When Medicare Does Not Alleviate Enrollment

Leave a comment

Cute couple smilingCindy Hunter received her Medicare card in the mail last Spring and she did not know much about Medicare. She and her husband, retired teachers who live in a Philadelphia suburb, decided she did not need Medicare because she shared her husband’s retiree health insurance plan. 

We were so thankful we had good insurance,” she said. So she sent back the card, telling officials she would keep Medicare Part A, which is free for most older or disabled Americans and covers hospitalization, some nursing home stays and home health care. But she turned down Part B, which covers doctor visits and other outpatient care and comes with a monthly premium charge. A new Medicare card arrived that said she only has Part A.

When Stan Withers left a job at a medical device company to become vice president of a small start-up near Sacramento, California, he took his health insurance with him. Under a federal law known as COBRA, he paid the full cost to continue his coverage from his previous employer. A few years earlier, when he turned 65, he signed up for Medicare’s Part A. With the addition of a COBRA plan, he thought he didn’t need Medicare Part B.

Hunter and Withers now know they were wrong and are stuck with medical bills their insurance will not cover. Hunter called it “an honest mistake” and said there was nothing in the written materials she and her husband received indicating that if they had Medicare Part A, his retiree coverage could not replace Medicare Part B. Withers had no idea he made a bad choice.

Thousands of seniors unwittingly make similar mistakes every year, believing that because they have some type of health insurance, they do not need to worry about signing up for Medicare Part B. Generally, insurance other than that provided by a current employer will not exempt them from Medicare’s strict enrollment requirements. Seniors’ advocates and some members of Congress want to fix the problem, backed by a broad, unlikely group of unions, health insurers, patient organizations, health care providers and even eight former Medicare administrators.

Medicare’s Part B enrollment rules have not changed since the program was created in 1965. Seniors can enroll only when they first become eligible — usually three months before and after the month they turn 65 — or when their job-based insurance ends. If they miss this opportunity, they have to wait until the months of January through March to enroll and then coverage only begins July 1. Most will not be allowed to buy any other health insurance policy during that time.

And if they delay signing up for 12 or more months after becoming eligible, many will be hit with a permanent penalty added to their Part B monthly premium. In 2014, about 750,000 beneficiaries paid late penalties, raising their Part B premiums an average of 29 percent, according to the Congressional Research Service.

“The rules have not changed, but our lives have,” said Joe Baker, president of the Medicare Rights Center, an advocacy group that is leading the effort to update the enrollment process. When Medicare began, the government wanted seniors, especially younger and healthier people, to sign up quickly and so the deadlines and late penalties were incentives to get them in the program.

But these days more seniors work past the Medicare eligibility age, get health insurance through their employer or their spouse’s, or have individual health insurance coverage, Baker said. The problem is not that people are going without insurance. “The confusion that we really see is with how Medicare interacts with other insurance coverage,” he said.

Hunter, 62, became eligible for Medicare earlier than 65 because she gets Social Security disability benefits. She’s receiving two chemotherapy drugs to control ovarian cancer. This fall her oncologist’s office told her there’s “something going on with your insurance,” she recalled. After many calls to her husband’s retiree plan, Social Security, Medicare and even her congressman, she learned that her insurance would only pay a share of the bills for her treatments after deducting the amount the insurer said was Medicare’s responsibility. “But Medicare isn’t paying because I don’t have Part B,” she said. So Hunter is responsible for that portion.

Withers thought the health plan he purchased through his old employer would count as job-based coverage, but COBRA is not a substitute for Medicare Part B, a point no one mentioned when he submitted his paperwork. He should have signed up for Part B when he left his previous job.

“How could there be a rule that no one knows about?” Withers asked.

In addition, the private plan has refused to pay thousands of dollars in medical bills because the company argued that he should have had Part B and those are Medicare’s responsibility.

Confusion over COBRA is just one of many reasons that people miss their opportunity to enroll in Part B. Others think, incorrectly, that getting Veterans Health Administration benefits, job-based health insurance from a company with less than 20 workers, retiree coverage from a former employer, or individual health insurance coverage exempts them from Part B’s lifetime late penalties and waiting periods with no insurance.

To help seniors avoid such mistakes, bipartisan legislation has been introduced in both the House and Senate that would allow people who miss their initial Part B enrollment deadline to sign up in the fall, when millions of seniors already in Medicare are choosing private drug or medical plan changes. Part B coverage would begin the month after they enroll. It would also allow most people who enroll late to apply for retroactive coverage to their initial eligibility date and request a waiver of the late penalties if they can prove they were misled (currently, an exemption may be based only on misinformation from a federal government representative, i.e. Social Security or CMS).

“Because I didn’t ask Social Security and they did not provide any wrong information, there was nothing they could do,” Hunter said. “They said if they had given me the wrong information, they might be able to do something.”

Seniors “should not face penalties or gaps in their Part B coverage simply due to bureaucratic snafu,” said Rep. Patrick Meehan, R-Pa., who co-sponsored the House bill. “I’ve had seniors contact my office and say they simply had no idea of existing deadlines — or that they faced penalties down the road for missing them.”

The legislation also would require Medicare officials to notify all Americans prior to their 65th birthday about signing up for Medicare. Currently, the federal government and some states notify only those 64-year-olds who have health insurance though the Affordable Care Act’s marketplaces.

Although the bill did not see action before the end of the 2016 congressional session, Meehan said he will reintroduce it in 2017.

Getting an official government notice before turning 65 explaining when to sign up for Part B would “absolutely” help, said Withers. “There should be something that tells people what they need to do.”

You’re Not Just ‘Growing Old’ If This Happens To You

Leave a comment

doctor-taking-blood-pressureWhen Dr. Christopher Callahan examines older patients, he often hears a similar refrain. “I’m tired, doctor. It’s hard to get up and about. I’ve been feeling kind of down, but I know I’m getting old and just have to live with it.”

This fatalistic stance relies on widely-held but mistaken assumptions about what constitutes “normal aging.”

In fact, fatigue, weakness and depression, among several other common concerns, aren’t to-be-expected consequences of growing older, said Callahan, director of the Center for Aging Research at Indiana University’s School of Medicine.

Instead, they’re a signal that something is wrong and a medical evaluation is in order.

“People have a perception, promulgated by our culture, that aging equals decline,” said Dr. Jeanne Wei, a geriatrician who directs the Donald W. Reynolds Institute on Aging at the University of Arkansas for Medical Sciences.

“That’s just wrong,” Wei said. Many older adults remain in good health for a long time and “we’re lucky to live in an age when many remedies are available.”

Of course, peoples’ bodies do change as they get on in years. But this is a gradual process. If you suddenly find your thinking is cloudy and your memory unreliable, if you’re overcome by dizziness and your balance is out of whack, if you find yourself tossing and turning at night and running urgently to the bathroom, don’t chalk it up to normal aging.

Go see your physician. The earlier you identify and deal with these problems, the better. Here are four common concerns that should spark attention — only a partial list of issues that can arise:

Fatigue. You have no energy. You’re tired all the time.

Don’t underestimate the impact: Chronically weary older adults are at risk of losing their independence and becoming socially isolated.

Nearly one-third of adults age 51 and older experience fatigue, according to a 2010 study in the Journal of the American Geriatrics Society.  (Other estimates are lower.) There are plenty of potential culprits. Medications for blood pressure, sleep problems, pain and gastrointestinal reflux can induce fatigue, as can infections, conditions such as arthritis, an underactive thyroid, poor nutrition and alcohol use.

All can be addressed, doctors say. Perhaps most important is ensuring that older adults remain physically active and don’t become sedentary.

“If someone comes into my office walking at a snail’s pace and tells me ‘I’m old; I’m just slowing down,’ I say no, that isn’t right,” said Dr. Lee Ann Lindquist, a professor of geriatrics at Northwestern University’s Feinberg School of Medicine in Chicago.

“You need to start moving around more, get physical therapy or occupational therapy and push yourself to do just a little bit more every day.”

Appetite loss. You don’t feel like eating and you’ve been losing weight.

This puts you at risk of developing nutritional deficiencies and frailty and raises the prospect of an earlier-than-expected death. Between 15 and 30 percent of older adults are believed to have what’s known as the “anorexia of aging.”

Physical changes associated with aging — notably a reduced sense of vision, taste and smell, which make food attractive — can contribute. So can other conditions: decreased saliva production (a medication-induced problem that affects about one-third of older adults); constipation (affecting up to 40 percent of seniors); depression; social isolation (people don’t like to eat alone); dental problems; illnesses and infections; and medications (which can cause nausea or reduced taste and smell).

If you had a pretty good appetite before and that changed, pay attention, said Dr. Lucy Guerra, director of general internal medicine at the University of South Florida.

Treating dental problems and other conditions, adding spices to food, adjusting medications and sharing meals with others can all make a difference.

Depression. You’re sad, apathetic and irritable for weeks or months at a time.

Depression in later life has profound consequences, compounding the effects of chronic illnesses such as heart disease, leading to disability, affecting cognition and, in extreme cases, resulting in suicide.

A half century ago, it was believed “melancholia” was common in later life and that seniors naturally withdrew from the world as they understood their days were limited, Callahan explained. Now, it’s known this isn’t so. Researchers have shown that older adults tend to be happier than other age groups: only 15 percent have major depression or minor variants.

Late-life depression is typically associated with a serious illness such as diabetes, cancer, arthritis or stroke; deteriorating hearing or vision; and life changes such as retirement or the loss of a spouse. While grief is normal, sadness that doesn’t go away and that’s accompanied by apathy, withdrawal from social activities, disturbed sleep and self-neglect is not, Callahan said.

With treatments such as cognitive behavioral therapy and anti-depressants, 50 to 80 percent of seniors can expect to recover.

Weakness. You can’t rise easily from a chair, screw the top off a jar, or lift a can from the pantry shelf.

You may have sarcopenia — a notable loss of muscle mass and strength that affects about 10 percent of adults over the age of 60. If untreated, sarcopenia will affect your balance, mobility and stamina and raise the risk of falling, becoming frail and losing independence.

Age-related muscle atrophy, which begins when people reach their 40s and accelerates when they’re in their 70s, is part of the problem.  Muscle strength declines even more rapidly — slipping about 15 percent per decade, starting at around age 50.

The solution: exercise, including resistance and strength training exercises and good nutrition, including getting adequate amounts of protein. Other causes of weakness can include inflammation, hormonal changes, infections and problems with the nervous system.

Watch for sudden changes. “If you’re not as strong as you were yesterday, that’s not right,” Wei said. Also, watch for weakness only on one side, especially if it’s accompanied by speech or vision changes.

Taking steps to address weakness doesn’t mean you’ll have the same strength and endurance as when you were in your 20s or 30s. But it may mean doctors catch a serious or preventable problem early on and forestall further decline.

Unaffordable Drugs? Millions Buy Medicine Outside U.S.

1 Comment

pill-bottles-in-pharmacyAs drug prices have spiraled upward in the past decade, millions of generally law-abiding Americans have committed an illegal act in response: They have bought and imported prescriptions outside the U.S. 

One was Debra, of Collinston, Louisiana, who traveled to Mexico four times a year for 10 years to get diabetes and blood pressure medicine. She quit going in 2011 after the border patrol caught her returning to the U.S. with a three-month supply that had cost her $40. The former truck driver drew a stern warning not to do it again, but got to keep her pills.

“I didn’t know what I did wrong,” said Debra, 51, who now pays $120 a month at Walmart for her five medications while she waits to join Medicaid.

It is no secret that some Americans regularly buy prescription drugs on the Internet or while traveling abroad. But the popularity of the approach is underscored by the results of a Kaiser Family Foundation poll conducted in November 2016. 

Eight percent of respondents said they or someone in their household had imported a drug at some point, a figure that would translate to about 19 million adults in the U.S. based on current Census population estimates.

Even the proportion found in the poll may be low, said Andrew Zullo, a clinical pharmacist and a doctoral student at the Brown University School of Public Health who has researched the subject. “People are uncomfortable talking about the cost of their own health care, and they do not want to admit they are struggling to pay for their own medicines,” he said. Some may also be reluctant to reveal they have broken the law.

Still, 8 percent is far higher than in surveys conducted by government interviewers, which suggested the number was about 2 percent in 2011 — though the government survey focused only on purchases in the previous 12 months. The Kaiser poll queried a nationally representative sample of 1,202 adults.

The Internet has made it easier for Americans to buy prescription drugs abroad, frequently from disreputable sources, according to Jaime Ruiz, a spokesman for U.S. Customs and Border Protection.

The Food and Drug Administration has cautioned that many online pharmacies are not what they portray. An international crackdown in 2014 found that many packages of medicines purportedly from Australia, Canada, New Zealand and the U.K. contained drugs from other countries, including India, China and Laos.

Zullo acknowledged that imported medications could be inferior or expired. Some could be counterfeits. But many medicines purchased from another country are the same as the ones patients buy in the U.S.

When purchased outside the country, many prescription medicines cost half or less than they do in the U.S.

According to the FDA’s website, it is generally illegal for Americans to import drugs into the U.S. for personal use. The law is not rigorously enforced, in part, because it is difficult to monitor the entry of medicine in luggage and small packages. But in 2015 the FDA implemented a rule that would give government border inspectors expanded authority to destroy drugs imported for personal use at their point of entry.

In the poll, people who had imported medicines ranged from college students in their 20’s to retirees in their 80’s. They bought medications to treat chronic conditions — such as high blood pressure and thyroid problems — as well as acute problems such as sinus infections and acne.

Amanda, a 27-year-old graphic designer in St. Paul, Minnesota, was stressed out by the murky legality of the situation when she tried buying migraine medication while in college five years ago. “That was the most difficult part, trying to be an honest citizen but also getting an affordable prescription,” she said. She could not afford to pay $150 a month for her medicine, but found an online Canadian pharmacy that sold her a three-month supply for $60.

Robert, of Los Angeles, has relied on foreign pharmacies for seven years to get medicine for his friend’s severe asthma. Robert, 38, travels internationally for his job producing live shows. Each time he is in Mexico or France, he buys 10-packs of inhalers and 20-packs of nebulizer solution for a fraction of what they would cost in the United States.

His friend’s asthma would require inhalers costing $300 a month if she purchased them in the United States. Robert estimates that he saves at least $2,500 a year by buying the drugs overseas.

“I love her to death,” he said. “I will do whatever I can to take her stress away.”