Sunday, October 4, 2015

IBM Medicare OneExchange - Over 65 COBRA coverage

I recently had a conversation with a Medicare counselor and realized, once again, how difficult it is to understand Medicare rules as relates to employees who are currently working, are over 65 and think they about to be let go from the company (aka part of a "resource action").  Even the counselor got it wrong.
As long as you continue to work for IBM and it has more than 100 employees (which might become an issue if resource actions continue), your primary health insurance coverage is provided by IBM Group Health Insurance (GHI).  When you turn 65, I recommend you call Social Security and enroll in Medicare part A (hospitalization insurance) because it is "free". You can do this any time.  Medicare part A insurance will act as secondary insurance to IBM GHI and likely offer no benefit.  However, there may be times when it provides extra coverage.  For example, it might cover an "in-patient" procedure where your GHI might only cover the procedure as "out-patient".  It also is good to do it because you'll be "in the system" and it will be easier to enroll in part B when you are terminated or decide to stop working. There is rarely any benefit to enrolling in part B and paying the part B monthly fee.  Enroll in part B before you stop working if you know for sure you are going to be terminated and you want to guarantee there are no hiccups within various enrollment systems when you are no longer working.
The day you stop working is the day your Medicare part B and part D insurance must be active (UNLESS your spouse is still working and can add you to their insurance) to have continuous coverage. At that point, all insurance companies consider Medicare to be your primary insurance - even if you did not enroll.  This can be really confusing because often, as part of your severance package, you will be offered a COBRA.  When you stop working and you are Medicare eligible, COBRA is SECONDARY INSURANCE.  In fact, it is very expensive secondary insurance. Unfortunately, insurance companies don't bother to look at your age and tell you that.  As long as you stay well, the insurance company will likely cover your doctor services as if it is primary insurance.
IF YOU GET SICK and the bills start to pile, the insurance company will typically review your file, look at your age and then send you a letter telling you - WHOOPS - they are a secondary policy since you are Medicare eligible.  Sometimes they even claw back payments to doctors and hospitals that they have made. When people complained, they sometimes return paid premiums rather than agree to not do a claw back.  It can be a financial nightmare.  Unfortunately, there is nothing illegal about selling you a COBRA plan because, as I said, it is secondary insurance.
There is another awful aspect to the COBRA nightmare for people over 65.  The day you stop working you'll enter a Medicare enrollment period called a Special Enrollment Period.  You have 8 months to enroll in Medicare and not be slapped with a penalty when you do enroll.  If you have a COBRA that is an 18 month COBRA and you don't know the rules, you could face a 10-20% part B premium penalty FOR LIFE depending on the time frame of that 18 months.  More importantly, depending on the time frame, you might have to wait until January of the next year to enroll in part B and your coverage will not begin until July 1st of that year.  
Sometimes people decide just to pay for part B when they turn 65 rather than have to deal with any of these problems.  That is quite a bit of overkill.  I recommend enrolling in part A, and the day you are told you "might be terminated" call Social Security and enroll in part B.  The day you are terminated, call OneExchange and buy a part D, medigap or Medicare Advantage plan from them so you can get your IBM health benefit subsidy.


Thursday, October 1, 2015

IBM OneExchange Medicare - the "Doc fix" law and Medigaps

I embedded this topic as a sidebar in another post but realized yesterday when I was working with some Medicare counselors to help people figure out their Medicare options that even they did not know what Congress did when they passed the "Doc Fee Fix" law at the end of March 2015 so I decided to make it a separate topic.
In case you don't understand the basis of this law, here's some background.  Skip this paragraph if you know about the 2003 law.  In 2003, a law was passed to implement a Medicare fee formula that would reduce a doctor fee for services a little bit each year to "reduce" Medicare costs. Each year, doctors would threaten to opt out of treating Medicare patients and each year Congress would temporarily postponed the implementation of the law.  By 2015, doctor fees would have been reduced by 21%. This got the attention of many doctors who were seriously going to opt out of Medicare - hardly a good thing for a senior population that is rapidly increasing as boomers age.

Finally, in March 2015 Congress permanently eliminated that formula by repealing the 2003 law. However, there was, of course, a lot of horse trading among congressional constituents to make it happen. There were other things embedded in the new bill (H.R.2) to appease various factions.  For example, legislators included a provision to eliminate Medicare Supplemental plans (medigaps) that are "first dollar payer" plans beginning 2020. One medigap plan that does first dollar pay is the "F" plan. It carries a hefty premium but if you have original Medicare and an "F" plan you never have to pay a bill if a procedure is covered by Medicare. 
Congressional representatives believe people who have such plans "go to the doctor more" and thereby cost Medicare more money.  While it is probably true a small percentage of people who have such plans go to the doctor more, the root cause is likely because they are sicker.  Maybe that's why they buy those plans which, as I said,  are the most expensive plans.  But no one in Congress is doing root cause analysis nor reading position papers to find out if their hypothesis is correct.  Our legislators just decided those plans cater to people who are hypochondriacs.  There probably are some.  But the notion that a large number of people buy "first dollar pay" plans to be able to frivolously use doctor services is not true.  Who wants to go to the doctor?  As a sample of one, I sure don't. 
More interesting still, Congress did this to individual Medicare Supplement plans but did not make the same demands on companies that provide secondary group insurance to Medicare eligible retirees (as IBM once did) nor did they make the same demands on Medicare Advantage insurance  providers.  If first dollar pay plans are bad, why aren't they bad across the board?  It makes no sense. But then, it is Congress. Here's a thought - do they really just want  to privatize Medicare?  I'll leave it to you to figure out who the "they" are.
How does this impact you?  If you think you want a medigap "first dollar pay" plan then buy the insurance plan before 2020.  There are no guarantees, but typically when Congress eliminates a Medicare supplement plan type (as they did for J plans) they grandfather people who already have it so they can keep the plan. It is possible the insurance companies will decide to terminate those plans and then you're out of luck.  But, my bet is, they will just keep increasing the premiums until the plans are no longer worth having.  Once again, I think the only recourse we have  to stop Congress from mucking with Medicare is to work through organizations like AARP to create as strong a lobby as possible to influence Congress to treat seniors better.  Of course, if congressional representatives were forced to use Medicare just like the rest of us, none of this would happen at all.

Tuesday, September 29, 2015

IBM OneExchange Medicare Reminders - OneExchange insurance offerings

If you are on Medicare (meaning you are over 65 and are retired from IBM) you probably got an email from OneExchange about Medicare's open enrollment which is October 15 - December 7. This enrollment period is dictated by Medicare and happens every year.  It is the time of year to analyze whether your Medicare part D insurance (for prescription drugs) and/or your Medicare Advantage insurance (for those not using original Medicare) still match your needs and, if not, to switch to new insurance coverage to begin in 2016.
Reminder: Medicare open enrollment DOES NOT apply to Medicare supplement insurance policies (aka medigaps).  The rules for when or if you can change to a different medigap policy are determined by where you live (the state).  For example, in California you can change 30 days starting with the day of your birthday but there may be a preexisting condition coverage waiting period of up to 6 months.  In New York, you can switch medigaps any time and the change will be effective the beginning of the next month. In other states there is no change window and you are at the mercy of the insurance companies to decide if they want to sell you a policy. There have been many requests to Congress to federalize medigap enrollment but so far it has fallen on deaf ears.
Reminder: OneExchange is an insurance agent.  They sell Medicare insurance policies that pay them commission.  They do not sell all the Medicare insurance policies that are available for to you to buy. Buying insurance from OneExchange is like buying a car from a Toyota car dealer.  They are only tell you about what they sell.  HOWEVER, you must buy one heath or drug insurance policy (Dental and Vision insurance doesn't count) from OneExchange to get your IBM health retirement benefit. .  For example, if you bought a medigap policy you qualify for your subsidy.
Reminder: Go to  beginning on October 15, 2015 and use "Find a Plan" to see the complete list of insurance policies available for you to purchase in your zip code.  Insurance companies decide what policies to sell by zip code demographics because the "younger" the Medicare eligible population the better.  It's akin to insurance companies that sell flood insurance in locations that do not flood.
Reminder: Part D and Medicare Advantage insurance companies change their policies from year to year. They add or remove drug coverage to formularies or change tier pricing. They change pharmacies. They add or remove doctors from their network (Medicare Advantage plans). They change co-pays.  Read all the literature your existing company sends to you.  Frequently the literature will say "we changed our pharmacy network".  That's all they legally have to do to notify you of a change.  You have to then figure out the details.  Call them  and go to  to see what they changed.

Sunday, September 27, 2015

IBM OneExchange Medicare Budget Cuts to Federal Support Services for Seniors

Every day, about 10,000 boomers turn 65 and become eligible for Medicare.  What is the federal government's response to this tsunami of seniors?  Congress keeps cutting support programs to help seniors through the transition.  There has been a drastic reduction in the number of local Social Security offices in the last 5 years.  There now is a push in congress to further reduce the funding of State Health Insurance Assistance (SHIP) offices.  Every state has SHIP which was put in place to help people understand state laws for things like Medicare Supplement policies, structures of Medicare Advantage programs and requirements for low income support programs.  The Senate Appropriations Committee recently suggested a 42 percent cut in funding for SHIPs—from $52.1 million to $30 million.
The SHIP program is a network of over 3,300 local SHIPs with more than 15,000 trained counselors that provides one-on-one assistance and health care education for millions of people with Medicare. Between 2005 and 2014 SHIP assistance has increased 270 percent, from 1.2 million people assisted in 2005 to 3.4 million in 2014. If funding were reduced by 42 percent, about 1.5 million fewer people would receive assistance.

The funding for SHIPs is already less than it should be. Since fiscal year 2011, SHIP funding has not kept pace with inflation and has not accounted for the increase in the size of the Medicare population. If it had, then funding for fiscal year 2016 would be about $62.8 million. In addition to urging Senators to reject SHIP funding cuts, tell your Senators that even if the spending stays the same it is still about $12 million short of the preferred $64 million after adjusting for inflation and the increased number of people who have Medicare.
These kinds of program cuts are not widely understood by the general population.  Tell your friends what Congress is proposing to do to reduce help for seniors.

Sunday, August 9, 2015

IBM Medicare OneExchange Medicare and custodial services coverage

For a number of years, I have been a volunteer with the Medicare Rights Center. From time to time I handle a call from the son or daughter of an elderly person with early dementia who is being release from the hospital after a fall or medical problem.  The caller always feels the patient is not ready to be release back home because of both their mental and physical condition. They want to know how to stop the hospital from releasing the patient. These calls are really difficult because there are no quick and easy answers to offer. The answer starts with a rather flat statement.  Medicare does not cover custodial care aka long term care.  If the patient is physically able to walk a few steps, has no other treatable medical problems, and the doctor does not prescribe any physical therapy then the hospital is going to release them.
This is the kind of situation that requires advanced understanding of Medicare coverage otherwise the caregiver will use the wrong words when appealing to the doctor, the hospital, and Medicare.  If they talk about the dementia, they will be told Medicare does not cover custodial care and appeals will be denied.
What does Medicare cover?  Medicare covers remedial care.  That is, Medicare covers rehabilitation. That can be provided in a Skilled Nursing Facility (SNF) or as an outpatient.  The purpose of remedial care is to stop the patient from getting physically worse.  It used to be that the patient had to improve. Those Medicare rules were changed about a year ago.  Knowing about Medicare remedial coverage can provide the right words to goad the doctor, hospital and Medicare into transferring the patient to a SNF and might give the caregiver some time to determine next steps as well as improve the patient's stamina.

The right words need to revolve around physical condition.  That means, in a case where the patient is elderly, the words need to be about how the patient's strength has waned from being in a hospital bed and how they need physical therapy to regain their strength before they return home or they will risk injury.  Those words are really important to use if the caregiver must do an emergency appeal to Medicare to stop the hospital from releasing the patient. The case to be made is the doctor and hospital are doing an inadequate job assessing the patient's strength and ability to walk. Risk of injury is also important to say.  DO NOT use ANY words about cognitive problems aka dementia. There is no rehabilitation for dementia.  Dementia falls into the category of long term care.

This is only a temporary fix to buy time.  The caregiver needs to do advanced planning regarding custodial care. Many people make arrangements for the elderly person to reside with them.  If that is not an option, then it may be time for a nursing home. The only private insurance that covers nursing home costs (which are substantial) is long term care insurance. The older a person, the more expensive the insurance premiums. Even for younger people, the premiums are substantial.  Medicaid is the only government insurance that provides custodial care but eligibility is limited to low income people with few assets. The rules for Medicaid vary from state to state.  In New York, if a person is low income (less than $1000/month)  and has few assets they might be eligible for Medicaid.  New York also has a program called Medicaid spend down which allows expenses for medical treatment to be subtracted from a person's income to determine Medicaid eligibility.  If the person qualifies for Medicaid, they are eligible to go to a Medicaid nursing home.  However, government budget reductions have caused the services in Medicaid nursing home facilities to diminished in recent years. It was never stellar.

AARP and other organizations are lobbying congress to include custodial care coverage in Medicare or provide people with the ability to buy into Medicaid because by 2020 about a third of our population will be over 65.  Given the current congressional opposition to the Affordable Care Act, it's a long shot. Petition your legislators if you believe more government remedies should come into play to help the elderly population deal with long term care costs.

There are no easy options for custodial care.  But knowing the right words to say if you encounter the described situation might provide you some short term relief while you consider your options.

Saturday, August 8, 2015

IBM Medicare One Exchange Fall Enrollment for 2016 Medicare Insurance

Although it is early to start thinking about Medicare insurance coverage for 2016, the Medicare Advantage insurance providers will soon start flooding our mailboxes with  advertisements.
The literature companies send out in August are typically generic descriptions of their plans.  The details for their 2016 offerings won't be "officially" available until  September.  However, it is also the time when notifications are mailed for discontinued plans and/or plan modifications (such as prescription drugs no longer being on a plan's formulary or premium increases) for your current plans.  It is easy to get inundated with marketing information and overlook important plan notifications. Make sure to read everything you get in August and September from your 2015 insurance plans.  People frequently overlook formulary changes, health plan changes and discontinuation notices that will affect their 2016 coverage. 
Before the barrage of information hits, take some time to look at the pros and cons of your current health and prescription drug coverage.  If you are dissatisfied with the cost of your coverage based on premiums, copay/coinsurance or formulary coverage - it's a good time to consider what kind of coverage you want in 2016.
The insurance policies you are able to buy in 2016, as a Medicare recipient, are offered by zip code and will be listed in starting October 15, 2015.  You'll have until December 7, 2015 to chose and enroll in a different plan. After December 7th, you will not be able to change your coverage again until October 2016 for January 2017.  The one exception to that is if you want to switch from a Medicare Advantage plan to use original Medicare.  You can do that from January 1 - February 15. But there are a lot of other implications to doing that so it is not an easy switch. None of this applies to people with Medicare Supplemental plans (aka medigaps).  The rules for when and if you can change a medigap policy are determined by your state.  Contact your State Health Insurance Assistance Program (aka SHIP) to find out those rules. The phone number can be found at
The Medicare Advantage and part D insurance companies always offer their policies based on zip codes.   If you have friends in other states or even in other counties in your state that rave about their policies, it may not help you decide on a plan because their policy might not be available in your zip code.  Also, don't forgot, the insurance policies offered through OneExchange are a SUBSET of the insurance polices you are able to buy in your zip code.  That's really important to remember.  For example, if the OneExchange prescription drug insurance policies do not provide coverage for the drugs you need or the cost of your drugs is high, look at the Rx insurance policies listed on or call Medicare (1-800-MEDICARE) to look for a less expensive Rx policy. You only need to buy ONE policy from OneExchange to be able to get your IBM HRA funding.  You do not need to buy all your Medicare insurance from OneExchange.
If you feel your 2015 insurance policies provide good coverage AND the insurance companies do not make significant changes to those policies for 2016 then there is NOTHING to do with either Medicare or OneExchange to continue coverage and get your IBM HRA in 2016.  
If you think it is time for a change then do some research and figure out your options. Do this yourself, don't rely on an insurance agent. That's like going to a Ford showroom and expecting a sales person to tell you about Toyota. Like OneExchange, insurance agents sell a subset of insurance policies you are able to buy. If you have original Medicare, a change you might consider is to switch to a Medicare Advantage plan.  Remember, once you go to a Medicare Advantage (MA) plan you trade a national coverage plan for a zip code based plan.  You also need to do a thorough job of looking at cost sharing for an MA plan. The insurance companies usually do not tell you about all the aspects of cost sharing unless you ask.  For example, ask them what is the copay for an out of network specialist or an ambulance. That might give you some insight of the true cost of their policy. Even better, ask for a complete schedule of cost sharing. Reputable companies will provide it.  Most importantly, make sure the doctors you want to see are included in the insurance policy network.  In October, look online at or call 1-800-MEDICARE to be sure your drugs are still covered by your plan and that you are not overpaying for your drugs. 
So, get ready - fall enrollment will be here before you know it!



Tuesday, July 21, 2015

IBM Medicare OneExchange Reimbursement for Opt-Out Doctors

I wrote about this a while ago but thought it was worth another posting because it continues to be an area that is annoying and there is no place that I found on OneExchange's site to tell you what to do.
Last week I submitted two paid bills from a doctor that does not accept Medicare.  That is, the doctor has chosen to "Opt Out".  He doesn't submit his bills to Medicare for processing (and denial) and my supplemental insurance is a standard medigap so it will not cover anything that Medicare will not cover.  Sometimes retiree secondary insurance provided by companies (yeah, there are still companies that still provide group plan coverage) do cover procedures not covered by Medicare such as acupuncture.  These insurance policies often want the doctor bill to be processed and denied by Medicare before they will pay for the services. We lost that kind of coverage when IBM threw us over the wall to OneExchange but if you have a spouse who covers you with that kind of insurance, there is a way for you to submit the claim to Medicare yourself.  The directions are on
I don't often go to opt-out doctors so I didn't submit the claim the exact way OneExchange wants it done.  Of course, they denied my claim.  They said I had to submit an EOB from my insurance company with the bills.  That's really clear direction!  What they want to see is how much the insurance company had paid because I wasn't clear on the OneExchange claim form that this was an opt-out doctor service.
A digression: an EOB is an Explanation of Benefits statement that comes from a private insurance company.  OneExchange is assuming, by using that phrase, that I either bought a Medicare Advantage policy or I have original Medicare and bought a secondary policy.  Neither might be true and, as a claimant, I might only have original Medicare coverage.  If so, then the only thing I'd receive is an "MSN" or a Medicare Summary Notice, which is the original Medicare statement that is sent quarterly from Medicare.  OneExchange uses "EOB" even when they mean "MSN". 
Back to the topic of the blog post.  There are no directions anywhere from OneExchange on how to submit an "Opt-out" claim. Here's what to do:
  • You need a bill from the doctor that is marked paid in full.
  • You need the receipt for that payment (credit card or check) so do not pay the doctor in cash unless they can give you a separate receipt with your name on it! If you paid from an account, you must prove the payment is from an account that belongs to you so be sure there is some identification on the statement you provide that names you as the payer. I ran into this because when I print out my credit card transactions there is no owner name on the print out for a single item.  What I do now is make a copy of my credit card, black out all the numbers but the ones that match the print out and submit the card image with the claim to prove it was from my account.
  • You have to write on the OneExchange claim form that the doctor has opted out of Medicare. For extra measure, I also write it on the doctor's statement.  
I forgot to write the opt-out information on the claim form (I only wrote it on the bill).  So, of course, I had to resubmit the claim. 

For most of this year submitting claims to OneExchange has been less irritating for me that last year.  Nonetheless, it is still annoying.

Saturday, June 13, 2015

IBM Medicare OneExchange Original Medicare Out of Pocket Costs

I decided to try to decipher a bill I received yesterday from a provider.  It is almost impossible figure out how something is billed, why Medicare paid what they paid and what is due from the patient. It took me a couple of hours but I finally understand the bill.  I went back and forth between my MSN statements, my medigap EOB statements and the provider bill (which was particularly unintelligible).
The complicated Medicare billing is brought to us by CONGRESS!  They set the fee structure and they regularly fool with it.  Remember the ugly spate of legislative activity in 2013 that resulted in sequestration?  That resulted in a 2% reduction in provider payments. However, it did not change the patient coinsurance payment.  The easiest way to explain this is by way of example.  Suppose the Medicare approved doctor fee for a service is $100.  Prior to 2013, Medicare part B would have paid the doctor 80% of the fee or $80 and the patient would pay 20% of the fee or $20 (assuming the doctor accepts assignment).  HOWEVER, because of the 2% reduction from sequestration, now Medicare pays the doctor 2% less (on the $80) or $78.40.  MEANWHILE, the patient still owes the doctor $20.  So, when you get a bill from the doctor that shows how much Medicare approved, how much Medicare paid and how much you owe thank your congressional representatives for making it almost impossible to understand.
I know I keep harping on how congress niggles with Medicare but it is so important to all of us to know how this Medicare piggy bank keeps being raided.  I just read something about how the TTA (Obama's fast track trade) bill tried to imbed another cut to Medicare providers buried in the bill to pay for the cost to implement it.  There was going to be another 0.25% cut to providers.  Happily, the house voted to remove that provision. But it was only after the medical community raised a stink.  In an earlier post, I mentioned that resident doctors are paid salaries out of the Medicare budget.  Everyone benefits from the services of these beginning doctors.  Meanwhile, legislators scream about the high cost of Medicare.
Back to the topic of the blog - patient out of pocket costs in original Medicare.  Congress structured a payment process that varies between coinsurance and copayments.  Once again, it couldn't be more confusing.  What's the difference?  One is a percentage (coinsurance) and the other is a fixed amount (copayments).  Most of the time copayments are used for outpatient hospital related services and coinsurance is used for doctor related services.  Again, an example is the easiest way to explain it.  Suppose you have a cast on your arm.  If you go to the hospital as an outpatient to have the cast removed, you will pay a copayment.  So, if the hospital fee is $150 to take the cast off, your copayment might be $40.  The amount of copayment depends on the city where the hospital resides.  If you go to a doctor, it's an office visit so the service fee is likely to be less.  Let's say it's $100.  Your payment would be a coinsurance of 20% or $20.
Generally speaking, it is more expensive to have a service rendered by a hospital than by a doctor. But not always. The obvious case of WAY MORE EXPENSIVE is using the emergency room for services.
Medicare has a wonderful publication that describes original Medicare costs.  It came from the site:

It's also important to remember original Medicare has no cap on out of pocket costs.  The only way to get an annual cap on out of pocket costs is to either buy a medigap plan or buy a Medicare Advantage plan.  This year I have been using a medigap K plan to have a cap on out of pocket costs.

If you are using a Medicare Advantage plan none of the rules described in the above publication apply.  Medicare Advantage plans are required to cover the same services as Medicare and are required to stay within Medicare's fee schedule. However, they can restrict who provides the services, pay providers less than the Medicare approved fee, and/or shift more of the fee burden onto patients.  Demand to see their cost sharing breakout for all procedures.  They are famous for having low copayments for primary care doctor and freely disclose those payments in marketing literature.  But when you step into the land of a specialist or an emergency they often shift to coinsurance payments and/or very large copayments (such as for ambulance services).  They can also change cost sharing from year to year so each year ask for the cost sharing terms. The government caps Medicare Advantage policy holder out of pocket costs to about $5000/year (which is the cap in my K plan).

Friday, April 24, 2015

IBM Medicare OneExchange - A Medicare Tutorial by Kaiser Foundation

The Kaiser Foundation is a great resource for information about Medicare.  The foundation regularly issues reports and statements about Medicare ranging from its history, how it works, who uses it and how much it costs.  They also regularly issue position papers to Congress to try to guide legislators to make informed decisions about Medicare.
For example, legislators have embedded in a recent law, H.R. 2 aka the "Doc Fix" law, a provision to eliminate Medicare Supplemental plans that are "first dollar payer" plans.  Congressional representatives decided people who have such plans "go to the doctor more" and thereby cost Medicare more money.  While it is probably true a small percentage of people who have such plans go to the doctor more, the root cause is likely because they are sicker.  Maybe that's why they buy those plans which are substantially more expensive.  But no one in Congress is doing root cause analysis nor reading position papers to find out if their hypothesis is correct.  Our legislators just decided those plans cater to people who are hypochondriacs.  There probably are some.  But the notion that people buy "first dollar pay" plans to be able to frivolously use doctor services is not true.  Who wants to go to the doctor?  As a sample of one, I sure don't.  Kaiser Foundation did advise Congress it was not true.  Congress chose to ignore them.  Amazing.
Anyway, the following report, issued in March 2015, by Kaiser is very comprehensive.  It covers the history of Medicare, an analysis of the users of Medicare and the impact of the Affordable Care Act.  It is a long report but I urge you to read it and become educated about Medicare because there is so much misinformation in the media.  This report will help you separate fact from fiction and maybe even be inspired to push your Congressional representatives to act on real information instead of hypothesis:
I also urge you to pay close attention to what legislators do to Medicare because the changes are subtle and buried in bills like H.R. 2.  Remember, if a representative stays in office for five years they get federal health insurance coverage for life and don't use Medicare.  They have no vested interest in keeping Medicare robust. My hypothesis is majority legislators are taking a back door approach to privatizing Medicare. This "first dollar pay" legislative change did not apply to Medicare Advantage plans.  If it is bad then it should be bad for any insurance plan.  Why not restrict Medicare Advantage plans from doing it?   Do they want to push people to Medicare Advantage plans?  As more people use Medicare Advantage plans, the original Medicare insurance pool will shrink until it becomes unaffordable for the federal government to maintain as an option.  Is there is a slow drum beat to reduce Medicare insurance coverage by pushing seniors into private "managed care" insurance coverage? 

Sunday, April 12, 2015

IBM Medicare OneExchange - Medicare information resources

Medicare is complicated.  Medicare is constantly changing.  Changes are usually small but can have a big impact.  Some changes are great such as the gradual closing of the doughnut hole because of the Affordable Care Act (aka Obamacare).  Some changes aren't really changes, they are just sudden enforcements of existing law. Nonetheless, these changes are confounding.  One example is the current Medicare push to enforce drug denials for "off label" drug usage. There are no easy ways to find out about policy changes.  AARP sometimes will highlight a change in their publications.  But, typically Medicare recipients don't find out about them until they encounter the situation.
I volunteer on a help line at a non-profit organization called the Medicare Rights Center (  Recently, there have been a number of calls regarding the "off label" denial issue.  My normal inclination is to suspect the insurance companies.  However, in this case it is the Medicare administrative arm - CMS that issued instructions to insurance companies to do the denials.  When part D legislation was passed into law in 2003, the insurance rules for drug coverage stipulated drugs are covered only for FDA approved conditions. The reason Medicare cares about what is covered is because Medicare subsidizes the insurance companies.  For example, there is a pain alleviation drug called Lidocaine and it comes in patch form.  It was approved in 1999 by the FDA to treat pain associated with shingles. However, doctors often prescribe it to help with muscle pain.  That's an off label use.  A woman called who had been using the patch for five years for back pain.  Suddenly, her part D plan denied coverage.
There was no explanation in the denial notice about why this drug was suddenly denied beyond "not medically necessary".  There is also no point in appealing the denial (unless the off label use is related to a cancer treatment - then Medicare is more flexible) since it is Medicare enforcing the off label restrictions - not the insurance companies.  If you want more information about off label drug use rules in Medicare here is a link:
 Unfortunately, doctors are as clueless as patients about an enforcement until they encounter it.  Sometimes there are workarounds.  For example, if you use a doctor that does not accept Medicare and that doctor orders a lab test at a lab that will accept Medicare,  the test will not be covered by your Medicare insurance because the origin was from a non-participating doctor.  The enforcement of this rule started a couple of years ago.  Non-participating doctors now work with doctors who do accept Medicare to ask them to submit lab tests so that it will be covered.  It's crazy to me to force people to only go to Medicare doctors for everything but that's how the law was designed. 
The Medicare Rights Center has a great information data base you can search at  but it is unlikely you will find this type of information.  I suggest when you encounter a baffling denial, call the Medicare Rights Center (1-800-333-4114) because they will know what is trending.  They also have a great subscription (free) newsletter that often highlights these trends.

Of course, you can also always call 1-800-MEDICARE to ask questions.  Did you know --- the Medicare helpline is available 24 hours a day, 7 days a week? The best time to call is late at night or early in the morning.  I suggest you use the rule of 3 when you call Medicare.  What is the rule of 3?  Call 3 different times to ask the same question.  Medicare call center agents highly vary in capability.  It's not as bad as OneX.  I am not sure that's a compliment.
Finally, if you think the Medicare "rule" is unfair, complain to your congressional representative.  Tell them, if the rule is so great, why aren't they required to use Medicare when they retire from congress. Retired congressional representatives get federal health insurance coverage for life if they have been in congress at least five years.  That's actually less then the eligibility for Medicare, which requires 10 years of work.   Also, support AARP.  It is a powerful resource as a Medicare lobby organization.