Medicare: A Worthy System with Some Wrinkles

Medicare is frequently in the news these days. It is a political hot button, as it is a health insurance program that is both respected and controversial at the same time. Medicare is not just a program for retirees. If you become disabled before retirement age and are awarded Social Security Disability benefits, you will be entitled to Medicare benefits after a 24 month waiting period.

Some disability recipients do not even have to wait for 24 months to start Medicare. The standard 24 month waiting period for Medicare has been eliminated for SSDI recipients diagnosed with Amyotrophic Lateral Sclerosis (“ALS”), sometimes referred to as Lou Gehrig's disease, and for individuals diagnosed with end-stage renal disease or kidney failure. These two exceptions are due to the poor prognosis of these diseases and the result of extensive lobbying efforts by support groups and advocates who work with individuals from these populations.

Regardless of when you may be entitled to Medicare, you need to understand some limitations of the program. Generally speaking, I think it is a valuable and effective program. Both of my parents are at retirement age and they both are Medicare recipients. It has been especially helpful for my mother who was diagnosed with both breast and colon cancer five years ago, which has metastasized. Her treatments are costly and Medicare has helped to defray the costs.

However, you must be aware that Medicare does have certain limitations, especially if you require some medications that are costly and often considered blockbusters drugs for the pharmaceutical companies that produce them.

 As you are probably aware, drug companies are constantly developing break-through medications that treat a variety of conditions, ranging from autoimmune disorders to end stage cancers. The companies have high research costs which are often reflected in the price of the new medication. Typically, it would be impossible for a consumer to pay for these cutting edge medications without insurance. However, even with exceptional insurance, the cost of certain medication co-pays can be cost-prohibitive for a consumer. Due to this conundrum, many pharmaceutical companies have issued “coupons,” so patients can still access these medications in spite of the high market price. Typically, these coupons are available to consumers who have a standard insurance program.

 The problem is that once you are on a government-sponsored insurance program like Medicare, you can lose your eligibility for these valuable coupons. Thus, you may be able to access certain medications while you have private insurance, but as soon as you switch to Medicare, you may lose your eligibility for certain life-saving medications.

 For example, a client of mine needed to take a Neulasta injection in order to boost certain blood cells to continue chemotherapy. She is a Medicare recipient and did not qualify for a “coupon” to help with costs for the medications. I called Amgen, the pharmaceutical company that makes Neulasta, to see what her options were. Normally, there are foundations that help with costs of such medications for Medicare recipients. However, when I placed this call about three months ago, I was told that the foundations that help Medicare recipients were out of funding at that time. Thus, her only choices were to pay the high cost for the medication or forego the treatment. Clearly, this is not a choice that anyone wants to make.

Medicare is an excellent government health plan, but it is not without its problems. It is always important to know what your health insurance plan covers and what it does not, especially if you are switching to a government-run program. This way, you can look into supplemental policies which may help you to defray your treatment costs.

Got a question about SSDI or SSI that you need us to answer? Please check out our website at www.westcoastdisability.com . We try to provide you with helpful information on our website that will allow you to successfully navigate the Social Security Disability process. Also, feel free to email me your questions at megan@westcoastdisability.com or call me at (800) 459-3017 x 103.