Medicare Open Enrollment: What People Living With COPD Need to Know

[Emily Brown] (0:00 - 0:26)

Don't let open enrollment go by without checking to make sure that your plan still works for you. We've kind of said this over and over, but it's because it's really important. It's so tempting to sort of just let your plan roll over, especially if you haven't had any problems with it this year.

Your drug list can change, your networks can change, your costs can change, and the plan that worked really well for you in 2026 might look different in 2027.

[Arnelle Konde] (0:34 - 1:38)

Welcome to the Lung Health Champion podcast brought to you by the COPD Foundation. Each episode brings practical tips, expert insights, and a powerful lived experience. If you have lungs, you belong here, so let's take a deep breath together and get started.

I'm your host, Arnelle Konde, Education Coordinator at the COPD Foundation. And in this episode, we're talking about Medicare and what people living with COPD and other chronic lung conditions should know when navigating their coverage and healthcare. To help us with today's conversation, we're joined by two wonderful guests.

First, we have Audrey Chavez, a respiratory therapist who works directly with people living with respiratory conditions and has seen many of the questions and barriers that can come up when patients are accessing respiratory care. And we're also joined by Emily Brown from the Patient Advocate Foundation, who helps patients navigate healthcare and understand their options when they encounter barriers to care. Welcome, Audrey and Emily, thank you for being here.

[Audrey Chavez] (1:39 - 1:39)

Thank you.

[Emily Brown] (1:40 - 1:40)

Thank you.

[Arnelle Konde] (1:40 - 2:00)

So, Emily, let's start with the basics.

Medicare enrollment can feel overwhelming, especially when people start seeing information about changes from year to year. Medicare open enrollment for 2027 and what people should know as they review their coverage. Absolutely.

[Emily Brown] (2:01 - 3:19)

And I want to say thank you again, Arnelle, and the COPD Foundation for having us today. Open enrollment is a really important time for Medicare beneficiaries. It extends from October 15th to December 7th every year.

And any plan changes that you make during that window take effect January 1st of the following year. So, for this year, it will be January 1st, 2027. And during open enrollment beneficiaries can switch from original Medicare to a Medicare Advantage plan or vice versa.

They can change from one Medicare Advantage plan to another or they can join, switch, or drop a prescription drug plan. So, really, open enrollment is an opportunity to just double check your current coverage and to make sure that you're in the best plan for the year ahead. Whether that is original Medicare or an Advantage plan, insurance coverage is so individualized as are your healthcare needs.

So, what works for your neighbor or even your spouse doesn't mean that it's the right choice for you. So, it's a good idea to just take time every year to review your coverage.

[Arnelle Konde] (3:19 - 3:31)

Thank you for that overview, Emily. So, when people think about their Medicare coverage, some may mainly focus on that monthly premium. What are some other costs or coverage details they should pay attention to?

[Emily Brown] (3:31 - 4:22)

You're right. A lot of times when people shop for insurance, they forget about all the other costs that are associated with having coverage and using it and just kind of focus on that monthly premium. But there are a lot of other expenses that can bubble up.

So, you should be looking at your annual deductible, which is that amount that you pay out of pocket before insurance kicks in. You need to be looking at your co-pays and co-insurance for treatment costs and physician visits. And you need to be looking at your maximum out-of-pocket limits.

So, that is going to be the total amount that you would have to pay per year, especially for medications. But depending on what kind of plan you have, it could also be for your medical care as well.

[Arnelle Konde] (4:22 - 4:26)

And why is it important to look at whether your medications are covered?

[Emily Brown] (4:26 - 5:53)

Insurance plans can update their formularies annually. The formulary is just a covered, your covered drug list for your plan. So, your medications can shift to a higher tier on that plan, which means that you would be sort of open to higher co-insurance or higher costs.

It could require prior authorization or require your physician to do a lot of extra paperwork, or there's a chance that your medications could be dropped altogether. So, it's really important to make sure that every year you are looking at your plan drug list to make sure that your medications are still covered since the tier and the requirements can change every year. Even if it was covered this year, it might not be covered at the same rate or perhaps at all for the following year.

And I'll just add on to that a little bit. Not only should you be looking at your prescriptions, but you also need to be looking at your pharmacy because costs can vary significantly based on whether you are going to an in-network pharmacy or a preferred pharmacy versus an out-of-network or non-perferred pharmacy. Making sure that the place where you're getting your medications as well is a part of your plan is really important.

[Arnelle Konde] (5:53 - 6:03)

Yes, and speaking of medications, for someone living with COPD, what are some of the things you would encourage them to look at when reviewing their coverage for the upcoming year?

[Emily Brown] (6:03 - 8:05)

Sure. Well, like I said, open enrollment matters every year. So, even if you're happy with your plan, plans can change, drug list can change, cost can shift.

So, especially for folks with COPD, it is important to check medications in halers. I would say probably medications in inhalers is the biggest one. So, checking your formulary drug list for those specific medications that you use, whether it's a rescue inhaler or a maintenance inhaler, any biologic that you're taking because the coverage that you have this year could be different next year.

I would check your oxygen in any respiratory equipment. If you use a nebulizer, CPAP or BIPAP, check your cost share. Check to see if there is a required supplier that you have to use to get those supplies and whether those supplies are covered at the rate that you use them.

So, you don't want to be in a situation where, you know, your insurance company is only authorizing X amount of bottles of oxygen a month and your needs exceed that. That's going to you're going to run into some issues with that. So, it's a good idea to just check that.

You want to check on pulmonary rehab, see how many sessions are allowed. If there's referral requirements or any kind of copays associated with that, you want to check to make sure your pulmonologist is still in network. Check your copay for specialist visits, which is often higher than primary care copays.

Beyond that, I think thinking about anything that you use regularly, whether it's home health, pulmonary function tests, help with smoking cessation. So, really just the core message here, don't just renew your plan on autopilot. Make sure you are checking each part and piece individually because one thing can change that really impacts your care and your cost, even though everything looks the same.

[Arnelle Konde] (8:05 - 8:28)

Absolutely. So, key takeaway, make sure you check everything. I like that comment you made about not doing it all the time.

I like that. So, Audrey, let's shift to you and what you see in your work. As a respiratory therapist, what are some of the common questions or barriers you've seen people living with COPD encounter when they're trying to access respiratory care?

[Audrey Chavez] (8:28 - 9:47)

Some of the barriers that I've seen people face is because I see people when they come into the hospital, and oftentimes they're coming into the hospital because something went wrong. You know, most of the time, they could get an illness and like a virus and they've just gotten sick and they need to come in to see us. But also quite often, maybe they ran out of their medication and it was too expensive and they couldn't refill it.

And it's just like Emily said, where now their medication is no longer covered. So, they couldn't spend the extra several hundred dollars sometimes and they were trying to figure it out late in the game. And then they got a virus and they got sick and here they are in the hospital.

Other times I see issues with oxygen, specifically because people moving or their DME company that they were using doesn't now cover them where they live now and trying to navigate that. And the way that oxygen is billed through Medicare is really complicated. Trying to navigate that and trying to figure out a company that can service their needs where they are now can be really challenging.

[Arnelle Konde] (9:47 - 9:51)

Do you see people having difficulty accessing pulmonary rehab?

[Audrey Chavez] (9:51 - 10:25)

Yes, I do. I do see people having difficulty with accessing pulmonary rehab either because of cost, because their insurance doesn't cover, or maybe their insurance does cover, but their portion is, it could be up to maybe $75 per clinic visit. And if you're supposed to go two to three times a week for 12 weeks, that's a lot of money.

And then I also see difficulty accessing pulmonary rehab just because of the number of people trying to get into pulmonary rehab and the limited spaces that we have open.

[Arnelle Konde] (10:26 - 10:30)

Are there situations where coverage issues make it harder for someone to get the care they need?

[Audrey Chavez] (10:31 - 10:55)

Yeah, there are. I see a lot of people who their insurance doesn't cover what they need. And it's just like Emily says, where they went through and they picked a plan.

It could be a bill full of their own that now they didn't realize they were going to have these medical problems, or they didn't realize that their plan didn't cover what they were needing already. So, yeah, it's very important to go through that with a fine tooth comb.

[Arnelle Konde] (10:55 - 10:58)

So what do you wish patients knew to ask earlier?

[Audrey Chavez] (10:58 - 11:34)

I wish they knew to ask what exactly their portion is going to be. What exactly their insurance is going to cover? And I wish that they would go through and look at all of the things that they were going to be using.

Like Emily said, do you go to the hospital once or twice a year and then have to go to a rehab? Are you going to be able to do that? Do you go to pulmonary rehab?

Are your medications going to be covered? Are your doctors still in network? All of these things, do you go to physical therapy outpatient?

All of these things that you are using, what you're consuming, is it matching your coverage?

[Arnelle Konde] (11:35 - 11:48)

I want to talk about the difference between being in the hospital and being at home. Can you walk us through some ways Medicare or insurance questions can come up differently during an inpatient stay versus outpatient care?

[Audrey Chavez] (11:48 - 12:47)

Medicare Part A is for the acute care. So that's what covers you while you're in the hospital. Medicare Part B is for outpatient.

So that's what covers specifically for COPD patients that covers nebulized medications and the nebulizer machine. But it also covers if you need to go to, like, a subacute rehab or if you need some sort of therapy after the hospital. And so you need you need both of those types of coverage just in case you get into the hospital or you need services outside of the hospital.

Medicare Part C is the Advantage plans. And then Medicare Part D is for all the drug coverage. And there's one other thing that I wish people knew is that if you don't sign up for Medicare for the each part of the Medicare when you're eligible for it.

And then you go to try to sign up for it later. There's a penalty for not signing up for when you were eligible.

[Arnelle Konde] (12:47 - 12:59)

Wow. And for someone who is living with COPD and is preparing to leave the hospital, what are two or three questions you would encourage them to ask about their ongoing respiratory care?

[Audrey Chavez] (12:59 - 13:57)

What they're going to need over time. So if I'm sending them home on oxygen, I would want them to ask, or I would tell them, is this going to be something that we think is going to be for forever? Or is this going to be a short time?

What's the plan there? If the person is a snowbird and they I live in Idaho, if they're going to go down to Arizona in the winter, they would need a different insurance plan than like an Advantage plan. They would need like a traditional Medicare plan so that they can ensure they have coverage in both states.

I would also encourage them to ask about alternatives. So if there is a, you know, we prescribe them one inhaler because maybe it's the latest and greatest thing, but there is a generic that their insurance company prefers. Or if there's some other alternative that's just as good or will meet their needs, is that going to be cheaper for them?

Or do they have options?

[Arnelle Konde] (13:57 - 14:08)

Now, Emily, listening to Audrey talk about some of those real-world situations. What should someone do if they're told that a medication, treatment, or piece of equipment isn't covered?

[Emily Brown] (14:08 - 16:43)

The first thing I will say is don't panic and don't treat the denial as final. A good first step is to rule out what we call soft denials, which are essentially administrative errors. So before filing like a more formal appeal, a good idea is to call the billing office and your plan provider just to check and make sure that there are no soft denials caused by a typo or potentially like just missing information.

We're human, and sometimes mistakes happen. So there's a chance that maybe your birthday got keyed in incorrectly. You know, maybe your claim was missing a diagnostic code.

And those are very simple things that can cause your claim to be denied. So it's a good idea to check on those sort of easy fixes first. And then if that does not correct the issue, you most likely have the chance to file a formal appeal.

Medicare actually has a pretty structured process for this, more so than a lot of private insurance plans. So if you get a denial, like from a Medicare Advantage plan or a Part D plan, you will get a written notice explaining why. And then from there, it generally goes up through five levels of appeal.

So the first is a redetermination where the plan reconsiders its own decision first. And then there's a reconsideration stage where an independent review organization takes a look, and that is outside of the plan. And if the care is still denied at that point, it can escalate further to an administrative law judge, the Medicare Appeals Council.

And even like a federal court, but most people do not need to go. We'll never need to go that far. And I will just make a note that deadlines matter a lot when you're talking about denials.

Typically, you only have about eight- excuse me, about 60 days to file, though that can vary between plans. But another important, really important thing to note, excuse me, is if it's an urgent need, you have a medication or a treatment that you need right away. You can request an expedited appeal, which will move much faster.

[Arnelle Konde] (16:43 - 16:46)

And when should someone seek help from a patient advocate?

[Emily Brown] (16:46 - 17:24)

I would say bring one in when you are not sure how to read the denial notice or to track the deadline for the appeal. I would say also if your doctor's office doesn't have sort of the bandwidth to help you gather the documentation you need. If your first appeal gets denied and you aren't really sure how to handle the next steps.

But honestly, whenever you're overwhelmed, navigating the appeal process for Medicare can get complicated really quickly. And that is exactly why advocates are there to help.

[Arnelle Konde] (17:24 - 17:38)

Now, I want to get into some practical tips. Audrey, I'll start with you. From the RT perspective, what are some things patients can do to make conversations with their healthcare team easier when they're dealing with coverage or access issues?

[Audrey Chavez] (17:38 - 18:26)

I think just being very open with good communication and say, I'm having trouble with this, I can't afford this, and let people know that you're seeking help and just ask, what do I do next? I don't know how to navigate this. I would really encourage people when they're signing up for their open enrollment to go through their state insurance.

There's usually, it's sometimes it's called SHIP in here in Idaho, it's called SHIBA, and it's a state insurance advisor. They're non-biased and they help you to pick your plan. That sounds a lot like what Emily does as well.

So if you can't find one in your state, please reach out to Emily because I know she's going to help you. Just tell them what your issues are and just keep asking questions.

[Arnelle Konde] (18:26 - 18:39)

And Emily, if someone listening today has a Medicare question or feels overwhelmed by their coverage, where should they start? What resources should they go to? I know Audrey mentioned SHIP and you have the Patient Advocate Foundation.

[Emily Brown] (18:40 - 21:45)

I think the most important thing to say up front is, you do not have to figure this out alone, and there is no wrong door to start with, but knowing which door will help you get the fastest answer does help. So in terms of when to contact Medicare directly, that is really going to be when your question is about the program itself. So are you eligible if you have questions about general benefits, how the different parts work?

If you think there might be an error on your account, you can call 1-800 Medicare 24-7. They're available all the time. And that's a really good first step for anything that's just about the program itself rather than your specific plan.

From there, it's a good idea to contact your insurance plan when the question is about your specific coverage. So if it's about a claim that got denied, whether a particular medication or provider is covered, what your specific costs are. That's when you need to reach out to your insurance plan directly.

And if you have a Medicare Advantage plan or a Part D drug plan, that plan, not Medicare itself, but that plan is actually who processes your claims and makes coverage decisions. So that is why it's important for you to reach out to your plan directly for anything that is more coverage-specific. And like Audrey brought up, there is SHIP, the State Health Insurance Assistance Program.

It is a fantastic program. It is one that I think a lot of people don't know about. As she mentioned, it's a federally funded program.

They offer one-on-one counseling to Medicare beneficiaries and their families. They aren't trying to sell you anything. They're not affiliated with an insurance company.

They really just want to help you figure out your coverage, compare plans during open enrollment. Figure out if you qualify for any financial assistance that might be available, basically just walking through your specific situation, and they are a great place to go if you're feeling overwhelmed. And for the Patient Advocate Foundation, we offer free case management assistance for people who have serious illness, including help with insurance denials, appeals, and access to treatment.

We also operate a copay assistance organization called Total Assist, which offers disease-specific copay assistance funds to help eligible beneficiaries afford copays, co-insurance, and any medical insurance premiums. And we also have a wealth of educational materials, including a new hub with a ton of open enrollment and Medicare content on PanFoundation.org. So, we have a lot of really great things to offer, as do, you know, SHIP and some of the other advocacy organizations out there.

[Arnelle Konde] (21:46 - 21:58)

Thank you, Bill, for sharing those resources. And before we get to our closing segments, I just want to ask, are there any topics or information that we haven't covered so far that you would like to discuss?

[Audrey Chavez] (21:58 - 22:35)

I just wouldn't say to be very careful with what you choose and know what your plan covers, because the patient's voice, the beneficiary's voice matters quite a bit more than the healthcare provider's voice. As healthcare providers, we will do the peer-to-peers, we will help you with the appeals, and we will help you with trying to get what you need. But if you call your insurance company and say, I am a beneficiary, my policy states that this should be covered, why are you denying it?

That goes a lot farther than all of our paperwork from the healthcare provider side.

[Arnelle Konde] (22:35 - 22:47)

Before we close, I'd love one final takeaway from each of you. So, Emily, as people are preparing to review their Medicare coverage for 2027, what are two things you want them to remember?

[Emily Brown] (22:47 - 24:28)

Two things I'd really want people to walk away with is, first, don't let open enrollment go by without checking to make sure that your plan still works for you. We've kind of said this over and over, but it's because it's really important. It's so tempting to sort of just let your plan roll over, especially if you haven't had any problems with it this year.

But as we've discussed, your drug list can change, your networks can change, your costs can change, and the plan that worked really well for you in 2026 might look different in 2027. So, even if you take 20 minutes to pull up your next year's plan details and check the pieces that matter the most to you, your medications, your doctors, your out-of-pocket costs. It's really going to be so beneficial to you and most likely save you money.

And I would say, secondly, you do not have to do any of this alone, whether it is calling SHIP for help, you know, comparing your plans, reaching out to an organization like Patient Advocate Foundation, asking your doctor's office or respiratory therapist's office for help. There are real people whose job it is to help you sort through all of this and feeling overwhelmed by Medicare, Medicare paperwork, the rules and regulations, all of that is not a sign that you're doing something wrong. It's a sign that the system is genuinely complicated.

So, that's really it. Just review everything before you renew and lean on the people who are there to help you.

[Arnelle Konde] (24:29 - 24:38)

Audrey, for someone living with CLPD or another chronic lung condition, what are two things you want them to remember when navigating their health care and coverage?

[Audrey Chavez] (24:38 - 25:43)

I think Emily said it great. You don't have to do it alone. You've got a whole team of people who are willing and wanting to help you.

That's why we get into health care is because we like people and we want to help genuinely want to help your, help you live your best life and have best quality of life. So, make sure you've got your list of medications, your list of doctors, any projected medical situations you think you're going to be in, are you going to have a joint surgery this coming year? Are you going to need to go to a rehab this coming year?

There are things that you won't know that are going to come up. But for the things that you can plan for or you can think, yeah, I'm probably going to have to get this hip done this year. You can put those all together, look through everything, ask for help, make sure you have somebody double-check it, go to the patient advocacy foundation, ask your pulmonologist's office, ask your primary care physician's office, make sure that you have the coverage so that you don't have to be scrambling when you need it.

Get yourself prepared.

[Arnelle Konde] (25:43 - 26:24)

Thank you, Bill, for those great takeaways. And as we close, I want all of our listeners to remember that Medicare can be complicated and navigating health care can feel even more challenging when you're also managing a chronic lung condition or any chronic condition. But as our amazing guests have shared today asking questions, reviewing your coverage and knowing where to go for help can make the process at least a little bit easier.

If this episode resonated with you, check out the resources linked in the episode notes and share this episode with someone who might find it helpful. Thank you again, Audrey and Emily, for joining us, and thank you for listening to the Lung Health Champion podcast.

[Disclaimer] (26:24 - 27:24)

Thanks for listening to Lung Health Champion. If today's episode helped you breathe a little easier, be sure to leave us a rating or review on Spotify or Apple Podcasts. It'll help the show reach other potential lung health champs.

If you have any questions about today's episode or have suggestions for topics you'd like covered on the show, feel free to reach out to us via email at share@COPDfoundation.org. For more insights on lung health, follow us on Instagram and Facebook by clicking the links in the show notes. For more info on what we do at the COPD Foundation, visit our website at COPDfoundation.org.

And don't forget to subscribe or follow the show on your favorite podcast app to make sure you never miss an episode as we continue to empower everyone to breathe easy. This podcast is for educational purposes only and is not a substitute for medical advice. Always consult your health care provider with questions about your care.