Author Topic: Medicare Part D and ADAP (Read 8818 times)

just_joe · « **on:** May 10, 2007, 01:19:31 am »

As a long term survivor of this disease I've now found myself with Medicare Part D and ADAP saying that I have met my catastrophic max. So I think that's their way of telling me "We expected you to be dead by now!" I am now getting bills form my doctor and the hospital because what was my share of cost with Medical is now no longer covered because they no longer cover meds. Did the masterminds that thought up this brain child called Medicare Part D even consider the position that this would put so many of us long term survivors? I've actually refused an outpatient procedure and told my doctor if he wants to run any regular out patient tests that he'll have to admit me in order to get Medicare Part A&B to cover them. Being on Social Security I certainly am in no financial situation where I can. Does anyone know if there is anything being done about this?

Robert · « **Reply #1 on:** May 11, 2007, 11:25:27 pm »

Joe....

I'm going to ask the Moderators to move this over to LIVING WITH HIV. I think you'll get a better response. I'm also on SS disability, Medicare (parts A,B,&D) and ADAP. I don't know exactly how it works, but ADAP is picking up any costs I incur when I enter the 'doughnut'. Don't know about other medical expenses as I haven't needed them, I guess (other than office visits and tests etc.)

robert

aztecan · « **Reply #2 on:** May 12, 2007, 12:29:07 pm »

Hey Joe,
Some states have come up with plans to cover this gap the media nicknamed the doughnut hole.

I don't know where you live, but you might check with your ASO regarding the programs they offer. We have a state-run insurance plan that takes up the slack, other states are using ADAP or some other plan.

HUGS,

Mark

gerry · « **Reply #3 on:** May 13, 2007, 02:05:31 pm »

Hmmm, I haven't really heard of Medicare stopping payment after "reaching catastrophic coverage." Even if you end up in the "donut hole" for Medicare D (prescription drug coverage), this should not affect payment through Medicare A and B (hospitalization and doctors visits), after co-pays and deductibles. That is of course unless the hospitals and doctors are charging more than the allowed Medicare reimbursements, in which case the Medicare beneficiary may be liable for the difference. Or, if you are receiving "out-patient" IV meds administered through a hospital infusion care in which only 50-80% gets covered after deductibles. But that's not because of reaching "catastrophic coverage." I think a clarification might be needed here.

mudman8 · « **Reply #4 on:** May 13, 2007, 02:38:35 pm »

this is a tough one, it gets so complicated, I'd find a benefits counselor to help you out.

david25luvit · « **Reply #5 on:** May 14, 2007, 05:31:23 am »

What you call a dougnut hole is actually called The GAP....and it runs thru $2500-3600 before medicare picks up again.
Don't ask me why? Seems to me if you're at that point....you can ill afford to pay full cost of your medications. Having
just entered the medicare A&B...and having read up on it online....I'm still at the point where ADAP is paying mine. But I
suspect that's about to change.........

I'm thinking I need to consult a benefits counselor too!

BT65 · « **Reply #6 on:** May 14, 2007, 09:42:29 am »

They (the people I call on the back of my Medicare Part D prescription card) told me that my prescription benefit doesn't have a cap, but we'll see. I know everything that is run by the government is subject to change. But I would definitely find a benefits counselor and let him or her sort it out for you instead of being so stressed about it.

aztecan · « **Reply #7 on:** May 14, 2007, 11:12:38 am »

I think, reading the first statement about ADAP and Medicare, that Joe has reached a catastrophic cap set on ADAP, but its not clear.

We have two programs here in New Mexico to help with this. One covers the person with Medicaid for his meds if that person's income falls below a certain level.

The second is an insurance coverage through the state medical insurance pool which essentially takes the place of a Part D. The premiums for this insurance, which can be between $200 and $400 a month, are paid by insurance assistance as long as the person in question is taking HIV meds.

I think there should be similar systems in other states, but I don't know that as a certainty.

HUGS,

Mark

just_joe · « **Reply #8 on:** July 06, 2007, 03:21:07 pm »

I've talked with my M.D. and he has no answers. I live in CA. and you would think that this state would be on top of this kind of situation. I even called my case worker at Medical and asked to speak to a supervisor who has never called me back. I'm sure I'll get some answers but until then I have told the hospital that $20 to $25 dollars a month is the most that I can affford to pay on my bill to keep it from distroying my credit and going to collections.

Robert · « **Reply #9 on:** July 06, 2007, 04:08:11 pm »

Joe.

"... my share of cost with Medical is now no longer covered because they no longer cover meds."

All your meds should be covered by ADAP. Mine are. Even the donut hole.

I think you're getting screwed. You say you're on Social Security. I am too. I have supplemental insurance with Kaiser (here in CAlifornia) that I pay $115.00/month. Along with ADAP (which pays for the prescriptions) I get complete coverage for all doctor visits and labs including dental and vision and hearing. $10 co-pay on my visits. (I think. Could be $25.00. I really don't know and I should.) On my last visit my Dr prescribed Androgel (testosterone) and I had a co-pay of like $6.00. That's it.

Do you have any sort of supplemental insurance? I know very little about any of this...I just can't comprehend it...but you should get some supplemental insurance with Blue Cross or somebody. In the meantime....like I said ADAP should cover your pills....

good luck.

robert
robert

Miss Philicia · « **Reply #10 on:** July 06, 2007, 04:09:16 pm »

just joe: no offense but it's been two months since you posted this, and if you've been waiting for a return phone call for that long no wonder it's not been resolved. Your profile says you live in San Diego, so surely your case managers office is not so far away that a long drive is an excuse. Why don't you present yourself in person and insist on some information? I've found in my past that sometimes this is the only effective way to get something done.

just_joe · « **Reply #11 on:** July 23, 2007, 01:50:28 am »

No offense taken. I've called several times with no result. As far as going down there I have a personal embarrassment about showing up in person because I don't look anything like what you'd expect from my labs and the medications. I know I shouldn't feel that way but for me to show up in person and ask or complain about my situation I feel would fall on deaf ears because of how healthy I look or at least that is my perception of how they would respond to my needs. I know that's no excuse but I turned to this forum to hopfully find out who I should contact or what I should do. Certainly I can't be the only long term survivor that is going though this. To clarify I have Medicare part A and B and I have Medical. Medicare Part D covers my prescriptions and ADAP used to pick up the slack until this past year where I was told that ADAP told my pharmacy that I had met my catastrophic max. I am now receiving hospital bills because my share of cost is almost half of what I make on Social Security. Since Medical used to meet my share of cost when they covered medications now they don't with Medicare Part D which leaves me now responsible for the "share of cost."

RapidRod · « **Reply #12 on:** July 23, 2007, 04:37:38 am »

just_joe, since when has looks become an issue with someone that has a disease? You need to get over that thought.

Dachshund · « **Reply #13 on:** July 23, 2007, 06:44:43 am »

Believe me the bureaucrat facing you on the other side of the desk could give two shakes about how you look...you are just another number and will be treated as such. You meet the guidelines you get approved and if you don't...well we all know the answer to that. So put your best face forward and become a little more proactive. It's a royal pain in the ass and it takes time...and you may not even get what you want...but coulda, woulda, shoulda will only leave you frustrated and defeated.

just_joe · « **Reply #14 on:** July 23, 2007, 05:33:51 pm »

It's been hard because I get that attitude from many of my friends and even my family. I can tell them what my numbers are the OI's I've had and all they see is this healthy looking man that doesn't look like he's been sick at all. It's almost like I sense a lack of compassion as if in their mind someone that's disabled from this disease couldn't possibly be that sick and look as healthy as I do.

Dachshund · « **Reply #15 on:** July 23, 2007, 05:41:32 pm »

Well if your are going to keep coming up with excuses you might as well just pay the damn bill. I bet when they start docking your social security you will go down there and quick.

just_joe · « **Reply #16 on:** July 23, 2007, 06:05:11 pm »

I have gotten answers from Medical several times. I've been told that with Medicare part D that Medical does not cover any medications. I've been told by Medical and the hospital that I am responsible for my share of cost which is on a monthly basis. So... because they changed the way the system works and didn't forsee this problem they tell me for whatever Medicare part A and B and Medical won't cover, that I am responsible for my Medical share of cost So if I suddenly become a dialysis patient and have to receive it on a regular basis that would leave me responsible for $850 a month. I only make $1200 on Social Security. That would leave me with only $350 to live on. I've asked my M.D., my pharmacy, Medical and no body seems to know the answer as to why or how this gap or donut hole was created and what they are doing to try to fix the situation. I turned to this forum because I thought someone might know something about what's being done to solve it.

Dachshund · « **Reply #17 on:** July 23, 2007, 06:28:16 pm »

I apologize for being short, it just seemed like you were fixating on your looks. Hopefully, someone can answer your questions for you.

Miss Philicia · « **Reply #18 on:** July 23, 2007, 09:30:24 pm »

I just get the sense you're being incredibly passive about all of this. Just making endless phone calls that aren't returned achieves nothing. I will state again you need to march into an office and have a bit of a Diva Fit and demand results. Are you this passive with your healthcare in general? This commentary about your appearance not being "diseased" enough is simply laughable -- sorry to be so harsh but perhaps some tough love will get you away from your computer and into someone's office that can solve this issue for you. Do you honestly think everyone on Medicare needs to looks like a wasting victim covered with KS lesions? Honey, this isn't 1985/

I'm quite sure you're getting the wrong information about the donut hole with Part D, and this "catastrophic max" term.

Robert · « **Reply #19 on:** July 23, 2007, 10:02:21 pm »

I just came back from a famly wedding. Everyone in my immediate family, brothers, sisters-in-law, nieces (and their husbands), nephews (and their wives) and friends know of my diagnosis. All weekend I heard how "healthy" I look. I have to admit, I look like a million bucks. I feel like shit, though.

My Dr is even impressed by the way I look. But she knows I'm anemic, tire easily, have severe memory problems, deep clinical depression etc. I'm not fit to work.

Like you, I'm on SSDI with about $1,200/month. I've got "supplemental" Medicare insurance with Kaiser which covers a lot of stuff but really has nothing to do with the "hole". That is an ADAP thing and you need to talk with the people at your hospital about it. Ask for the counselor who works specifically with ADAP. Your hospital/clinic must have its own ADAP ENROLLMENT WORKER. Don't just speak to just anyone in the financial aid office or the billing dep't. They don't know shit.

If that doesn't work, call the State of California Dept. of Health Services ADAP Medicare Part D Premium Payment Program. (916) 449-5993. This is a current phone number (well, I last used it in Jan,2007, 6 months ago) and someone there can help you.

gOOD LUCK...ROBERT

just_joe · « **Reply #20 on:** July 24, 2007, 03:05:12 pm »

As for the being passive... I disagree. As stated in my previous post I've talked with Medical, my M.D., the hospital, and my pharmacy. Both you and I know that not everyone looks the way they feel or are on paper but you can't tell me that there are some people in this world that have no idea what we've been through or are going through and don't think in the back of their mind... but this person looks healthy!

Finally! someone responded with some information. Thank you.

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Author Topic: Medicare Part D and ADAP (Read 8818 times)