Medicare Patient Costs

Here is a graphic representation of your 2008 out-of-pocket costs for Medicare if you do not have a Medicare Advantage plan or Medigap. Remember, Part A deductibles are paid once per spell of illness and Part B deductibles are paid once per year.

That looks like a pretty long list. But, according to the Medicare Rights Center, this amount was $3,757 in 2002 for the whole year on average for all Medicare patients. This did not include spending on noncovered drugs. Unfortunately, cancer is a more expensive disease, and patient out-of-pocket costs can top $10,000 for some cancer treatments today, particularly in colorectal cancer.

For this reason, as a cancer patient, it's critical that you have other insurance. According to Medicare, in 2001 only 11 percent of all Medicare patients had no other funding for their costs; don't be in that 11 percent! The other thing to note is that not all plans are full coverage for your expenses. Some have things called "caps," which means they will only pay up to a fixed dollar amount.

Financing Out-of-Pocket Costs

There are many ways of getting out-of-pocket costs paid. Nine out of 10 Medicare beneficiaries (patients) have some sort of supplemental coverage--some good, some not so good. What are the options?

• Employer sponsored health insurance - Do not get confused here. Sometimes, retirees have employer-sponsored insurance that is primary to Medicare. That means your employer pays before Medicare does. More and more, however, businesses are opting to give only supplemental (Medigap) benefits. Check with your employer or your union to see if these are available. These may be cheaper than Medigap and can possibly cover more things.
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• Medigap - Buying Medigap implies you must make a choice about what you want and what you are willing to pay. There are 12 different Medigap plans, which have letter names "A-L." For more information, click here. 
  Remember these things when choosing a Medigap plan:
  
  -- Not all plans are available in all areas. Your friends who live in a different state cannot tell you about a good plan. You need to look in your state.
  -- No plans cover Medicare HMO gaps. Each Medigap plan pays for a set of Medicare gaps in coverage for a section of the Medicare program. Plan A covers the least benefits for the least cost. The most popular benefits are plans C and F because they hit all the high-cost items at the lowest cost.
  -- None of them carry long-term health insurance, so insurers may sell you that separately. This is a separate type of insurance plan for the insurance industry.
  -- But beware of being complacent. It pays to shop around. The Internet affords you a great opportunity to look at plan features and compare. Remember that plans that have the same benefits may have vastly different prices.
  
  The things you should look at with each plan are:
  
  1. Which gaps in coverage they cover (compare them to our chart above of out-of-pocket costs for all aspects of the Medicare program) and what you might have to sacrifice to get those benefits.
  2. The size of your premiums (they should not vary by health status if you try to enroll during open enrollment or other federally mandated periods).
  3. Whether they file claims automatically. (Most of them do, but if they don't, your doctor may make you file them.)
  4. Whether it is a Medicare SELECT plan, which means that you are buying a standardized Medigap plan, BUT you must use specific hospitals and/or doctors.
  5. How long your premium rate is in effect and how they might change as you age. Read between the lines here.

• Lower income programs - Medigap can be too expensive for many seniors and people with disabilities. But there are options for you, even if you thought that you were out of luck as far as gap coverage. Even if you do not think of yourself as low income, check this out anyway. You might be surprised.
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  -- Medicaid as a supplement to Medicare - Medicaid is not a single type of insurance. Qualifying for Medicaid and the types of programs it offers varies from state to state. Each state has its own acceptance criteria. These criteria involve income, family size, medical condition, and assets. If you receive cash assistance under the Social Security Income program, sometimes known as SSI, you qualify. This program requires a very low level of income, but some states have special programs for low-income Medicare patients. Also, as a cancer patient, your medical expenses may qualify you for a program, even if you have a higher income. See our Medicaid pages for more information on qualification and facts about Medicaid.
  

  -- Medicare savings programs - Qualified Medicare beneficiary program (QMB) - Contact your state if you are close to these guidelines described herein for qualified Medicare beneficiaries (QMBs). First, use our eligibility calculator to see where you fit on the federal poverty limits (FPL) for this year. States must be responsible for all Medicare cost sharing for Medicare beneficiaries with incomes up to 100 percent of FPL and limited resources. In 2006, for this group, this income can be up to $837 a month for an individual, $1,120 a month for a couple, and resources that do not exceed twice the SSI limit ($4,000 for an individual, and $6,000 for a couple). Hawaii and Alaska income requirements are slightly higher. Click here for more details.

• -- Medicare savings programs specified low-income Medicare beneficiaries (SLMBs) - This program pays Part B premiums. The 2006 income limit for this group will be $1, 000 a month for an individual, $1,340 for a couple, and resources that do not exceed twice the SSI limit ($4,000 for an individual, and $6,000 for a couple). Hawaii and Alaska income requirements are slightly higher. Click here for more details.

  -- Medicare savings programs qualified individual (QI) - States have a limited amount of money for this program from which they must pay on a first come, first serve basis. They will pay the Medicare Part B premium for Medicare beneficiaries with incomes between 120 percent of the FPL and 135 percent of the FPL and limited resources. The 2006 income limit for this group is $1,123 a month for an individual; $1,505 a month for a couple, and resources that do not exceed twice the SSI limit ($4,000 for an individual, and $6,000 for a couple). Hawaii and Alaska income requirements are slightly higher. Click here for more details.

  -- Medicare savings programs qualified disabled and working individual (QDWI) - States must pay the Medicare Part A premium for certain working disabled Medicare beneficiaries who have exhausted their entitlement to premium-free Part A benefits and whose incomes do not exceed 200 percent of the FPL. The 2006 limit for this group, including SSI disregards, is $3,353 a month for an individual; $5,585 a month for a couple, and  resources that do not exceed twice the SSI limit ($4,000 for an individual, and $6,000 for a couple). Hawaii and Alaska income requirements are slightly higher. Click here for more details.

  -- If you think you might qualify for one of these programs, but aren't sure how to interpret the above information, there is a website called GovBenefits that can really help you investigate programs for which you might qualify.

• Private foundations - Over the years, cancer patients and others have found that their out-of-pocket costs for Medicare-covered drugs (and costs related to them) are simply too high. But their income is too high to qualify for programs sponsored by Medicare, Medicaid, and other state-funded programs, so they stop treatment because they cannot afford to pay any more money. Fortunately, some wonderful private foundations have stepped in, and it's just possible that your out-of-pocket costs might be covered by one of these organizations. The programs are for "lower-income" folks, but you do not have to be at the Medicaid level. The foundations can be very good resources for cancer patients because qualification is often based on all of your medical costs. See our Help for Cancer Patients pages to see if you might qualify for assistance from one of these charitable organizations.