What You Need to Know
Examine the coverage ‘gaps’ in different plans carefully.
Consider buying a Medicare Supplement Insurance (Medigap).
You want a plan that covers the doctors who know you and your conditions.
Sign up for a prescription drug plan to defray costs. Pay attention to the drugs each drug plan covers.
Your Medicare-related decisions will have a marked impact on how your later years play out. These decisions are even more critical if you live with Multiple Chronic Conditions (MCCs). Your healthcare can be complicated and costly.
A chronic condition is a physical or mental health condition that lasts more than one year. It requires ongoing medical attention and/or limits activities of daily life.
Two out of every three Medicare members have two or more chronic conditions. One out of three has four or more.1
Medicare recognizes 21 conditions as chronic. The most common are:2
- High blood pressure.
- High cholesterol.
- Coronary artery disease.
- Chronic kidney disease.
Is This Your First Medicare Selection?
If this is your first Medicare selection, your Initial Enrollment Period will begin around your 65th birthday. There is no limit to your choices — at this time. You are not subject to underwriting. Also, insurers cannot deny you coverage for any reason, even for pre-existing conditions.
But if you decide to make changes in coverage down the road, you could face medical underwriting. That could affect your premiums or you may even be refused by insurers due to preexisting conditions.
What Are Your Medicare Options with Multiple Chronic Conditions?
Your choices for Medicare lie between Original Medicare and Medicare Part C (or Medicare Advantage).
This includes Part A (hospital insurance) and B (medical insurance). It allows you to see any doctor or visit any hospital in the U.S. that accepts Medicare.
Part A does not cover all Medicare-eligible hospital or nursing facility expenses. Part B only covers 80% of Medicare-eligible expenses related to doctor visits, diagnostic tests, outpatient surgeries, and preventive care. You will be responsible for the difference.
You can choose to supplement your coverage to help with out-of-pocket costs. Medicare Supplement insurance (or Medigap) is offered by private insurers. It helps to pay the Part A and Part B annual deductibles. It also covers extended hospital stays and the 20% portion of expenses Part B does not pay (or coinsurance).
You can join an optional prescription drug plan (Medicare Part D) if you want drug coverage.
Medicare Advantage, also known as Medicare Part C, is a government-regulated all-in-one alternative to Original Medicare. It covers almost everything Original Medicare does, plus some extra benefits. Most Medicare Advantage plans include prescription drug coverage. MA is offered by many private insurance carriers. You will likely need to use the doctors in the plan’s network.
Medicare Part D
Part D is a private, government-regulated plan that covers prescription drugs. If no drug plan is integrated into your Medicare Advantage plan, you can buy a stand-alone plan.
What Should You Look for in Terms of Coverage?
Medicare Part A and B
Coverage for both is standard for all and will not be affected by your MCCs.
If you decide on a Medigap policy (also known as Medicare Supplement), Medicare has several predefined plans that private insurers can offer. It has also determined what each plan covers. Check exactly what each predefined Medigap policy will cover to decide how much exposure you want to take.
Many Medicare Advantage plans will work only with their own network of doctors. You will have to get referrals from your primary care doctor to see specialists. Check that your various specialists are in-network, unless you are willing to change healthcare providers.
Some MA plans have started offering lifestyle-support services. These include meals delivered at home, medical transportation and home modifications. These services are covered if your doctor prescribes them.
Most MA plans include prescription drug coverage. In selecting a specific plan, check that it covers all the drugs prescribed by your doctors. Also, make sure to check the cost. The Medicare website allows you to build a list of your drugs and then compare plans that cover them.
MA plans tend to adjust their covered medications and in-network doctors at the end of the year. This can be disruptive, especially with multiple conditions.
Medicare Part D
You may have many prescribed medications because of your MCCs. Medicare Part D can cut your costs significantly. However, each plan has different drugs they cover. You will have to find which ones include your medicine. Then compare costs.
Part D plans sometimes drop drugs from their list of covered drugs, or ‘formularies.’ Be sure to review that each year during Open Enrollment to ensure your medicines are still included. If not, you can change plans without penalty.
What Special Programs Might Be Available to You?
Medicare considers MCCs one of its greatest challenges. MCCs affect two-thirds of Medicare beneficiaries and account for 94% of Medicare spending.3 Medicare is exploring new programs and services to address the problem. Here are two.
Chronic Care Management Services
Chronic care management services build a comprehensive care plan that integrates all your health problems, goals, providers, medications and community services.4 The plan explains the care you need and how it will be coordinated. The plan will:
- Help you with medication management.
- Provide 24/7 access for urgent care needs.
- Provide support going from one healthcare setting to another.
- Review your medications and how you take them.
- Help with other chronic care needs.
You must have two or more serious chronic conditions that are expected to last at least a year.
How Much Do Chronic Care Management Services Cost?
You may pay a monthly fee for chronic care management services, in addition to the Part B deductible and any coinsurance. Two options may help you cover the cost: if you have Medicare Supplement insurance or the combination of Medicare and Medicaid.
Ask your healthcare providers if one of them offers these chronic care management services.
Does Medicare Advantage Offer Special Needs Plans?
Medicare Advantage offers Special Needs Plans (SNPs) for people with certain health conditions or circumstances.5 The plans tailor the benefits, doctors and drug formularies to the beneficiary.
One specific type of SNP is a Chronic Condition Special Needs Plan (C-SNP) which targets members with certain individual chronic conditions.6 Some C-SNPs are designed to serve people with combinations of common MCCs, such as diabetes and chronic heart failure.
How Do You Qualify for a Chronic Condition Special Needs Plan?
To qualify, you must enroll in Medicare Part A and Part B and live in the plan’s service area.
C-SNPs are not available in all states or regions.
In November 2021, there were 214 C-SNP plans in the U.S. serving about 411,000 people.7
A C-SNP will provide all the same coverage as Medicare Part A and Part B. It may also include custom benefits designed specifically for your needs. Some C-SNPs offer a care coordinator who helps you:
- Schedule appointments.
- Stick to your prescribed diet and exercise plans.
- Get the right prescriptions.
- Access community resources.
A C-SNP may include a monthly premium, deductible, coinsurance, and copay.8
Most costs will be covered for you if you have both Medicare and Medicaid.
All SNPs must provide Part D prescription drug coverage so beneficiaries can manage and control their special health care needs.9
To find a C-SNP in your area, call 800-MEDICARE (800-633-4227) or use Medicare’s Plan Finder.
What Are Your Costs with Medicare?
If you purchase Medicare coverage in your Initial Enrollment Period, the costs for your plan selection should not vary from someone with no chronic conditions. The same holds true if you sign up for Medicare later and qualify for a Special Enrollment Period for one of the many accepted reasons.
You will have premiums, deductibles, coinsurance and copays to pay. These depend on the plan you choose.10
Part A Costs
You do not pay Part A premiums if you paid Medicare taxes through payroll deductions for 10 years or more.
Otherwise, it will cost up to $499 per month if you did not. In 2022, you will have to pay a deductible of $1,556 for each hospital admission. Hospital stays 61 days or longer will cost a coinsurance of $389 or more per day.
Part B Costs
Part B premiums range from $170.10 to $578.30 in 2022, based on your household income. The annual deductible is $233 for everyone, plus 20% coinsurance of all Medicare-eligible expenses.
Medicare Advantage Costs
Medicare Advantage premiums vary by insurance company, the benefits and where you live. Plans have different combinations of deductibles, coinsurance, and copays.
Part D Costs
Part D premiums vary. Each insurance company sets its own rates.
Plans range from $6 in some states to over $200. You also pay a Medicare adjustment that varies with your income. That fee ranges from $0 to $77.90; it is added to your premium.
Part D plans also include cost-sharing. So you pay a part of each drug’s cost.
Plans have four phases. Prices vary every year. The following are for 2022.
The first is a deductible of $480 or less.
Then you pay your share of costs until the total cost of drugs paid by you and the plan reaches $4,430.
Next comes a coverage gap, or donut hole. Here you pay no more than 25% of your plan’s price for drugs until the total drug cost hits $7,050 (an additional $2,620), including manufacturer-provided discounts.
After that, for the rest of the year, you pay the higher of 5% of the cost of each of your drugs, or $3.95 for generics and $9.85 for brand-name drugs.
As someone with MCCs, you will likely have more doctor visits, prescriptions, and hospitalizations than someone with one or no chronic conditions. This leads to several important considerations:
- Examine the coverage ‘gaps’ in different plans carefully. They can become very costly. Gaps include deductibles, coinsurance, and copayments.
- Consider buying a Supplement Insurance plan (Medigap) if you enroll in Original Medicare (Part A and Part B). A Medigap policy helps with the considerable out-of-pocket expenses that can result from your MCCs.
- You want a plan that covers the doctors who know you and your conditions. Medicare Part C plans sometimes drop doctors from their network. You may be forced to change doctors or plans.
- Prescription drugs for your MCCs may be a high expense for you. A prescription drug plan can help defray those costs. You will want to pay special attention to the drugs each available prescription drug plan covers. You want all yours included, if possible.