In our office lunchroom recently a pharmaceutical rep informed us of changes to one of the more common Medicare Advantage programs that many of our patients use. During this discussion it came to light that I am not alone in my woeful lack of understanding of the different Medicare plans.

Open enrollment season for Medicare started Oct. 15 and ends on Dec. 7. This means millions of Americans older than 65 years of age need to pour through hundreds of pages of documents outlining rules on copays and deductibles, formulary coverage, and changing health care rules that have resulted from enactment of the Affordable Care Act (ACA). (The official government Medicare handbook for 2013 alone is 140 pages long.)

So, in the spirit of arming this dummy (i.e., myself) and other newbie practitioners with information to help us provide better care for our patients, here is a brief distillation of Medicare, with attention to some parts that may be more relevant to rheumatologists.

People over 65 years of age are eligible for Medicare, of which there are several parts:

• Medicare Part A. This part is also known as the Hospital Insurance Program. It covers inpatient care in hospitals and skilled nursing facilities – as long as such services meet criteria for the rendering thereof, of course.

• Medicare Part B. This is the Medical Insurance Program, which covers doctors’ services, outpatient care, and physical therapy. It covers x-rays, vaccinations, chemotherapy, and other outpatient medical treatments administered in a doctor’s office. For us this means infusional agents such as infliximab and rituximab, as well as some osteoporosis drugs such as zoledronic acid, which is infused, or denosumab, which has to be administered via subcutaneous injection by a health care professional.

• Medicare Part C. This is also called the Medicare Advantage Program. Private insurers are given money by Medicare to provide services covered under Medicare Part A and Part B. For additional premiums Advantage programs can also provide Part D coverage as well as other extras like dental coverage, vision care, and health club memberships.

It was in fact a Medicare Advantage plan, administered here in Rhode Island by a national provider, that spurred this discussion. This particular plan used to cover infusions (i.e., a Part B benefit) at 100% of the cost. However, rumor has it that beginning in 2013, the insurer will start to charge patients 20% of the cost. Imagine, then, how much money our patients on office-administered biologics will have to start shelling out for their treatments. Imagine the hardship for someone who has been well controlled, for example, on infliximab for years suddenly having to come up with several hundred dollars every other month?

• Medicare Part D. This is an outpatient prescription drug benefit. Unlike Part A and Part B, Part D is not standard. Though the different Part D prescription drug plans are regulated by Medicare, they are actually designed and administered by private insurance companies, who can dictate which drugs or drug classes they cover, and at what tier they offer the drugs. An individual can have up to 40 different Part D plans to choose from, and patients are left with the tough job of figuring out which drug plan best fits their needs.

This is also relevant to us because this is how our Medicare patients pay for most prescription drugs. This is also the source of a significant coverage gap, informally and infamously known as the "doughnut hole." In general Part D beneficiaries pay a deductible and Medicare covers the rest of the drug costs. When patients have spent about $2,900 (of their own money in the form of deductibles and of government money in the form of coverage), they become responsible for 100% of their medication costs, until they reach about $4,700 in out-of-pocket spending, at which point Medicare foots most of the bill for the rest of the year. Imagine, then, how difficult it would be for a patient with RA on a biologic, which can cost up to $3,000 a month.

Incidentally, thanks to government negotiations with pharmaceutical companies, in 2012 patients were responsible for only 50% of the cost of branded drugs instead of 100%. The ACA anticipates "closing" the doughnut hole by 2020; Medicare would continue to cover part of the drug costs, leaving consumers with a responsibility for 25% instead of 100%.

This all brings to mind wise words that a patient passed on to me. She told me that when she was first diagnosed with RA many years ago, the rheumatologist who made the diagnosis advised her to always make sure she had the best health insurance possible. I continue to share that advice with my patients today.

Dr. Chan practices rheumatology in Pawtucket, R.I. E-mail her at rhnews@elsevier.com.

Medicare for Dummies