Anonymous – Pennsylvania: I am 42, have three children, and am receiving Social Security disability benefits. I also have become addicted to Xanax, which has been prescribed to me in high doses. I wish the doctors would tell you had badly these medications mess with your mind! Despite my need for help, Medicare has denied me coverage for the rehabilitation help that I need.
Fortunately, I am about to get remarried to a wonderful man who has employer insurance that will cover the care I need. But here’s the rub. The rehab services we’ve contacted say that even though my new employer plan will provide primary coverage, they will send this claim to Medicare anyway, and it will once again be denied! The rehab people are thus telling me to drop Medicare.
I called the agency and was told I can drop Medicare without threatening my disability benefits. However, if I do cancel Part B, I will face big re-enrollment penalties if I again need Medicare before turning 65. That’s a long way off, and who knows what my health insurance needs will be over the next 20 years?
I just keep hitting roadblock after roadblock with Medicare. I am sure I am not the only person is this situation. I have been calling rehabilitation centers for years in state and out of state and no one will help me. I have even been kicked out of hospitals because they say there is no help for me there! This is so frustrating for people who really want help.
Phil Moeller: Unfortunately, you have lots of company here. Xanax is a powerful benzodiazepine drug prescribed for anxiety and depression; others include Ativan, Dalmane, Halcion, Librium, Restoril, Rivotril, Serax, Valium, and Versed, according to Pennsylvania state prescribing guidelines. Addiction to these drugs is a serious and growing problem.
In terms of whether Medicare will cover your treatment, the key variable is whether such care is proscribed as medically necessary, according to Patrice Muchowski, head of clinical services as AdCare Hospital, which operates treatment centers in Massachusetts and Rhode Island and is part of the larger, nationwide American Addiction Centers network.
Medicare will cover addiction treatment that doctors and other licensed caregivers think is medically necessary. If your doctors went through the proper steps, it’s likely that Medicare would cover your care, she said. But she said it’s not clear from what you described exactly what steps you and your doctor already have taken.
Odds are, however, that showing up at a hospital with your Medicare card is not going to get you the covered care you seek. Benzos are very powerful, she stressed, and the best way to come off of them is through “a very, very, very slow taper (program), done either by a physician prescribing it” or a hospital familiar with such treatments. Not all hospitals are equipped to provide that treatment, but ask for a “level 4” facility, Muchowski advised. This is rated as the highest level of addiction care by the American Society of Addiction Medicine.
Muchowski had these additional suggestions, while emphasizing that she would need to know much more about your situation to provide informed guidance:
- Not all drug rehabilitation facilities accept Medicare, so make sure you’re talking with one that does.
- A psychiatric facility might be worth pursuing, as they usually take Medicare. The American Academy of Addiction Psychiatry has a referral service.
- Speak to the person prescribing your Xanax to discuss outpatient programs that can provide you professional help in tapering off this drug. Your prescriber has the right to lower the dosage as well, which could be part of a formal tapering program.
- Your fiancé’s employer might have a formal employee assistance program that can help you.
Here’s an email from Steve in Massachusetts that illustrates the issues and decisions that people with disabilities may face if they return to work:
“I am 44 years old, blind, and have had Medicare for about 10 years because of my disability. I did go back to work full-time a few years ago but have continued to pay for Medicare (Parts A and B). It is my only insurance right now, but the out-of-pocket costs are getting expensive.
As a result, I have recently gotten health insurance from my employer and I had planned to stop Medicare. I saw my doctor last week and told him the situation. He recommended that I not stop my Medicare because he said that it could be very hard to get it back, given that I am more than 20 years away from retiring. He recommended that I keep Medicare and look for a secondary insurance. I trust my doctor, but I do not think he is an insurance expert by any means!”
One-size-fits-all answers don’t work here. A person’s specific circumstances – age, health needs, insurance plans, and the like – are all different. What they do share is the need to understand how Medicare does and does not “work” with other insurance programs. This is a big-enough deal at Medicare that the program has an operations manual dedicated to what are called “coordination of care” rules.
Steve’s doctor deserves praise for at least thinking of this issue. Most doctors know very little about health insurance or the financial implications of their treatment. But Steve is right to want a second opinion about what his doctor told him!
Medicare rules permit a disabled person to reacquire Medicare coverage at any time prior to age 65.
Medicare rules permit a disabled person to reacquire Medicare coverage at any time prior to age 65. The issue here is whether, when the person re-enrolls, he would be subject to substantial late-enrollment penalties because he did not have continuous Medicare coverage.
For someone on Medicare who is not disabled, getting employer insurance clearly permits them to drop Medicare without encountering penalties upon re-enrollment. The same should hold for those with disabilities. However, I’ve encountered many illogical things about Social Security and Medicare, so I recommend that people contact Social Security to confirm how the agency would treat them.
In nearly all cases, the employer plan is the primary payer of covered claims and Medicare is what’s called a “secondary” payer.
If a person has a high-deductible plan with, for example, a $3,000 deductible, basic Medicare (Parts A and B) can be used to pay claims in the deductible phase of the coverage. Even with its monthly cost of nearly $145 for most enrollees, Medicare can make sense in some situations.
Beyond high deductibles, Medicare also can help pay some of the covered expenses not fully paid by an employer plan. Usually, it does not make sense to get a Medicare Part D plan here or a Medigap supplemental plan. You would be paying for things your employer plan already covers.
Before making this decision, however, it’s important that anyone eligible for Medicare by virtue of age or disability ask their employer to certify that the employer’s drug coverage is at least as good as a typical Part D plan. If an employer plan does not meet this “credibility” test, then the person must get Part D. Employers are required to provide credibility statements annually.
One final point here is that anyone in this situation who must get a Part D plan need not also pay for Part B of Medicare, although they do need to sign up for premium-free Part A.
I am pretty sure that people with such options can get their coverage coordination questions answered by talking with someone in their employer insurance benefits office. I am also pretty sure, based on literally thousands of reader emails, that talking with their insurer has a popularity rating akin to having a root canal without anesthesia. Time and time again, the best advice I have is that people should speak first to their health insurers, not to me.