The Gap

I recently was hit by a crash course on the infamous 'donut hole' we all hear about in relation to Medicare. Being in the situation I am in, candidly I am disabled and only have Medicare, I am susceptible to this unfortunate guideline. For years living in New Mexico I was covered under Extra Help. I never knew exactly what that was, but I had little to no costs for my prescription drugs. Moving to Texas in 2013 obviously changed many things.
When we first moved to Texas things seemed to be running smoothly. I updated my contact information and lost no time receiving my benefits. I needed to enroll in a new Part D Prescription plan because they vary state to state. That was a bit confusing but with a lot of questions and tenacity I figured it out. Because we had moved here just before my major surgery and my husband stayed home to care for me, I qualified for Medicaid in Texas. Why not take advantage of all the help you can get if you are doing your best to help yourself? I did not understand that it was a short-term qualification due to the fact I had no idea how they determine eligibility.
Every year Medicaid reviews all cases to determine requalification. They send out a notice with your information on it, ask if anything has changed, require a signature, and give you an easy prepaid envelope to send it all back. Neat and tidy. Well, not so neat. Thinking nothing had changed because my husband has worked the same job for seven years and I have received the same check for the last several years, I was shocked when I received a notice of loss of coverage beginning August 1, 2014. After running in circles trying to figure this determination out I was finally told that I had only qualified due to my husband's need to stay home while I recovered. Although the surgery was a year ago I had been covered all that time. I had no idea they allowed a year for this type of coverage. I appealed the decision due to extremely high prices for my prescription drugs, but I was denied. Since then I have hit dead ends time and time again.
I was told many times, in my efforts to regain the coverage Medicaid was providing, that I should apply for Extra Help. I continued to believe I would continue to have it because I had no idea I had it in the years prior. Finally I came to understand that Extra Help is actually a low-income subsidy that helps pay for prescription drugs. Now, our family is no where near poverty. We are simply in the same cast most of the nation is in at the moment so, again, I had no idea what or why I had these benefits. I assumed, biggest mistake we all make, that this was how Medicare worked. I never saw a 'donut hole' in my coverage so I assumed, bad girl, it had something to do with costs I don't run across. I became disabled at 25 and became eligible for Medicare at 26 years old. We are all just beginning to understand employer insurance dealings, let alone Medicare. I should have done my research.
Losing Medicaid and Extra Help seemed like no big deal to me. I had put my nose to the ground to find a Medicare Advantage plan that would cover more than traditional Medicare. I found one under United Health Care and it's great. It covers everything I need at locked in out-of-pocket costs. It comes with one downfall I did not know about Medicare Advantage plans. They all follow Medicare guidelines. In comes that dreaded 'donut hole' possibility. Again, I didn't realize it was approaching because I had lost Medicaid in August so I assumed, here's that word again, that meant Extra Help was gone as well. "Extra Help" sounded very much like Medicaid, interchangeable. Is Medicaid not extra help that you could receive? It was/is to me. No, no, no. Extra Help is actually a program. My Extra Help ended December 31, 2014. I received a notice, yes, but Medicaid, Medicare, supercalifragilisticexpialidotious. ??? These notices were foreign to me. Even employer and private insurance is a mess of jargon and loop holes no one understands. Now we are in the early months of 2015.
My husband works at the pharmacy where I get my prescriptions. He is nice enough to take control and make sure I get refills and such on time. He refilled everything he could at the end of December just in case a deductible, we didn't see coming, hits. I had one in the past so preparation was smart. I'm glad he did. With that in mind you can imagine it took me a bit to need a refill. "Insulin. That'll be $200+. Seizure medication. That'll be $260. Colitis. $95. Digestive enzymes. $45." Cough, cough, cough.."uh, WHAT?!" Something must be wrong. The pharmacy called my insurance while I simultaneously called for myself. This is when the nightmare began.
Here's how it works. There is a deductible to be met, $160. Then you begin paying for your drugs under the Tier system, a prescription vocabulary word meaning what category a drug is placed in. If you ask how they categorize drugs you will immediately realize no one really knows the answer. Tier 4 drugs are $95, Tier 3 drugs are $45, Tier 1 and/or 2 are around $8, and anything not in formulary....well, I haven't been able to decipher how they determine pricing, but obviously I have some. You have a limit of $2960 before you hit the gap or 'donut hole', this number is a combination of what the plan pays as well as your own out-of-pocket costs. Once you hit the $2960 you fall under 'gap coverage'. In gap coverage you pay 65% for generic drugs and 45% for brand name. If you look at that in terms of an actual prescription it does not look promising. One, just one, of my seizure medications is over $1000 for the generic meaning I am going to pay over $650 for one prescription. I have ten, four of which do not have generics available as of yet. What happens next you ask? Catastrophic coverage. Catastrophic coverage begins when your out-of-pocket costs, not the plans pay out as well, hit $4700. In this stage, you end up paying only 5% for your drugs. With a person like me you would think that would be hit quickly, but they get you when they start by counting their pay out as well as yours then do a switch when it comes down to counting only your costs. $4700. Do you have that under your couch cushions? Could you even follow the maze of numbers outlined? After a month and a half the pharmacy and I finally saw the potential for financial destruction. It would be difficult for any person or family to afford that every year when they have maintenance drugs long term. Even quick prescriptions could put a dent in your pocket. It is unbelievable that they help you get in the donut hole and retroactively eliminate their help to keep you in the hole. Capitalism and health care do not belong in the same sentence, let alone used against ignorant people.
Ignorant may seem like a derogatory term, but it is not. It definitely does not mean we, as patients, are stupid. It simply means we are uneducated insurance navigators. A lesson I learned the hard way. Be informed. Be prepared.
Every year we receive this giant package with a huge book and some pamphlets that drop out here and there, all regarding our benefits and any changes. Most of us keep it but it is never opened. Some toss it. Rarely does anyone actually dive into it. Hear me loud and clear when I say OPEN IT. Educate yourself. Use what you know about yourself for certain to begin. For myself I looked at hospital costs, ER co-pays, office visit co-pays, procedure out-of-pocket costs, and I simply checked to see if my drugs were on the plans formulary. I only looked at what I'd be paying, at the moment, for my drugs. I never looked beyond December 31 or thought to look at deductibles and stair steps. I knew I had lost low income subsidies and I spoke with the insurance agent about it. I am sure he tried to cover all his bases before I decided on a plan, but I was probably selectively hearing what I thought was important. Assumptions and arrogance will never do you good.
I thought I knew it all. I had been to school and worked in the health care field, my husband works in a pharmacy, and I am a very involved patient. I believed any "assumptions" I was making were "educated guesses". Two very different things. With those two words seeping out if my pores as I crumbled under the weight of cost versus need for meds I knew I had to figure this out but I didn't know how. I was embarrassed, humbled, and desperate.
I had options and I had to move fast. First, I called upon my parents for immediate assistance while I pulled myself together to get myself of the floor. My sister is a bulldog and will stop at nothing to make her little sister's life easier. An angel. She and I pulled our ideas together and bounced them back and forth to iron out details of each option. Here is what I faced and many Medicare patients have to face:
1) Divorce- If you are married the government takes the household income as a determining factor for low income subsidies. Couples who have been married decades sometimes get quiet divorces with all the legal necessities laid out in the divorce to cover what is appropriate for them. Children and family often are in the dark about the divorce, but it is the only way some people can afford medical care. This just wasn't an option I felt comfortable with for my family.
2) Talk with your doctor- Often times doctors can change a prescription to a lower cost drug to help the patient afford their meds. Many patients either talk to their doctor during a typical visit about what they can afford or what their plan will cover and the doctor obliges. It may also apply to office visits and procedures. Many times the doctor can schedule things in the most affordable ways for the patient. This does not work if there is no leeway for the doctor. In my case, there was no leeway for meds or office dealings.
3) Buy private health insurance- We hear about supplement plans and advantage plans for retired, elderly, Medicare patients. What many of us do not realize is these plans are not for disabled. In the state of Texas all insurance providers have to offer at least one Medigap plan for disabled under 65 or those with end stage renal disease. The catch is they have to approve you just as Medicaid or Medicare would, but each plan has different requirements for approval. In addition, plans that are associated with Medicare, meaning they are offered to patients or coupled with Medicare, have to follow Medicare guidelines for prescription drugs stair step set up. Medicare deducts a premium from your benefits check each month. Buying private insurance would also require a premium. Add in the out-of-pocket costs and it may not be very beneficial. In my case it was a moot option.
4) Stop taking prescription medications- I actually contemplated this because I was at a complete loss. We all see how blatantly wrong that actually is. Any where between 12-28% of Medicare patients stop taking their medications only because they cannot afford them. This is incredibly dangerous. Bottom line says you can't squeeze water out of a turnip and turnips sure don't pay for meds. That is my case. I had to look at it like this, not taking medications is deadly but financial ruin is not. Figure out a way to pay.
5) Get a loan- This sounds good in theory. If you take enough regular medications to get into the gap or even to get to catastrophic coverage you need extra money to pay for it. Loans are extra money that you have to pay back. If you can't afford it in the first place, how can you afford to pay back a loan? It may work for some. If that is what gets you there who cares what I say? I did the math for my situation and it would take two years for me to pay back a loan I would get to pay for one year of my medications. Tack on next year and the year after. Soon enough, I wouldn't even remember how much I owed or the bank would lock the doors every January when they saw me coming.
6) Online discounts- It is very possible to find discounts for medications online. Sometimes the manufacturer offers discounts. The drug reps even bring coupons to the doctors' offices and pharmacies. It is a bit tedious, but worth it. Common medications and new medications are the easiest to come by. Get into that cloudy area of lesser used meds and it can be tricky, sometimes hopeless. That was the way it turned out for me. It got to a point where the manufacturers customer service reps were making me feel like the biggest idiot on the planet. I got spoken to as if I should already know what discounts are offered. I even ran across a lot of them who had no idea the company they worked for made a drug of that name.
7) Employer insurance- If you are retired or disabled this option is often null and void. If you are married you may be in a good place to add coverage to your existing Medicare plan. Of course, as with any insurance, you have to wait for open enrollment which does not happen in January. If you are knowledgeable and prepared, jump on that open enrollment railway. If not, don't fret until you have exhausted all avenues. If a life event happens most employer insurance will allow the employee to add a dependent to their benefits. A life event includes marriage, divorce, death, loss of job, etc. It is determined by the Benefits Department or Human Resources. I, luckily, landed in this category. Due to the fact that I lost my low income subsidy, Extra Help, as of December 31, 2014 I was within the timeframe....sort of. We didn't apply for the addition until 45 days had passed. In our favor, for Medicare patients the time frame is widened a bit, but I also showed proof of attempts to appeal and/or manage the costs ourselves.
These were all the options given to me by Medicare, my insurance agent, my family, my research, you name it. It is hard to believe that these extreme options are all Medicare patients have to turn to. My words (I cannot call it wisdom) are to be fully educated on all your health care needs and options. We knew from day one that I could be added to my husband's insurance when I had to stop working. We got information on costs and laid out a pro's and con's list. Our immature minds thought it would take too much money out of his check so we couldn't afford it. Even when we came across this weapon of mass destruction called "The Gap", we got more information and laid it out. I was so certain there was a better option. I was so certain the government could not put people in need in such a difficult situation. I was certain other people in my situation had more options I just hadn't found yet. After trudging through the minefield of costs, information, and misinformation we came to the final decision to add me to his coverage. I can proudly say I have a PhD from the school of hard knocks in Medicare and its options.
I have always been an overachiever. School came easy to me and I thirst for knowledge. I have been entangled in the medical world since before I could even drive. Yet, I was so ignorant. I probably will come across more obstacles that humble me with my own ignorance on the matter. This, however, drives me to be even more active in the changes and guidelines outlined for any and all coverage I get. I learned to save receipts for tax deductions. I have a file folder for it all. I organize and juggle appointments. I am diligent about my medications. I research every aspect of the diagnoses I receive along the way. I am the poster child of Type A personality. I missed this. I missed some of the most important information I need. I actually didn't miss it, I disregarded it.
I don't enjoy complaining. I don't enjoy laying out financial struggles. I don't enjoy spilling my guts about disability and Medicare. I certainly don't enjoy Medicaid. The truth is, these topics have a negative stigma. A few people abuse the system and  it puts a bad taste in the mouths of those working so hard and still paying towards the system. But, if you flip that you see that many who paid into the system and did everything right often need to rely on that system. Someday we all do. Take the stigma away. Away from finances, needs, and charity. We all have them in some way, shape, or form. And charity is exactly that, charity. If we cannot open the conversation about some of the most common struggles for many Americans today, we continue to live in a lie. A lie that is turned in to a façade'. A façade' of a carefree, luxury filled life. Underneath that façade' is debt or secrets or holes. God put people on this earth in masses to come together as a community and help each other. We all have a place in this world, but we are all needed or the puzzle isn't complete. This includes knowledge. Get out there and make sure all your ducks are in a row. If you see someone struggling along the way and you have knowledge that may be useful, pass it on. These tangled webs of money making health care fields are impossible to get through without an armor of knowledge. As embarrassed and humbled as I am by all of this, I am proud to have found a solution. I can now move forward with more wisdom. I have many years to come and yearn for more wisdom no matter how hard it knocks me down.

Lesson Learned- Competitive Bidding Program

Moving is always an adventure. Most of us loathe the process, but enjoy the change. Moving to a new state entirely for the first time in your life while you are ill and receiving new technology in treatment is more than an adventure. I am but a sad New Mexican who is ignorant to how the world outside of New Mexico works. The Federal part of our wonderful country is a layman's understanding as well as the history for myself. But New Mexico is like a small town that runs at a very low speed and is off the beaten track.


Along this first year in Texas, I have been through my share of awakenings. In the short five or six weeks I had before having my gastric stimulator implanted, I had to move in, familiarize myself with the area, get address changes for everything under the sun, switch my son's insurance, and do all the preliminary stuff for the surgery. I thought all that was hard. I thought all I had to do is get acquainted with new doctors and get a new driver's license. Boy, was I wrong.


Doctor's alone have kept me on my toes. Of course there are several and frequent appointments for my stimulator. The first year of recovery and calibrations is tough. I also have had to establish with a neurologist, an endocrinologist, a dermatologist, and a rheumatologist. If you have read some of my previous posts you will know that a rheumatologist is no longer necessary as the symptoms seem to be a latent version of adrenal insufficiency that has been difficult to pinpoint. I am still needing a urologist for interstitial cystitis and an ophthalmologist, but the task seems so daunting at the moment I have procrastinated greatly. Unfortunately, it seems as though my primary care doctor needs to be replaced. That's a topic for another post, but let's just say she's not the best with being thorough or with her bedside manner.


I am on Medicare so none of this is easy. Less doctors in Texas take Medicare so it was like finding a needle in a haystack just for the doctors and services I need. I have changed prescription drug plans three times. Recently, I ran into a new road block. This story has plenty of twists and turns. Are you ready?


Back in early November, an 18-wheeler somehow came into our apartment complex and smashed our mail center. It is just a gazebo with the mail boxes all around. Supposedly his GPS took him the wrong way, but any logical person would know not to turn into an apartment complex in an 18-wheeler. Needless to say, every one's mail was in there. The apartment management had no real answers for us other than, "You can now pick your mail up at the post office until the insurance can get us a new mail center." What about the mail that was in our boxes at the time? A mystery yet to be solved. Here we are at the beginning of April and we are still picking up our mail at the post office.


I had been running low on pump supplies for a few weeks now and I had not received any word about my automatic shipments like I usually do. Medicare makes you go through a third-party supplier and they usually send me an email the day it is shipped. I finally called them. I was informed that Medicare is no longer contracted with them. They have switched to a "Competitive Bidders' Market" in our area. I was advised to call Medicare to move forward because I should have received a notice back in October or November. Do you see where this is going?


Just a few months earlier, I had been working with my doctor's office on getting a new pump supply prescription because mine had expired. We began the process in late September, but the back and forth was finally done with in November. I received everything I needed. Now, switching over to a new supplier meant getting a new prescription. I knew this would be a potentially long process, but gritted my teeth and pushed through, step by step getting increasingly more frustrated. I couldn't get my old supplier to send out complimentary supplies to get me through. They could not transfer the old prescription; don't ask me why because they gave me an answer that makes absolutely no sense as most things in the medical field do. The manufacturer somehow had no record of me since 2011. Well Medtronic, I bought a new pump in 2012 that you sold me, I have been receiving supplies since than that the third-party gets from you, and finally I have an Enterra gastric stimulator implanted in my abdomen that you all made and registered for me eight months ago. (Everybody clap your hands for eight productive months) They also refused to send out some "hold-me-over" supplies all due to the fact that no one has a "current" prescription except the supplier who no longer supplies me. Aaahh


I start putting one foot in front of the other to begin the long process of finding a new third-party supplier. When I called Medicare they gave me three phone numbers of three different suppliers. The first two did not supply pump supplies. Check them off. The third said they did. Yay....they began the registration and started the paperwork right away to get me squared away. It took only a week of back and forth confusion this time to get the new prescription done. I finally received my supplies last Friday, and they were the wrong supplies.
It was a generic brand of supplies that claimed it works for all pump models including...and it gave a list of manufacturers and models. My model was not on the list. Next step, call the manufacturer to see if the generic is even possible. There is a high likelihood that the pieces do not fit my model and may possibly crack it. I turned back to the supplier. Suddenly, no one was available in the pump department to service my call that day so I left a message. That felt odd. I did tons of research on the Internet, because where else do you turn for honest information (haha). I kept coming across the same information the manufacturer had given me. Nothing can be done on a weekend so I tried to block it out until Monday. I did contact my NM diabetic educator to ask for supplies because no office here has them on hand. I also contacted my sister who has a similar model of pump. Both are doing what they can to help with supplies until I have this straightened out. I finally gave in and paid cash for supplies to give me a bit of a cushion. Stockpile baby, stockpile. Then I get a call saying they will not ship out supplies because I am a Medicare patient who needs to go through a third-party supplier with a prescription.


On Monday I called the third-party supplier, All American Medical, and notified them of the mistake. I was informed they do not supply my particular needs. Back to Medicare I go. I got two phone numbers for the "Competitive Bidders' Program". Surprise, surprise. These suppliers do not supply pump supplies. At this point I am thinking, "this competitive-bidding program is definitely not organized or handled well". When I was waiting on hold for the umpteenth time with Medicare, I decided to go online to see if I could pull up some names for this "Competitive Bidders' Program". Thank the Lord, I did. 17 were listed for my zip code so I went straight down the list. I called everyone of them I could and was very specific about the supplies I needed for my particular pump. About five businesses in, I found one. They only supply Medtronic pump supplies. Phew. Now, I await the aligning of the third-party and my doctor's office. This time I talked to my doctor's nurse and drilled into her what I need the prescription to say so I can leave this trouble behind as quickly as possible. By this time, I believe she feels the same.


Little by little, you learn how to navigate the world. New Mexico is not in the "Competitive Bidders' Market" so I had never dealt with this. Apparently, the program is new across the board but some states do not fall into it. After ripping my hair out, losing my cool with every single person I talked to, and spending all weekend trouble shooting with my family's help, I now know exactly what to ask when dealing with Medicare and third-party suppliers. I also know that screaming does not help a thing. As if at the ripe ol' age of 31 I didn't know that, but, ya know, long term stress can manifest an entire person you do not recognize. Luckily, the beast in me is only in view sparingly and this year I am releasing all demons so soon I can be the me I have always known....or possibly, quite possibly, a better me.
I am noticing more energy. I am noticing a more nourished look throughout my body. I am noticing a lighter heart. The volunteering, church, my son's school and teacher, and enjoying our new surroundings has really started to bring to light the me I used to know and embrace. Being so ill everyday can wear on you and most of us feel a great deal of guilt, inadequacy, and grief when going through a change like a diagnosis of a new disease along with its symptoms. Sometimes we get lost in it all and forget who we really are or think because the disease has caused limitations that somehow limits our personality or self worth. This healing process and recovery from what I have been through these past few years including the gastric stimulator implant has been a long road, but proving to be worth it. Lessons learned, wisdom gained, strength and resilience abound and a new heart and mind rise from the ashes made by the bridges of our "old" selves burned like the Phoenix.
That was a bit off track, but the lesson of "no matter how many times I think I've got it covered" i.e. my insulin pump supplies and Medicare, there is always a wrench coming in, eh hem "Competitive Bidders' Program", to teach you a new lesson. Along the way more layers of yourself are pulled back to open up a new part of you.
I certainly don't mean this post to come across like I am worse off than anyone else or that I have seen more pain than others. I know that is not the case by any stretch. I just realize everyday that I have not seen every struggle or I would know how to face them more appropriately.
Never stop learning....just try to stay level headed unlike I did.