avoid hospitalizations and other pricey medical care.

“If you need an insulin pump and it’s the right therapy, for the Medicare program it easily pays for itself over time,” Gabbay says.

Q: My 85-year-old husband has been diagnosed with anxiety and depression. He had a stroke last year and now spends most of his time in bed. His mind is failing and he’s frequently confused. Taking care of him is exhausting, but I’m concerned that unless the doctor gives him a diagnosis of dementia I can’t qualify for respite care. What are the criteria?

A: Coverage for caregivers to take a breather from caring for a loved one at home is spotty.

In general, the traditional Medicare program only pays for respite care if a patient has entered hospice. To be eligible, the doctor has to certify that the patient is terminally ill and expected to live for six months or less. The program pays for the Medicare beneficiary to be moved to a hospital or nursing home for up to five days at a time so the caregiver can get some rest.

It doesn’t sound as if your husband is in hospice, however, so this is probably not an option.

Some Medicare Advantage Special Needs Plans may cover respite care, but there’s no requirement that they do so, says Elaine Wong Eakin, executive director of California Health Advocates, a Medicare advocacy group.

Special needs plans are Medicare Advantage managed care plans that limit membership to certain types of beneficiaries and tailor services to their needs. Some only accept people who have certain diseases such as dementia or heart failure. Others only sign up people who are eligible for both Medicare and Medicaid, the federal/state health program for low income people. Still others accept only beneficiaries who are institutionalized and need nursing home care.

Eakin advises checking with your state health insurance assistance program to find Medicare Advantage special needs programs or other community services that might meet your needs.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

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