Filling the Medicare Drug Gap
J. Greene


Q: I oversee my father’s care, since he had a stroke two years ago. He is covered by Medicare and I have also gotten him supplemental coverage from his previous insurer, but where do Medicare recipients get prescription drug care? I can’t seem to find any information on it anywhere.

A: Sorry to be the one to tell you, there is no prescription drug coverage under traditional Medicare. You can find it in certain Medicare Supplement Plans and if you sign up for particular Medicare HMOs, but you’re on your own if you’re among the two-thirds of beneficiaries who have the original insurance plan.

      The lack of prescription drug coverage for Medicare recipients has long been a burden for the elderly, but it's gotten even heavier in recent years as drug costs have risen and new breakthroughs have made new, expensive medications available for many ailments that plague older people.
      Some people on fixed incomes may have to choose between buying a prescription drug or getting groceries for the week. Such horror stories have prompted some members of Congress to start talking about providing drug coverage under Medicare, but they face significant opposition for two reasons: It's expensive, and pharmaceutical companies like things the way they are.
      That's not to say that the current marketplace doesn't offer assistance. Diane Archer, executive director of the Medicare Rights Center helped us put together this list of possibilities:

bulletBuy Supplemental Coverage that includes prescriptions. There are 10 different Medigap plans (lettered A through J) offered by insurance companies, and three of them (H, I and J) offer some prescription drug benefit. However, they pay only half the cost of the drug, you pay a $250 deductible, and there are caps on the total amount they'll pay (ranging from $1,250 to $3,000). However, certain Insurance Company plans now offer discount cards for their policyholders that help with things like drugs and vision.
bulletJoin an HMO that covers drugs. Be careful, because not all of them offer this benefit, and some that do have restrictive caps on the total they'll pay and which drugs they'll cover. Ask questions before you join any HMO, and try to keep tabs when area HMOs announce new restrictions on their Medicare plans. The tradeoff in joining an HMO, of course, is that you have less choices in care and of doctors and hospitals.
bulletPeople with a low enough income might qualify for Medicaid, the government's insurance program for low-income people of all ages, which provides some prescription drug coverage.

      Meanwhile, cross your fingers that Congress comes up with some help for seniors and disabled people who have to pay for their medications. Nearly 20 percent of disabled people on Medicare pay more than $100 a month for drugs, according to a recent survey by the Henry J. Kaiser Family Foundation. So at least you aren't alone.

Q: My husband had stage 111B lung cancer that was found in October and since then the cost has just about wiped us out. We are now on a program for his medicines, but we were wondering if there is any reimbursement plan for what we have already put out in medicines? We are both on Social Security with no other income.

A: Unfortunately, insurance coverage isn’t retroactive. It’s always worth a try to ask your current health plan, but it’s highly doubtful they’d be willing to spring for coverage you didn’t pay for. Diane Archer of the Medicare Rights Center recommends you also check with your Congressional and Senate offices to find out if there are other resources for people in your situation. And she notes it’s good for politicians to know that the lack of prescription drug coverage for seniors is a problem.

      Because you have a limited income, though, you might qualify for Medicaid, which provides health care to low-income people of all ages. Check with your state to see if you qualify. Also, some states have special funds to help low-income Medicare recipients with the costs of prescription medicine. Check with your state department on aging to find out if such a fund exists where you live.
      Another idea: Pharmaceutical companies sometimes offer medications at low or no cost in hardship cases. The U.S. Senate Special Committee on Aging has compiled a list; to get it go to the committee's Web site publications page and look for publication 105-DRG.
      Also, keep in mind there are some exceptions to Medicare's no-prescriptions rule. For instance, if you're in the hospital, the drugs prescribed there are paid for. Also, certain oral chemotherapy agents are covered. And in the unhappy event that your husband's cancer is terminal, Medicare will pay for hospice care in your home, providing medications and home care workers to help him through the last months of his life.
      As always, if you have a Medicare problem or question, there is local help available. Contact your area's Medicare Insurance counseling service, which goes under various names but can be tracked down by calling (800) 434-0222. On the Web, try the government's Medicare site, or the Medicare Rights Center.


Medicare Return
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