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Ketki Patel, MHA, is a Program Operations Specialist/Post Award Specialist for the University of Washington Thoracic, Head and Neck Oncology Research Program in Seattle, Washington.

Ketki is an experienced Patient Financial Advocate with a demonstrated history of working with clinical trials/research, medical oncology, and holds knowledge in prior authorization of inpatient and outpatient chemotherapy and appealing all types of claim denials. She has experience working with the drug manufacturers for drug assistance and copay assistance in the hospital billing setting.

The Empowered Patient - Knowledge is Power when Combating Cancer
Fri, 11/01/2019 - 14:25
An Overview of Medicare Terms and Options
Ketki Patel, MHA, GRACE Guest Contributor
With the plethora of Medicare options available, here is an overview of Medicare terms and options along with things to consider when choosing a Medicare plan.

Let's start with the basics:  there are four main parts of Medicare:
  • Medicare Part A – Hospital Plan
  • Medicare Part B – Medical Plan
  • Medicare Part C – Medicare Advantage
  • Medicare Part D – Prescription Plan


Part A is your hospital benefit and covers items such as inpatient care, skilled nursing facility care, some home health care, and hospice. Medicare Part A covers your stay if your provider orders medically necessary inpatient care of at least two nights (known as the Two Midnight rule), your facility or hospital accepts Medicare and admits you as an inpatient, you require treatment that can only be given in a hospital, and the hospital’s Utilization Review (UR) team approves your stay.  This is important as It is standard of care for some common chemotherapy regimens to be done in the inpatient setting due to continuous infusion requirements or to monitor for severe reactions.

Part B is your medical benefit and covers providers’ visits, most lab tests, injections, and outpatient services such as infusion or injectable chemotherapy/immunotherapy (when you receive care in the hospital outpatient setting but are not admitted to the hospital), Medicare Part B generally pays 80% of approved costs of covered services, and you pay the other 20% (or if you have a supplement plan, the supplement plan will pick up the remaining 20%, we'll get there later on in this article).

Part C consists of Medicare Advantage plans, these plans give you a way to get your Part A and Part B benefits through a private insurance company that contracts with Medicare, similar to commercial insurance. Most Medicare advantage plans can include prescription drug coverage as well, which is something you don't get through Part A or Part B. One thing to keep in mind with Medicare Advantage plans is that they, like commercial plans, follow the same in network and out of network stipulations, so it is important to confirm your healthcare provider is contracted with the Medicare Advantage plan you are considering before you switch, or else you may need to obtain a referral to continue your care or find a new provider all together, or face higher out of pocket costs.

Part D is your pharmacy benefit also known as your prescription drug coverage. Like Medicare Advantage, Medicare Part D is available through private insurance companies. You can sign up for a stand-alone Medicare Part D prescription drug plan if you stay with Original Medicare (Part A and/or Part B).  Part D is what covers your oral chemotherapy prescriptions and can prove to be quite costly with meeting the “Donut Hole” requirements. The Donut Hole is a temporary limit on what your Medicare Part D plan pays for covered prescription drugs. While in this coverage gap, you’ll pay a higher share of out-of-pocket costs for your medications. Many changes took place in 2019 to Part D and continue into 2020, the coverage gap was closed for covered brand name drugs and will close for generic in 2020, however the out of pocket threshold and the amount to get to catastrophic coverage is going to increase for 2020. Catastrophic coverage is the point at which you have met the out of pocket requirements for your prescription. This is why it’s important to work with your financial advocate and try to find relevant third-party funding and disease specific copay assistance programs (PAN, PAF, etc.) to help offset these high costs, the drug manufacturer can’t really help in these scenarios as CMS has considered that a kick back.  Another option, if you meet income requirements are the Qualified Medical Beneficiary Program (QMB) and the Specified Low-Income Medicare Beneficiary Program (SLMB) to get help from the state to pay for premiums, deductibles, and other out of pocket costs.  QMB will help offset Medicare A and B and deductible/coinsurance costs, whereas SLMB only helps with Medicare B costs.


Medicare Part A benefits begin the first day of the month you turn 65. If your birthday is on the first day of the month, your benefits will begin the month before you turn 65. If you enrolled in Medicare Part B when you applied for retirement, your Part B coverage will begin at the same time. If you do not qualify for Social Security retirement benefits or benefits from the Railroad Retirement Board (Railroad Retirement provides retirement benefits and comprehensive survivor and unemployment-sickness programs for the nation's railroad workers and their families), then you must enroll in Medicare Part A manually during your initial enrollment period.

Medicare Advantage Plans are different than Medicare supplement plans. Medicare supplement plans, also known as Medigap, were created to help supplement the costs associated with Medicare Part B plans, as mentioned earlier there is a remaining 20% that Part B doesn't cover. Medigap insurance provides coverage for many of the co-pays and some of the co-insurance related to Medicare-covered hospital, skilled nursing facility, home health care, ambulance, durable medical     equipment, and doctor charges. Medigap coverage does come at a cost as it usually has a higher monthly premium but could result in lower out-of-pocket expenses than some Medicare Advantage plans.  Medigap is definitely a wise investment if you plan to undergo chemotherapy with original Medicare as your coverage, as the 20% can quickly add up with all of your visits and the Medigap will be a better option in the long run.

Many healthcare institutions aren't really equipped to help you choose a Medicare plan, as it can be considered enticement if they tell you to choose one plan over another that benefits the hospital’s bottom line, so they will generally refer you to the local benefit office or an insurance broker.  An insurance broker may get paid a certain amount or commission to sell you a plan. As you can see, you really want to determine where your healthcare needs lie and determine which coverage is best for you.  There have been many obstacles lately with Medicare Advantage for example there is a high deductible upfront, or with Medigap plans there are now wait     lists to enroll, or stipulations due to pre-existing conditions. My recommendation is to really do your homework and review all your options, as the offerings all vary by state.  Please contact your financial advocate to provide you with resources specific to your location.


Do you have questions for Ketki?  Please join the conversation in our community forums!

*Please note:  The below links are information only and GRACE has no relationship with these organizations.

Helpful Resources:

The Medicare website also offers a free tool that can help you find and compare health plans, supplemental policies and prescription drug plans in your area

In Washington State, I typically refer patients to this website, there is a plethora of information regarding Medigap Plans, Medicare Advantage Plans, and contact information to a local advisor based on your location:




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