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July / August 2010
Shortchanged
by David Capogna
A 17-year veteran of HIV tries to cash in on health care reform’s “doughnut hole” fix and Medicare’s coverage for facial fillers.
Dollars to doughnut holes:
The Federal Government Health Care Reform Act, passed in March, promises that by 2020 it will shut the so-called “doughnut hole”—the gap that opens up when a Medicare Part D participant exceeds prescription coverage and doesn’t close until drug costs rise high enough to trigger catastrophic coverage.
The doughnut hole costs money—lots of it. Under private insurance, my HIV meds were expensive. But when I switched to Medicare, the costs grew. In 2009 I paid a $310 deductible plus just 25 percent of drug costs until I hit $2,830. Then I paid full price for drugs until my out-of-pocket costs reached $6,440. At that point catastrophic coverage kicked in, covering my meds again. Even after cashing in all my coins and subsisting on PB&J sandwiches, I still maxed out my credit cards.
The new health care reform throws a one-time $250 rebate to Medicare D recipients drowning in the doughnut hole. Beginning next year, all our brand meds will be discounted at 50 percent (meaning about $500 per month rather than $1,000 for my Truvada). Gradually the discounts will grow, closing the doughnut hole by 2020. My only fear—a big one—is that the new law doesn’t prevent drug companies from raising their prices.
Medicare fails to save (my) face:
In March, the Centers for Medicare and Medicaid Services (CMS) announced that HIV-positive Medicare participants who have facial wasting and are depressed as a result would be covered for facial filler treatment with Radiesse or Sculptra, the two injectable FDA-approved fillers—effective immediately. Suffering from lipodystrophy and glum, I thought I’d get a Sculptra touchup from my Medicare participating dermatologist.
Medicare is like any insurance: Numbers rule. Pre-authorization numbers, billing code numbers, referral numbers, mind-numbing numbers. It took awhile, but CMS has finally released the “J-code” numbers for Radiesse and Sculptra reimbursement. For more information and to get the billing codes, visit cms.gov/transmittals/downloads/R1972CP.pdf.
Search: veteran, doughnut hole, medicare, facial filler, Medicare Part D, private insurance, medicaid, Radiesse, Sculptra, FDA, lipodystrophy, glum, dermatologist, J-code
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John DelRossi, Philadelphia, PA, 2010-10-16 15:58:08
Hello everyone- the Rossi Wellness Center performs Sculptra and Radiesse injections for HIV+ patients with lipoatrophy. John DelRossi, PA-C, has performed over 800 procedures, more than any other HIV provider in the Philadelphia. Rossi Wellness Center does bill Medicare as well as your secondary. You will be responsible for costs only if Medicare refuses reimbursement. You do not have to go to NY. Office number 215-238-9100
Michael, Riegelsville, PA, 2010-07-16 03:04:38
The most well-known doctor to do Sculptra injections in Philadelphia, Robert Winn, does not participate in the new Medicare coverage. The Mazzoni Center, with which he is lead I.D. doctor, will not bill Medicare. The reason I was given was that most patients at Mazzoni do not have secondary insurance, so while Medicare pays 80%, the remaining 20% of costs are not recooped. Even tho I have secondary coverage which pays the 20%, they refuse to change their policy for me. Do I have to go to NY?
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