Choosing your Medicare Plan – Part 1

Your eye health and your vision is our top priority. Each year, during open entrollment, you have an important choice you have for your health insurance that will have a big effect on how the care you have access to, and how much you pay for your care overall.

As you may know, Open Enrollment (the time of year you can switch your medicare insurance plans) begins in Novmeber ends in December, if you are of Medicare age, or close to it, you have an important decision to make. You must know your options and what they mean for you.

As you may know, most retina related eye conditions in people in the Medicare age range require medications that must be administered in the office by me, your retina specialist.  These are eye medications for macular megeneration (dry and wet), diabetic eye disease, and vein occlusions, etc.   More and more medications are on the horizon for these, and other retina treatments.

But there is a catch: you might not be able to reasonably access these medications if you don’t have the right Medicare plan.

If you have a commercial non-medicare plan (typically through your job or spouse’s job), or Oregon Health Plan coverage, or Veterans Administration coverage, you typically can receive any/all of these medications with little or no out of pocket expenses.   Please hold on to these types of plans as long as you can!

But if you don’t have those types of coverage, and are eligible for medicare (or will be soon), you typically have two main options you must consider:

1. Medicare Advantage: This is considered “Part C.”  You assign your Medicare benefits to a private insurance company, like United Healthcare or Wellcare.   They may give you perks like a gym membership, etc.  BUT, the problem is that nearly all medications administered in a doctor’s offices are not fully covered by these plans, meaning you likely have a large out of pocket expense for some things like retinal medications, joint injections, and infusions.  For eye treatments, this can be between $250 and $800 per month out of pocket.
   1. As you know, we used to have a program called “Good Days” to help with these costs, which picked up the out of pocket expense.  However, it appears that Good Days will no longer be funded and will not be able to cover these out of pocket expenses.
   2. Choosing a Medicare Advantage plan may seem inexpensive, but it carries very high out of pocket costs if you have an issue like a retinal condition or many other conditions.  This unaffordable cost essentially prevents you from having the best medications for your vision.

But, there is a better, and often less expensive option, to allow you to get the best eye care and other care.

2. Medicare Part A and B + Medigap/Supplement:  This is considered the ideal plan.  With this arrangement, you will have complete access to medications you might get in the doctor’s office (like retinal treatments) with little out of pocket cost per treatment.
   1. Medicare A and B (“Traditional Medicare”) alone covers 80% of costs, but leaves you to pay for the 20% of all healthcare costs.  This 20% out of pocket is unaffordable for most people if you need most retinal treatments and basically any type of complex medical care. For eye treatments, this can be between $250 and $800 per month out of pocket, currently, if you have Medicare Advantage!
   2. To cover the 20%, it’s typically best to purchase a Medigap / Supplement plan. This is a private insurance plan (MODA, AARP/United Health, etc) that pays for the 20% and reduces your out of pocket expenses to near zero, in most cases.  They typically require a monthly premium for this extra plan, but this cost is much less expensive than the out of pocket costs of ongoing retinal treatments.
   3. If you go this route, evaluate your options.  There are many Medigap / Supplement plans available.  The best Medigap / Supplements plans are Plan A – G, M or N.    Plan K or L still leave you with higher out of pocket costs.
   4. Understand: there will be a monthly premium, but that premium will typically be less than the out of pocket costs associated with most eye treatments or infusions/ injections.

What you can do:

If you have Medicare A and B + Medigap/Supplement, KEEP IT!

If you currently have “Medicare Advantage” (such as Wellcare, AARP, etc) please consider changing to Medicare + Medigap/Supplement.  We believe that it is well worth the cost.

If you are enrolling in Medicare for the first time, please consider changing to Medicare + Medigap/Supplement.

Vist These Resources:  

1. Visit the website Medicare.gov, or call 1-800-MEDICARE
2. Find a Medicare Agent to talk to: Medicareagentshub.com
3. Make sure you know the out of pocket cost under your plan for the following retina medications:    Eylea,  Eylea HD,  Vabysmo,  Syfovre,  Izurvay

Read more here!