Thursday, October 22, 2015

IBM Medicare if you STILL have problems ...

I just read new comments by a few blog readers and it appears retirees are still having service problems with OneExchange.  I posted a couple of email addresses a long while ago that might be useful if you get totally fed up and want to contact some IBM executives.  I am putting them in this post to make it easier to find them.

Dr. Rhee at is in charge of the OneExchange program.  If that doesn't work, try his boss, Barbara Brickmeier as she is the VP of HR programs.  She is at

Saturday, October 17, 2015

IBM Medicare plan finder for 2016 Open Enrollment and Aetna transition

On Thursday, 10/15/15, the Fall Open Enrollment began for Medicare.  This is the time of year you can change to a different Medicare Advantage plan, original Medicare or a different part D plan. The changes must be made by midnight December 7, 2015 and are effective January 1, 2016.
A subset of  IBM Medicare eligible retirees were allowed to stay on the IBM Group Heath Insurance Aetna (HMO or PPO) for the last two years and didn't use OneExchange.  This year they join the club. The IBM Aetna plan is terminating at the end of December 2015 and the retirees must now deal with OneExchange to buy at least one health insurance policy (Medicare Advantage, Medigap or part D) before the end of the year to get their HRA.  I just helped someone who is dealing with this situation and it was a little unsettling.
What IBM did for this group of people is more than a little patronizing.  They automatically enrolled eligible retirees into a 2016 individual Aetna Medicare Advantage plan which includes prescription drugs and sent out new health plan cards. These are plans ANYONE in your zip code can buy if it's available.  There is no unique IBM benefit in these plans. She thought she had the same IBM Aetna plan and just was getting it through OneExchange.  I bet that is the norm. The new plan was not a good fit, particularly for her drug coverage, so we worked through some options and decided original Medicare with a Medicare Supplement and a separate part D plan provided better benefit. I highly recommend affected retirees scrutinize the new Aetna plan to be sure it provides the right coverage. Another aspect to consider is that Aetna will be merging with Humana. Customer service is likely to be a nightmare in 2016.
The words used in the IBM letter said the new Aetna plan was a "comparable plan" but did not include dental nor vision coverage. Comparable is such a nice, empty word. It's like saying two houses are comparable because they both have bedrooms and bathrooms.  If these retirees do nothing, from Medicare's perspective, they're enrolled in the Aetna plan effective January 1, 2016. Technically, those retirees would have until the end of February 2016 to select a new plan because they have a "Special Enrollment Period" (SEP) from Medicare if they hadn't been automatically enrolled. Maybe it was just a kind gesture? It would have been a risky choice for anyone to wait until January or February of 2016 to select a new plan and be uncovered until the next month. By being automatically enrolled, those two months of the SEP are now gone because they now have a 2016 plan. Maybe if they call 1-800-MEDICARE and demand to be dis-enrolled they will get the full SEP.  I don't know if that is possible.  I suspect IBM did the automatic enrollment to give OneExchange significant commission from Aetna because they will be the insurance agent of record for those automatic enrollments. They know many elderly people will not understand what happened and take no action. I wonder if it is legal.  The bottom line is make sure you get the plan you need and not the plan IBM decided you want. Your SEP gets a little complicated. I believe you have until the end of December to pick a new plan.  But, after December 7th (the Open Enrollment period end), I think you can only enroll one time in a new plan, meaning you cannot keep changing your mind after December 7th.
This Open Enrollment  I need to switch to a new part D plan for my spouse and myself for 2016.  My spouse's current PDP plan does not cover a new drug.  My plan provides the lowest price only if I go to a Walmart pharmacy, which is the preferred network pharmacy. It is nine miles away, in a busy city and the service leaves a lot to be desired.  I always find a reason to go to a non-preferred pharmacy two miles away and pay a higher copay! Obviously, it isn't a good plan choice for me.  The basic advice is chose a part D plan with the lowest total of annual premium and drug costs that meets your needs. 

My approach to choosing a new part D plan was to first use the plan finder on  I use that tool because it is the "official" Medicare plan finder.  If there is wrong information in the results from the federal government plan finder I can file a complaint with Medicare.  It also provides information on ALL the part D plans available in my zip code. OneExchange will only show part D plans that pay them commission (reminder - OneExchange is an insurance sales agent)! After deciding on a PDP plan, I went to OneExchange to see if they sold it.  It was on their list so that makes our part D switch easier since we can enroll through OneExchange and setup automatic premium reimbursement with one phone call.
If OneExchange did not have the plan, I would enrolled in the new PDP online at as there is an "enroll" link in plan finder.  If you don't like doing that then call 1-800-MEDICARE to enroll.  I do not recommend calling the insurance plan to enroll. They will likely try to up sell you to a Medicare Advantage plan and/or might enroll you in the wrong PDP or, worse still, a Medicare Advantage plan, by mistake.  It is misery to correct those problems because there is no easy way of proving it's wrong. They keep a voice recording of you agreeing to enroll.  If you enroll through Medicare it is far easier to correct any mistakes made by customer service.  As usual, be sure you make notes on the day, time and agent who helped you.  That's also true for OneExchange.  The new plan will send enrollment information within a couple of weeks.  Don't wait until late November to enroll.  Enroll early to make sure you got the plan you wanted and/or the information matches the information you saw online.  If not, you have time to correct it because you can enroll as many times as you want until December 7th.
I decided we will both enroll in the same part D plan because my spouse delegates insurance problem resolution to me!  His current plan wasn't particularly easy to work with and neither was mine. With both of us on the same plan at least I only have to learn one plan!  Oh, the joys of problem resolution.

Speaking of easy to use, the plan finder is not easy.  There is a lot of information but it is mostly designed for an experienced user.  Social workers and Medicare advocates navigate it very well.  The casual 65+ year old user experience is frustrating.  For example, it seems if you enter at least one drug even if you don't take any drugs (like Lisinopril) and select only one pharmacy in your zip code, plan finder will give you more information about plan choices and plan details. There is also some important "lingo" that you need to understand:

  1. Pharmacy networks
    How you fill prescriptions is an important aspect of choosing the best part D plan. Plans might have out of network pharmacies that will not accept your insurance plan, in-network pharmacies that will accept your plan but at a higher copay price, preferred in-network pharmacies that will accept your plan at the lowest copay price, and mail order pharmacies. Not all insurance plans use a network pharmacies structure. The plan status of a pharmacy you select will be displayed in the plan finder results.  Beware, the results you see may not show a plan's "lowest price" pharmacy unless you happen to select it. Before you enroll in a plan, find out which pharmacy offers the lowest price so you can do an accurate comparison of plans. If you cannot easily find it, call the insurance company and then run plan finder again with that pharmacy.  Also, it seems if you select more than one pharmacy, plan finder will show a subset of the plans available in your zip code which are best match to the pharmacies you selected. That's why I recommend only picking one pharmacy because it doesn't do that if you pick only one pharmacy.  I cannot provide logic for why and it is worthy of a complaint to Medicare. 
  2. Drug Tiers

    Drug tiers are categories that relate to prescription copay pricing. There are typically 5 tiers or categories for drugs. The higher the tier number, the higher your copay. Plans change the tier for a drug from year to year.  That's why it is really important to run plan finder every year to be sure you are getting the lowest price for your prescriptions. Each insurance company defines what their tiers mean and decide where to slot a drug. A drug might be tier 2 in one PDP and tier 3 in another PDP.  All the plans might put the drug into tier 2 but tier 2 can mean something different in each plan.  On the first screen for PDP results you will see a box that describes the deductible and the plan tier information in summary.  It isn't very helpful, doesn't say tier and looks like this:
        Drug Copay/ Coinsurance: $1 - $4, 20% - 35%.     
    The interpretation for that line is tier 1 & 2 drugs copays range from $1-$4, tier 3-5 coinsurance ranges from 20% - 35%. Really clear, right?  To see a plan's definition of tiers you must enter a drug (even if you don't use drugs).  Click on the plan name and go to the screen showing the details of the plan and the cost of the drug. Scroll down to find a link that is titled "View Drug Benefit Summary" (it is after the bar chart of drug costs) to get tier details. The detail will also help you better understand the plan's pharmacy network structure. I made a copy of a couple of tier structures for 2016 as examples:
  3. Drug Formulary
    The drug formulary is the list of drugs the plan will cover.  It's really important to find out if a drug is covered.  The plan finder results show with a "yes" or "no" as to whether all your drugs are covered by a plan.  Even if the plan shows a "no", in the details of the plan, the results will include the cost of the uninsured drug in the total yearly cost calculations.  It was designed to be helpful but I think it is confusing. You can apply a filter (on the left side before clicking to see plan details) to only see plans that cover all your drugs.  If you decide to use a plan that does not include your drug on its formulary, the cost of that drug will not count in calculations for doughnut hole computations.  That means you'd exit the doughnut hole only based on cost of drugs that are covered by your insurance plan.
Do not get distracted by which plan has a deductible and which doesn't.  It is sort of irrelevant.  The two most important factors are making sure your drugs are on the plan's formulary and the total annual cost of the plan for each kind of pharmacy. Usually mail order pharmacies are cheapest for 90 day supplies. But not always. The second example above is a plan that has the same pricing structure for retail pharmacies and their mail order preferred service.  If you use another mail order service (a non-preferred mail order service) your cost would actually be higher than getting supply from a retail pharmacy!
Medicare automatically saves the prescription information you enter on plan finder anonymously to enable you to retrieve the list in a subsequent session.  The id and password to retrieve your drug list will show on the upper right side of the drug entry page.  Retrieve the list by entering the id and password on the drug entry page the next time you use the tool. If you make changes note the new id and password for the changed list. They'll save those lists for years.  The trick is for you to remember where you recorded the ids and passwords!

If you have prescription refill scripts with your 2015 PDP pharmacies and the new plan has a new pharmacy network,  at the end of the year (while you still have the old plan) ask the new retail or mail order pharmacy to contact the old retail or mail order pharmacy to have them transferred so you will have them available in January 2016 without having to ask the doctor for new prescriptions.

If you want to learn more about Medicare's plan finder there are helpful videos on the right side of the plan finder screen.  There are also some scenarios available to practice.  I tried those and did not find them particularly helpful but maybe I am missing something. There are 5 case studies with different situations and a link to the training at:
Happy Open Enrollment!



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.  
Update 10/29/15: Congress continues play with Doctor fees in the latest budget bill.  As usual, it is a "small negative item" in a big budget agreement that has a lot of pluses for Medicare and Social Security in particular and a great deal of good for the functioning of government overall.  It's the small negative that is irksome and unlikely to get a lot of attention.  Unfortunately, it is another reason doctors will decide to "opt out" of treating Medicare patients.  I've written before about the 2011 "sequestration" cuts that affected almost every government budget including Medicare that was part of a 2011 budget bill.  The cut for Medicare was a 2% fee reduction for medical services that was applied to the part of payment Medicare makes to providers.  What happened after that bill passed is easiest explained by way of example.  If the Medicare approved fee for a particular service was $100, Medicare would pay $80 and the patient would pay $20.  The 2011 bill provision cut the Medicare part by 2%, meaning Medicare paid the doctor $78.40.  However, the patient still has to pay the $20. 
The sequestration cut was supposed to expire in 2021, but Congress kept extending the expiration date such that it was pushed to 2024. Who even knew they were doing those extensions!  This new bill pushes the expiration of Medicare sequestration to 2025.  It's no wonder doctors want to stop treating Medicare patients.  What they are more likely to do is shift more cost to the patient.  As a remedy, the doctors can  charge a fee above the Medicare approved amount.  They can charge up to 15% more than the Medicare approved amount.  The 15% is called a limiting fee or an excess fee.  Guess who gets to pay that "excess"?  The Medicare patient, unless they have a secondary insurance policy that will cover it.  Not many of the medigap policy types  cover it - a few expensive policies do.  Sometimes, retiree secondary insurance will cover it.  Meanwhile, the fee schedule for procedures has not increased in years so even if sequestration expires and doctors start charging the limiting fee maximum, they will either do more factory style treatment or will walk away from treating seniors. Slowly, gradually, Medicare insurance is less and less a wonderful benefit for elders in our "Great Society". 

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).