Have Diabetes and Enrolling in Medicare? Start Here
Enrolling in Medicare and need help? SHIPtacenter.org is a free service that offers localized, expert help in choosing all of the different aspects of a Medicare plan – including programs that may lower your out-of-pocket costs – that will be right for you. Need help accessing insulin? Head to GetInsulin.org to create an access plan.
In the United States, Medicare is a federal health insurance program for people aged 65 years and older, as well as for certain younger people with disabilities (those under 65 who qualify receive disability income from Social Security or the Railroad Retirement Board, or have End-Stage Renal Disease or Lou Gehrig’s Disease (ALS)). It functions quite differently than most other types of health insurance, and it is important to be very precise about which plan you sign up for if you are living with diabetes.
Starting in 2021, some Medicare plans will cap the out-of-pocket cost of insulin prescriptions, but not all plans offer this coverage and only certain people qualify. For this and other intricacies of Medicare, here’s what you need to know.
When to enroll in Medicare
For most people, Medicare eligibility is based on age. You can sign up during a window starting three months before the month you turn 65 and ending three months following your birthday month, or you can sign up during Medicare Open Enrollment, which is Thursday, October 15, 2020 through Monday, December 7, 2020 for 2021 coverage.
If you are already covered under a Medicare plan, this Open Enrollment period is the only time in which you can make changes to your coverage, so it is worth reviewing your plan to see if any changes are needed. This year is an important year to review any existing coverage, as the cost of insulin will change under some plans in 2021.
Understanding your options for Medicare is important, and the two basic options are to 1) enroll in Original Medicare Parts A and B, or 2) enroll in a Medicare Advantage (MA) plan. The authoritative place for evaluating available options for Medicare coverage is the Medicare Plan Finder.
What do all the types of coverage mean?
Medicare consists of four parts:
- Part A covers primarily inpatient hospital and skilled nursing facility services.
- Part B covers primarily physician and outpatient hospital services, as well as equipment like insulin pumps, test strips and some CGMs. It also covers the insulin used via tubed insulin pumps.
- Part C is offered by private insurance companies and covers the same benefits as Part A and B, plus many offer drug coverage, similar to Part D
- Part D covers prescription drugs that you typically obtain at a pharmacy – like your insulin if taken via pens, syringes, or a tubeless insulin pump – and may also cover disposable insulin “patch pumps” (like the Omnipod). New in 2021 (enroll before December 7, 2020 for coverage) is the Medicare Part D Senior Savings Program, which caps the monthly cost of insulin taken via pens or syringes at $35 on select plans (be sure to select “insulin savings” in the Medicare coverage search tool to find eligible plans).
For more explanation on these and other things to consider when enrolling in Medicare as a person with diabetes, visit our partner JDRF’s guide on Medicare enrollment. This guide includes guidance on additional cost savings qualifications, Medigap plans, and more.
Finding the best plan, step-by-step
You can sign up for Medicare online, via phone at 1-800-MEDICARE (1-800-633-4227), or by visiting your local Social Security office. Medicare Advantage plans are sold through private insurers.
1) To review Medicare plans, use the Plan Finder. For the purposes of this walk-through, we are going to go through the process of finding an ideal Medicare Advantage plan (comprehensive Medicare coverage offered through private insurers).
2) From there, you will enter your home zip code, then press continue. Confirm your county, and answer the next question on whether or not you receive help with your costs from any of the listed programs, then press next.
3) In the next question (shown below), be sure to select that you do want to see your drug costs when you compare plans. In the question directly afterward, you’ll select how you normally receive your prescriptions (in pharmacy or via mail order, or both).
4) Next, when adding your prescription drugs, be sure to add each drug you take to get the most accurate summary of what you can expect your costs to be in 2021. When you enter your insulin type, be sure to select “add brand instead” (as shown below) when a pop-up window prompts you on whether you would like the generic version of your medication. This will ensure you can get the exact medication your doctor has prescribed. For each medication, you will enter details around how much of the medication you take. Once you’re done adding medications, click the green button that says Done Adding Drugs. You will then enter your pharmacy information (you can search for your pharmacy if you don’t know exact contact details).
5) Once you’re done adding your pharmacies, you will land on a screen that lists all of the different plans that are available to you. On the top right, click on the green button that says Filter Plans.
6) A filter screen will come up. In the top right, click on the box next to Insulin Savings. You can also click on any of the other filter options you want included in your plan. Then click Apply Filters.
7) When comparing each plan, click on “View drugs and their costs” to find out what your true out-of-pocket costs will be before and after your deductible. Your plans available will be different than the one shown below; this is just an example.
8) Once you click on View drugs + their costs, you will be taken to a screen that shows expected out of pocket costs based on the drugs you require and the plan coverage. In the two examples seen below, you will find that one offers $35 out-of-pocket coverage for insulin, while one does not cover the type of insulin required. These little details are very important to pay attention to in order to ensure that the plan you select truly covers the type of prescriptions you need. Note that the second plan was still included under the “Insulin Savings” plans, so this can be a little tricky. Make sure to double check.
9) Once you’ve found a few plans that you think may work for your needs, you can click Add to Compare under any of the plans, then compare them to other options. Be sure to keep in mind that a plan with a low premium may not have ideal drug coverage, so may end up costing you more money over time than a plan with a higher premium but strong drug coverage.
Overall, take time with this process. Important to note is that many people qualify for coverage under both Medicare and Medicaid, which offers more help with costs. To find out if you qualify, or for help with any and all Medicare questions, visit SHIPtacenter.org. This free service offers localized, expert help in choosing all of the different aspects of a Medicare plan that will be right for you.