My husband only receives Medicare because of his transplant. He is not otherwise eligible. His three-year anniversary is in February. How will we know his coverage is terminated? Is there something he needs to do? Also, is the law that covers immunosuppressant drugs for transplant patient indefinitely still in effect?
ETA: He has group coverage, so it’s not a matter of being able to afford medication or treatment. I didn’t know how we would be notified so he can start using his group coverage as primary. It looks like social security will send him a letter. Thanks, everyone.
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Yes, he will need to find a new insurance carrier. If he doesn’t have access to eligible plans through his job or through you as a spouse, he’ll need to explore options on the insurance exchange. He can verify his termination date by visiting Medicare.gov. Since every state has its own insurance exchange, you can use Healthcare.gov to identify the correct exchange for your state. Don't get scared by the website saying enrollment ends Jan 15. He is eligible to enroll at anytime once his other insurance ends. Be cautious of fraudulent websites pretending to be official enrollment sites; always ensure the site has a .gov domain.
Shopping for insurance can be time-consuming, so plan to spend a few hours over several days reviewing and comparing plans. For transplant-related needs, here are some important considerations:
Lab Coverage: Some plans require a 20% - 50% coinsurance for lab work. If your husband gets labs done every few months (such as drug level troughs), these costs can quickly add up—potentially reaching $1,000 or more each time. Other plans might charge just a single copay per lab visit, such as $20 or $50. Compare these carefully.
Doctor Network: Confirm that his doctors and transplant specialists are in-network to avoid unexpected costs.
Prescription Copays: EDIT - If you have an eligible insurance plan they will cover his immunosuppressants and any other drugs he needs. Medicare will not cover them in this case because you have insurance. Make certain the copay is not ridiculous, and you should be able to look under the "formulary" for the coverage to see if the drug is covered and what tier it falls under.
Unfortunately, insurance plans are typically structured so that you have to choose between paying a higher premium with lower out-of-pocket costs for doctor visits, labs, and medications, or paying a lower premium with significantly higher costs for those services. It’s important to carefully weigh these options based on your husband’s expected healthcare needs and frequency of medical visits. You will need to determine what works best for you. I personally prefer to pay a higher premium every month so I know how much my costs are going to be for the year.
Additionally, you should check if he qualifies for a subsidy, which can help offset the cost of coverage. The Healthcare.gov website will guide you through the process and calculate any subsidies he may be eligible for.
You can also contact the transplant financial coordinator or social worker for additional guidance. They often have valuable insights and resources to help navigate the process.
I also had some great help from calling the healthcare.gov helpline 1-800-318-2596 when I was learning about all of this. This is also helpful if you do not want to go through the website.
Hello redpanda67, thank you for sharing such useful information. My daughter will also come off Medicare in June this year. She will turn 26 years old soon after and will come off my insurance (through my employer) also. She is a student and has two and a half years more to go to finish school. So I am trying to figure out if the health insurance offered by her university will be enough or if it is better to go through healthcare.gov. I will use your suggestions when shopping for her insurance. Thanks so much. I am concerned that health insurance offered by universities for students might not be enough as most college students do not have such serious health issues. Also her university offers 75/25 for in network coverage. Would it be good to get a secondary insurance to help meet the 25% out of pocket? Also my daughter goes to school in a different state than where we live. So, she would need coverage in both states. If anyone has been in this situation, please share your experience and ideas.
I was a graduate student and postdoc with medical insurance provided through the university, my postdoc was the same plan as the undergrads. While I can't say for certain about the insurance at her specific school, the two most important items to check are the formulary for medications and lab coverage.
Most schools typically use a combination of Blue Cross student plans or United Healthcare plans. If she is on a large campus that includes a medical school, the coverage might be even better. Most of these will have some out of state coverage, it just depends on the policy.
Feel free to message me if you’d like assistance navigating or figuring out her insurance coverage
Hi Redpanda67, thank you! My daughter’s university also has a medical school. It would really help if the insurance offers decent coverage. Her university offers United Healthcare’s plan. We’re reading through the certificate of coverage now. We will keep your advice in mind and focus on formulary and lab coverage. Thank you so much! Will message you in case of any questions.
Additionally to the other replies. Since he was on Medicare for the transplant, make a note of the transplant date and when he first signed up for Medicare. When he turns 65 he will be eligible for Medicare Plan B coverage of immunosuppressant drugs, not Plan D but rather Plan B. That way Medicare picks up 80% of the cost. You can buy a supplemental plan that will cover the other 20%. This is my case, I am 69 and haven't paid a cent for immunosuppressant drugs other than the Medicare deductible ($230 per year) and the insurance premiums since turning 65. Since you can't continue your employee coverage after you retire and become Medicare eligible, this is the best deal around.
He should receive a letter soon from Medicare informing him that his 36-month coverage will end next month. I would call the Social Security (not Medicare) office, as he should have received it by now.
I'm wondering about this too. Medicare sent me a bill through April and mine is also supposed to terminate in February. Please let me know if you find out anything about this, I have had trouble trying to get assistance over this when contacting Medicare....
I definitely will. Did you only receive Medicare for your transplant or were you on it for ESRD and dialysis? I’m wondering if they haven’t reached out because they think he’s still in ESRD.
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