MA/Med Sup Transplant Questions

[jdeasy]

I have a client that is on Wellcare's Sonata PFFS plan. He has to have a kidney transplant. He has been told by the doctor that his meds are covered by Medicare part B and are very expensive, about $6,000/mo.

I haven't gotten a definitive answer from Wellcare as to what his co-pay, if any, might be. This guy loses Wellcare as of Dec. 31 this year as it's not being offered for 2010, he will have a GI for a med sup and, obviously, that's what he wants to do. I am of the understanding that the med sup will pay all of the costs of the part B med that Medicare doesn't pay. Is that correct? If not, what will they pay?

Also, will this be a pre X problem with the med sup? He may not have the transplant until next year, does that make a difference as far as pre X?

The guy is in Indiana if that makes a difference.

 

[GreenSky]

You are completly correct. He will benefit from the GI provision and can go into a med supp with no pre-ex. As long as the drugs are under Part B he will have no out of pocket costs.

Actually, this is the best news he could get.

Rick

 

[jdeasy]

You are completly correct. He will benefit from the GI provision and can go into a med supp with no pre-ex. As long as the drugs are under Part B he will have no out of pocket costs.

Actually, this is the best news he could get.

Rick

I agree that this is good news as far as the bills being paid. I'm getting conflicting stories as to whether or not the meds or actually part B or part D.

I have had a little experience with that as I have a client that had a heart transplant about 12 years ago and she is on Wellcare PFFS Melody plan because she is also Medicaid. Her transplant drugs are covered under part B, but, there was a problem about a year ago where the companies were arguing over whether the drugs were part B or part D. It was affecting her out of pocket because she was QMB plus.Wellcare was claiming that the drugs were part D and Silver Script was claiming that they were part B. It turned out that there was some little known ruling in 1999 that affected how transplant drugs would be classified and, since her transplant was before 1999, her meds were to continue to be part B. Anything after that was to be part B for 12 months or so. Today when I called, none of the people that were part of that discussion have any recollection of it and have to do further research.

In this guy's case, the transplant is most likely not going to happen until 2010. He just went on the list. He is on UA's Platinum plan for his part D now, so, he is OK if they say the meds are part D.

He was taking very few meds before this. I tried to get him to go to a different part D with a lower premium last year and the year before. I'm sure glad he didn't take my advice on that.

 

[Cenla Agent]

Where will the meds be administered? In an outpatient setting, or through a pharmacy? Some Part B drugs can be picked up at the pharmacy, but if they are to be administered in any kind of office or facility they are definitely Part B.

Right when Part D was rolling out, I had a client who had had a transplant a few years prior and was on Medicare disability. The meds he was taking at the time were NOT covered under Part B. His COBRA had also run out (and thus his Rx coverage,) so until Part D kicked in his immunosuppressant meds were being picked up under a patient assistance program through one of the pharmaceutical companies. They were expensive, but IIRC not close to $6000.

Regardless, your client won't be any worse off than he was before so long as he has a supplement in place on 1/1/10.
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This article addresses the issue and links to some documents, although I don't know if it is the final word.
Medicare Part D - Is it Part or is it Part B

 

[jdeasy]

Where will the meds be administered? In an outpatient setting, or through a pharmacy? Some Part B drugs can be picked up at the pharmacy, but if they are to be administered in any kind of office or facility they are definitely Part B.

Right when Part D was rolling out, I had a client who had had a transplant a few years prior and was on Medicare disability. The meds he was taking at the time were NOT covered under Part B. His COBRA had also run out (and thus his Rx coverage,) so until Part D kicked in his immunosuppressant meds were being picked up under a patient assistance program through one of the pharmaceutical companies. They were expensive, but IIRC not close to $6000.

Regardless, your client won't be any worse off than he was before so long as he has a supplement in place on 1/1/10.
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This article addresses the issue and links to some documents, although I don't know if it is the final word.
Medicare Part D - Is it Part or is it Part B

Thanks for that info. I don't know where the meds will be administered. I'll try to find out. I doubt he knows yet. He was just informed that he needed a transplant. I think I was the second call he made.

 

[ronmelton3]

If he qualified for a PAP plan for his drugs in the past, do you think he'd qualify for LIS? That way he'd have no donut hole.

 

[jdeasy]

If he qualified for a PAP plan for his drugs in the past, do you think he'd qualify for LIS? That way he'd have no donut hole.

He makes far too much to qualify for LIS. Of course, this could cost him enough to make him qualify?

Right now it seems as though the transplant won't be until 2010. He will be on a med sup then.

From everything I've learned in the last few days, the part B meds that he gets at the hospital and at the doctor's office or the post treatment facility will be taken care of fully as long as we get him on a med sup. Any drugs that he gots at the pharmacy will have to go under his part D.

If he has to use the Wellcare plan this year, the part B drugs are subject to a 20% co-insurance, but, it does count towards his MOOP.

That's the stories I'm getting from everyone so far.

 

[Lee Sanford]

The SEP for non-renewal of contracts effective January 1 (as is the case here) starts October 1. This beneficiary may drop the MA as soon as November 1 and go ahead and pick up a Supp. In this situation, I would say the sooner the better.

 

[jdeasy]

The SEP for non-renewal of contracts effective January 1 (as is the case here) starts October 1. This beneficiary may drop the MA as soon as November 1 and go ahead and pick up a Supp. In this situation, I would say the sooner the better.

Are you sure about that? Where would I find this ruling? I agree, the sooner the better for this guy, if we could get him on a med sup two months earlier, all the better.

 

[Lee Sanford]

From Medicare Managed Care Manual Chapter 2:

Non-renewals - A SEP exists for members of MA plans that will be affected by plan or contract non-renewals that are effective January 1 of the contract year (42 CFR §422.506). For this type of non-renewal, MA organizations are required to give notice to affected members at least 90 calendar days prior to the date of nonrenewal (42 CFR §422.506(a)(2)(ii)). To help coordinate with the notification time frames, the SEP begins October 1 and ends on January 31 of the following year.
During this SEP, a beneficiary may choose an effective date of November 1, December 1, January 1, or February 1; however, the effective date may not be earlier than the date the new MA organization receives the enrollment request.
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Overview Medicare Managed Care Eligibility and Enrollment