Significant changes to Medicare in 2021

Don Baer

Moderator
Staff member
I don’t post much about these things but many of you know that I am an Insurance broker and for the past 10+ years have specialized in Medicare. I also am a volunteer counselor with a veterans advocacy group counseling veterans and their family in maters of health insurance and long term care, both VA and none VA. Enough about me the purpose of this post is to raise awareness to 2 very significant changes to medicare coverage for 2021.

The first Change is regarding Insulin – in the past with the exception of a few special need plans folks would pay for insulin as a tier 3 drug which meant that they would pay about $45 for a 30 day supply until they reached the GAP (Doughnut hole) and then after that they would pay 25% of the cost of the insulin. That meant by June most insulin dependent folks would see the price of their insulin go up to between $125 to $150 per 90 supply. As a result of this many would either cut down on their required dose or stop taking it all together. The end result was these diabetics would develop complication and many of them would die because of this. One of the complication of this is ESRD (End Stage Renal Disease), kidney failure. (Carol Reed was a diabetic and felt insulin was to expensive and therefore did not take it).

The Medicare has created a special program where some insurance companies can offer insulin for $35 both before and during the GAP. Not all companies are participating at this time but some of the bigger ones are. In Arizona United Health Care and Humana are offering it.

The second BIG change is for folks with ESRD – in the past these folks were not allowed to sign up for any type of Medicare insurance other than original Medicare and therefor had to buy a separate drug plan and were forced to pay 20% for all out patent services including dialysis. There is no max out of pockets. Now starting in 2021 they can sign up for a Medicare Advantage Plan. This means that going forward they will usually pay far less then the 20% for there out patent services and all Medicare Advantage Plans have a maximum out of pocket. Most also include a drug plan. Medicare advantage plans can be had for little or no cost. (Carol Reed died from ESRD).

I am putting this out there so that if you or anyone you know is effected by these two significant changes please tell them to get a hold of a broker learn more.
 
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Don,
My wife is retired and collects SS. Her dob 10/30/55. She received notice that charges for Medicare Part A & B would begin in October. My dob is 10/5/55. I will not retire until 2022 at the earliest. As I have good benefits with a high deductible medical plan and an HSA. As I understand it I do not need to sign up for Medicare until I retire? I have CLL so annual medical expenses are very high. Is my wife required to sign up for Medicare now even though she is covered under my employer's plan? I would greatly appreciate some direction. I don't mind discussing this here if you don't but if you prefer my personal email address is jlemley@usa.net or if you want we can talk on the phone personal cell nine o three seven three three six six six one

Thanka
Jack
 
Jack
I'll go ahead and answer here as others may want to know the same thing.

First of all you can’t sign up for Medicare until you are 65 or are on disability so you will stay with your group insurance until it is your time. Your wife is another story and you need to consider several things. First of all is her coverage under your group insurance considered credible coverage. I am most concerned about prescription coverage under Medicare guidelines. Only your group insurance can answer that question. If not then she will need to go on Medicare in order to avoid penalties later on. Next what is the cost for her to be covered under you group if is credible coverage. The part A costs nothing and the part B premium is $134.60 per month unless your household income is greater than $170,000/year. A plan G Medigap plan with a $190 deduct-able and a drug plan could be had for $150-$200/ month depending on where you live. With this coverage (Medicare A&B, Medigap and Part D) she would have full coverage with a $190/year. The alternative a Medicare advantage plan which essentially would replace Medicare has little or no deduct-able and a drug plan included could be had for little or nothing. With a Medicare Advantage plan most include eye glasses, some dental and a Gym membership at no extra charge. So you may be better of going on Medicare now rather then later. I personally have a Medicare advantage and am very happy with the coverage. I pay nothing per month other than the part B premium. My plan is an HMO. The only thing I pay is my part B premium of $134.60.

To sum it up as long as your group insurance is considered credible coverage you don’t have to switch but you might find it to your advantage as it might be cheaper and the coverage better. If you do decide to wait have your employer put in writing that the coverage is credible. There is a form that you will have to submit with her coverage later that the employer must fill out. The form is CMS-L564 , if you need I can e mail you a copy of the form in a PDF file. Without this form there are some fines you would have to pay when she does sign up for part B later and the fines are for as long as she is living. To opt out of B, on the back of the sheet her card is attached there is a place to sign to to opt out of B. Just sign it and send it in. I hope this answers you questions. If not ask away.
 
Thanks Don for this info, very timely for me as I go see my insurance specialist (broker) Thursday. I am diabetic, but not insulin dependent, hopefully that will not change.
 
Thanks Don for this info, very timely for me as I go see my insurance specialist (broker) Thursday. I am diabetic, but not insulin dependent, hopefully that will not change.
glad it was helpful. I just keep thinking about Carol. All her health problems stemmed from the fact that she felt insulin was to expensive. Not taking it caused her to have her toe amputated lots of hospital stays, kidney failure and eventual she died because of the cost of a medication. Do as your Doctor says my friend.
 
This may or may not help or even be relevant... My wife is diabetic and on two different types of insulin ...1. is long acting insulin -- she was on Lantus.. 2. the other is a quick acting insulin that she takes on a sliding scale .. it was Novolog.....
her son is also diabetic and gets his insulin through Walmart... he takes Novilin-R.
When Dianne was using the Lantus and Novolog we paid over $100 per vial even on insurance... Ed (her son) turned her on to Walmart's brand of insulin and now we pay just $24 & change for both Novilin-R and her 70/30 insulin... both are equivalent to the name brands and she is actually having less problems controlling her bloodsugar numbers.
 
This may or may not help or even be relevant... My wife is diabetic and on two different types of insulin ...1. is long acting insulin -- she was on Lantus.. 2. the other is a quick acting insulin that she takes on a sliding scale .. it was Novolog.....
her son is also diabetic and gets his insulin through Walmart... he takes Novilin-R.
When Dianne was using the Lantus and Novolog we paid over $100 per vial even on insurance... Ed (her son) turned her on to Walmart's brand of insulin and now we pay just $24 & change for both Novilin-R and her 70/30 insulin... both are equivalent to the name brands and she is actually having less problems controlling her bloodsugar numbers.
Novo Nordisk-manufactured human insulin can be purchased at Walmart stores without a prescription for $24.88 a vial (except in Indiana).
The most commonly prescribed form of insulin is insulin analogs, which require a prescription and are currently the subject of a controversy over soaring prices.
Not everyone can use the Novo Nordisk.
I looked up the Lantus and it is typically a tier 3 for both United Health and Humana so it would be covered at the $35 co pay price. Not every one responds the same to a certain med. I am glad you wife is responding well to the cheaper insulin, unfortunately not everyone does.
 
maybe you can answer a question don...
when I turned 65 the company sending me my testing strips and supplies told me they can no longer accept my insurance, I needed to find a medicare supplier for supplies. Do you have contact info on medicare suppliers for only diabetic testing supplies, not drugs?
 
Allen
Diabetic test supplies and needles are covered under Medicare part B, Not under part D. Not knowing your Medicare supplier it's kinda hard to answer so I'll have to be more general in my answer. Original Medicare will only pay for diabetic test supplies (needles, test strips etc.) but I believe they only contract with certain mail order companies, so if you have original Medicare with or without a supplement this is what your stuck with. The list can be found on Medicare.gov. If you have a Medicare Advantage plan they all contract with different companies. The best way to find the correct supplier is to call the customer service company for your particular company to find out. Normally if they don't take the one you have been using they will send you at no charge a testing machine for the brand they do contract with. That has been my experience. I could be more specific if you will tell me who your present Medicare provider is. Feel free to e mail me if you want.
 
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Allen I was on the Medicare.gov web site looking for some other information but since I was there I did some checking and it turns out you can get you test strip either mil order or by walk in if you have original Medicare. I didn't have you zip code so I wasn't able to do a specific search for your area but I did just pick a zip code at random and here is what I found.

The following will do either mail order or walk in.

(516) 671-1520​
(516) 671-2166​
(516) 759-1201​
and Walgreen doesn't do mail order​
(516) 671-4908​

With Original Medicare you are responsible for 20% of the cost but if you have a Medigap plan it may pick up the rest. Hope this helps. If your testing machine isn't on the approved list you will need to get a new machine.
 
Thanks Don! I will check with HR about the "credible" coverage question. So, if my group insurance is credible she doesn't have to sign up for Medicare until I retire? We will both be 65 next month. Please send me the form if you don't min (jlemley@usa.net). We live in Texarkana, AR (population about 20,000) so I don't think an HMO stile advantage plan would work. I don't plan on going on Medicare until I retire and if I have red correctly I won't be penalized for waiting 2 years beyond my 65th birthday?

Jack

Jack
I'll go ahead and answer here as others may want to know the same thing.

First of all you can’t sign up for Medicare until you are 65 or are on disability so you will stay with your group insurance until it is your time. Your wife is another story and you need to consider several things. First of all is her coverage under your group insurance considered credible coverage. I am most concerned about prescription coverage under Medicare guidelines. Only your group insurance can answer that question. If not then she will need to go on Medicare in order to avoid penalties later on. Next what is the cost for her to be covered under you group if is credible coverage. The part A costs nothing and the part B premium is $134.60 per month unless your household income is greater than $170,000/year. A plan G Medigap plan with a $190 deduct-able and a drug plan could be had for $150-$200/ month depending on where you live. With this coverage (Medicare A&B, Medigap and Part D) she would have full coverage with a $190/year. The alternative a Medicare advantage plan which essentially would replace Medicare has little or no deduct-able and a drug plan included could be had for little or nothing. With a Medicare Advantage plan most include eye glasses, some dental and a Gym membership at no extra charge. So you may be better of going on Medicare now rather then later. I personally have a Medicare advantage and am very happy with the coverage. I pay nothing per month other than the part B premium. My plan is an HMO. The only thing I pay is my part B premium of $134.60.

To sum it up as long as your group insurance is considered credible coverage you don’t have to switch but you might find it to your advantage as it might be cheaper and the coverage better. If you do decide to wait have your employer put in writing that the coverage is credible. There is a form that you will have to submit with her coverage later that the employer must fill out. The form is CMS-L564 , if you need I can e mail you a copy of the form in a PDF file. Without this form there are some fines you would have to pay when she does sign up for part B later and the fines are for as long as she is living. To opt out of B, on the back of the sheet her card is attached there is a place to sign to to opt out of B. Just sign it and send it in. I hope this answers you questions. If not ask away.
 
Thanks Don! I will check with HR about the "credible" coverage question. So, if my group insurance is credible she doesn't have to sign up for Medicare until I retire? We will both be 65 next month. Please send me the form if you don't min (jlemley@usa.net). We live in Texarkana, AR (population about 20,000) so I don't think an HMO stile advantage plan would work. I don't plan on going on Medicare until I retire and if I have red correctly I won't be penalized for waiting 2 years beyond my 65th birthday?

Jack
You are correct no penalty as long as you coverage is credible (that mean as good or better than Medicare). I e mailed the for to you. I also glanced to your are (texarkana and there are 6 medicare advantage plans available to you.
 
The total Medicare coverage is impossible for the average person to digest. The 1/2" thick book I receive never gets read. In my case, I have Medicare, a private supplement, VA takes care of most of my health needs, and the VA Mission Act for private care in many situations. If I have a health issue, I simply ignore the bills. After about two years I'll get a statement showing a balance due of $0.00.
 
The total Medicare coverage is impossible for the average person to digest. The 1/2" thick book I receive never gets read. In my case, I have Medicare, a private supplement, VA takes care of most of my health needs, and the VA Mission Act for private care in many situations. If I have a health issue, I simply ignore the bills. After about two years I'll get a statement showing a balance due of $0.00.
The book is obsolete the day it was printed because it is sent out for printing early in the year and usually around April and the plans are not finalized until the end of June so a lot of things change. In my opinion the book is a useless waste of money but hey it's the gov so what else is new. (Sorry didn't mean to get political). Also it only gives an overview not enough detail to be of any use. You have both Medicare (paying 80%) and the VA as your primary and the supplement as your secondary in both cases. The VA and Medicare don't work together but they both work with you supplement which is you secondary so that is why you don't pay anything the supplement pick up the VA or Medicare co pay. The paper you get is actually nothing more than a statement. You absolutely right it is far to complicated for the average person to understand and throw in the VA, Champ VA and Tricare and it becomes a quagmire. That's why the average person need to find a good broker to work with. It costs nothing to have a broker and if he has been around for more than 4 or 5 years he can be a real asset.
 
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