Wednesday, April 9, 2014

IBM Medicare and OneExchange - Know Your Rights

Several months ago IBM mailed out a thick manual titled "About Your Benefits: Post-Employment Summary Plan Description". The terms of this document were effective January 1, 2014.  THIS IS AN IMPORTANT DOCUMENT.
Most of what is in that manual is not applicable to IBM Medicare eligible retirees and you may have not bothered to even open the manual. However, there are several sections that are very important to Medicare eligible retirees.  Start from page 165 and try to read all the way through to the end of the manual. 
In the Legal Information the manual describes the appeals process if you claims are denied by Towers Watson.  It's important to know that process because there are timelines associated with appealing denied benefits claims.  Basically, it is a 60 day window from the time of denial for you to appeal. 
In the world of Medicare - it is also important to know the appeals process for all your claims handling.  If your insurance denies a claim there are also timeframes within which you must appeal or you can be denied again just based on the fact that you appealed "too late" even though your appeal was improperly denied and you would have succeeded in overturning the ruling had you done it on time.  Timeframes depend on the kind of insurance you have - Original Medicare or Medicare Advantage.
The net of this post is that we now have to know the process of how to appeal when an insurance company denies a claim - Towers Watson does not handle that.  And we also have to know the process of how to appeal when Towers Watson denies a reimbursement. 
Each time a claim is denied by an insurance company they are required to legally tell you the process.  The same does not apply to Towers Watson denying reimbursement claims. Dig out that IBM manual and put it in a place where you can reference it so you know what to do if you have a problem with Towers Watson claims. 

Saturday, February 1, 2014

IBM Medicare OneExchange - Use the email address

4/6/14 - I edited this post because of the name of the health insurance service Towers Watson provides as an IBM contractor for Medicare eligible retirees is now called "OneExchange" instead of "Extend Health". Originally, we were told they would use the name Towers Watson in 2014 but then they change the name of their "heath exchange" services department to OneExchange a couple of months ago. It amazes me how hard they work to keep things confusing.  In the future, I will use "OneExchange".  I also edited the text of this post to try to reinforce this name change in our brains. 

Towers Watson setup the email address (it used to be specifically for IBM retiree issues.  Maybe if we use this email address as the way to resolve problems and/or to describe Extend Health OneExchange interactions, IBM will be able to get an accurate picture of the issues we encounter.  I don't have a clue whether IBM does look or even cares about the service we are receiving from OneExchange.  I will guess it is low on their priority list.
Towers Watson's OneExchange is providing services to many companies - not just IBM.  Remember the original flyer that said they are supporting over 500,000 retirees. So, when you call you are just a member of that large client pool serviced by their agents. They record the call because they are insurance agents and, by Medicare law, they are required to keep accurate records of their client interactions but the likelihood that IBM will listen to our calls is low probability.
Towers Watson acquired Extend Health a year or so ago to get into the "health exchange" business so in addition to the name change to OneExchange -  there is also likely a consolidation going on within that superstructure.   I also keep putting "health exchange" in quotes because, as I have written many times, the services we are getting are the services of an insurance agent - so this name change is totally misleading.  Think INSURANCE AGENT any time you talk to them. There are NO special products being offered by Towers Watson that are unique group plans. Anything you buy from them is a product you can buy in the open market place. Frankly, it is really onerous that we are forced to buy at least one product from OneExchange but that was baked into the contract IBM has with Towers Watson so that Towers Watson could get the insurance agent commission. They don't even do the actual claims processing to give you HRA/FHA reimbursement.  Extend Health  Towers Watson uses a company called PayFlex to process claims.  PayFlex is not customer facing.  When you call to discuss claims with an Extend Health  OneExchange representative - they will either try to answer you (inadequately has been my experience) or they will talk to  PayFlex  and then come back to you to give you the answer. I personally have found the PayFlex processing site to be clumsy and the navigation to get from the Extend Health OneExchange site to the PayFlex site and then back again to be awkward. 
Calling Extend Health aka Towers Watson OneExchange to resolve an enrollment problem or a  reimbursement issue is hit or miss.  In addition to calling, send an email to the IBMsupport address to either document your call or to use as a first step to resolving your issues.  I believe you will have a more positive experience and that Towers Watson will be forced to present an accurate picture to IBM of our experiences. It may not change anything about our level of service but it is worth a try.


Monday, January 27, 2014

IBM Medicare Extend Health - Medicare and medigap (aka supplemental) claims crossover

If you are using Original Medicare and have a secondary medigap supplemental insurance policy the medigap usually will have a crossover agreement with Medicare to get your claims from Medicare. How the crossover agreement works will depend on the secondary insurance company that issued your policy. Automatic crossover claims processing is really easy.  After I set it up,  I never had to file any claims with Aetna.  Medicare automatically sent claims to Aetna.  Do not assume your new medigap insurance company will do the same.
I have a user account on so I can see claims filed by doctors and also see my insurance profile without having to call Medicare or wait for a Medicare Summary Notice (aka MSN) which is mailed out once a quarter.  I looked at my secondary insurance profile on  today and it still showed Aetna as my secondary insurance.  There is no capability for a Medicare recipient to change that field.  Only insurance companies are authorized to notify Medicare of changes and it takes approximately 6 weeks for a change to be implemented.
If you have a medigap policy, your secondary insurance company may be willing to work with both the old IBM plan and Medicare to make the change. Call your insurance company and ask if they will do it or if they have already done it. When I first used Aetna Integration, it took one call to them and they worked with both Medicare and United Heath Care to make the change. 
This time, my insurance company would not do changes because of how they do crossover. It is not automatic.  I am paying a really low premium for a medigap F high deductible insurance plan so  I had low expectations. Also, Aetna did not notify Medicare that my 2013 policy terminated which is sort of crazy because it means Medicare would keep sending claims until Aetna told them to stop.  Aetna would have to keep denying those claims -- all of which has to have some administrative cost. Anyway, I called Aetna to have them notify Medicare my plan terminated.  Then I called my new insurance company to find out how their crossover works. 
By way of example, this is how my company does it - which is not great but worth the low premium:
  • I ask the doctor's office to put the insurance company code on the Medicare claim form (in position 9D).  That code tells Medicare to fax or mail a copy of the claim to the insurance company. If there are Medicare employees involved in the process, I bet it doesn't work very well but it's worth trying.
  • If the doctor's office cannot, I could ask if them to fax or mail a copy of the Medicare insurance claim directly to the insurance company. Since that does require human action, I won't ask.
  • If the doctor's office cannot put the code on the claim,  then I will fax or mail a copy of the MSN to the insurance company when I get it. That is the official copy.  Print out of a claim from the website is not an "official" copy.
Even if there were automatic crossover, an F high deductible plan doesn't start paying until your out-of-pocket is $2110 for Medicare deductibles and copays. I will keep track of my Medicare deductibles and copays because I will submit them to Extend Health for HRA reimbursement. I'll also track it to be sure my insurance company starts paying if I hit the $2110 (and I sure hope that doesn't happen).  Even the IBM medical supplemental insurer United Heath Care was not good about keeping track of my out-of-pocket amounts (it was $4000 last time I used that plan) and made mistakes.

Friday, January 24, 2014

IBM Extend Health Reimbursement Account Rebate Process

The gods do not want me to have an easy time with Extend Heath for either enrollment or for HRA claims.  I just successfully submitted my first claim request to Extend Health after 3 weeks of trying. Don't read that sentence as I will be paid for the claim.  It just means they finally got the claim after several attempts, multiple phone calls and several emails.
In the beginning of January I faxed a claim to Extend Health.  I heard nothing for 3 weeks.  I called them last week and they said they never got my claim.  They blamed my fax machine even though on the same day I sent the fax to EH, I successfully sent a fax to Acclaris.  On Monday I sent another fax.  I called EH on Tuesday to ask if it had arrived and was told Monday was a holiday so they wouldn't have gotten it. After being on hold for 20 minutes they told me they had no fax from me but it would take a day or so to go through faxes they received.  On Wednesday I sent another fax and an email to the IBM support address asking for help.  I was then told by email that it takes up to 5 days to just enter a faxed claim into the system for processing. No one on in the call center told me that - they just led me to believe my faxing capability was not working.  In the meantime, I also found on the claims processing site there is a notifications setting to ask to have an email sent to you when a claim is received.  It is not on the main website for Extend Health where your profile is stored but on the website you are redirected to for the actual claims process.  I also found an email address - I sent an email to that address and it bounced back that the mailbox was full.
Today, I was finally notified my claim has been received because I had set the notification setting to do so.  Yay.
Friends told me to just mail in claims.  That means spending printer ink to make copies and stamps to mail it.  I didn't want to do it online either because I want rock solid evidence of claims I have submitted.
Here is my observation - people who pay the whole year's premium for their insurance up front in January, and send in a paper claim to Extend Health to get their money back are clever devils.  They only have to front the money to pay the entire year of premiums for a few weeks and then they get a check.  In one case, the IBMer and the spouse insurance premium costs for medigaps and part D plans for the year was the entire subsidy and the HRA account was drained in January.  That person has the money and doesn't have to deal with Extend Health again until next year.  How smart!

Saturday, January 18, 2014

IBM Medicare 2014 Remaining Enrollment Options for Extend Health Transition

Hopefully, Medicare eligible IBM retirees already selected and enrolled in replacement medical and part D plans by the end of 2013.  If not, there is still time for some people to do it.  I say "some" because there is a "Special Enrollment Period" (SEP) in 2014 but only for people whose plans were terminated.  For example, if you were using plans that terminated at the end of 2013 such as the IBM medical supplement plan, IBM prescription drug plan, IBM medical supplement and prescription drug plan, or Aetna Integration plan you have until the end of February 2014 to get a replacement plan without any Medicare penalty or preexisting condition underwriting and you will be able to get your IBM HRA subsidy.

There is a Medicare Advantage disenrollment period that Medicare offers at the beginning of every year from January 1 - February 14. During this time Medicare allows people to change from a Medicare Advantage plan to Original Medicare and get a part D plan.  HOWEVER, if you do so, you MIGHT not be able to get an insurance company to sell you a medigap plan if you want one.  This is called guarantee issue rights. State laws regarding medigaps come into play as well other factors. Make sure you determine your eligibility before you drop your Medicare Advantage Plan.  Also, you risk losing access to your IBM subsidy unless you buy a part D or medigap plan offered by Extend Health when you make that change (unless your spouse still has a EH offered plan).
There is an SEP that exists for the entire year that allows you to switch to a 5 star rated plan once during the year.  Again beware - if the 5 star plan is not an EH plan you will lose your subsidy when you make the change.
Medicare law regarding SEPs is complicated and it is easy for Medicare agents, Extend Health agents or non-profits to make mistakes when telling you your rights.  Be sure you ask multiple people, multiple times about your options. Here is a link to a document that describes various SEPs:

Friday, December 20, 2013

IBM Extend Health Check Your Enrollment Status

After you enroll using Extend Health services, they send your application to the insurance company that sells the policy.  If the insurance company accepts your application they will notify Medicare of your enrollment.  Medicare then either accepts or rejects the enrollment.  If it is accepted, the insurance company will notify you that the plan has been accepted and they are also supposed to notify Extend Health that you have successfully enrolled because they then have to pay Extend Health a commission for the policy you purchased.
A reason an enrollment might not be accepted by an insurance plan is mostly for medigap insurance.  If you try to enroll without any special enrollment period and have preexisting conditions in most states they can deny you. A reason Medicare might do it is if they think you already have coverage a different way.  So, for example, if you tried to enroll in a Medicare Advantage plan that included prescription drug coverage and also a part D insurance plan - Medicare would reject one of those enrollments because you cannot enroll in two part D plans.
You will know you have successfully enrolled in an insurance plan and are setup to get your subsidy from Extend Health if several things happen:
  1. The insurance plan tells you that you have been enrolled.
  2. Your profile is updated on Medicare's database . You can call 1-800-Medicare if you want to check your 2014 enrollment because the Medicare website will only show the plan you are using for 2013 - and it only applies to Medicare Advantage and part D insurance. Medigap insurance updates probably won't be accepted until January 2014.
  3. Your EH website profile shows that your application is completed.
  4. EH sends you a letter saying you have been successfully enrolled.
I have successfully enrolled.  However, my spouse's application is still "open" on the Extend Health website which means EH has not been notified by the insurance company that the policy is accepted.  However, my spouse's insurance company sent us a letter on November 8th saying the policy application is accepted.  On November 20th I check the EH application status and when I saw it was "open", I emailed Extend Health and they told me it takes a couple of weeks for the insurance company to notify them. I was surprised because the insurance company for my plan was quick to notify Extend Health that my plan was accepted.  Well, here it is December 20th and the EH website application status is still "open".  I just sent a second email to Extend Health telling them we are concerned about the status.  I am doing this to build a case so if they try to deny my spouse's subsidy we have proof we did everything "right" and can complain to IBM so that we can get the subsidy.
I am also doing this so that if something really messes up I can file a grievance with Medicare that Extend Health is not acting as a proper insurance agent on my behalf.
Now that we are in the individual Medicare insurance marketplace, it is extremely important to keep a record of every conversation you have with Extend Health (who is your insurance agent), your insurance provider, Medicare agents, Social Security agents and any other government agency agent you contact.  You must get names of the people you talk to and what you heard - down to time of day you heard it.  That is the evidence you will need if you have to do an appeal with Medicare for either inappropriate marketing (EH), claims denials (insurance companies), misleading information that caused you to make poor insurance choices (government agencies and/or EH) or grievances such as for poor customer service (EH and/or your insurance provider).
12/26/13 Update:  EH responded to my email by calling to tell me they had received notification from my spouse's part D plan so the application process is complete. How coincidental that they got notification shortly after receiving my email.  Amazing ... isn't it?   I looked on the EH website to be sure it had been updated and it was.  Finally, we are both set up to get our HRA subsidies.  It only took 2 months of work to do it! I should send a bill to IBM for project management services.

Friday, December 6, 2013

IBM's latest HRA Beneficiary letter is laugh out loud funny and pathetic

When I got the mail today I saw both my spouse and I had received yet another "Important Information About Your IBM Benefits" letter.  When I saw the letter I immediately wondered what new way they thought of to squeeze more money out of old people.  And, they are indeed squeezing away.  They are now at the bottom of the barrel scrounging for nickels and pennies.
Both my spouse and I worked for IBM so we each get our own subsidy. IBM just informed us that we are not eligible to leave survivor benefits to each other.  HOWEVER, if we do not return the form selecting NO survivor benefits our HRA will still be reduced!  Also, if we had a dependent and wanted to leave survivor benefits to that dependent - only one of us is allowed to do so. 
We had no intention of leaving benefits to each other as it made no sense for us since we are both in good health (knock on wood).  But, we do know a couple where the very ill spouse was going to do it so that the remaining spouse would get the extra benefit.  My guess is other couples had decided to do the same thing.  It must have messed up the "steal money from them" spreadsheet numbers and the bonus increases that would come from stealing old people money - ergo, this iteration of letters was sent out to make sure we understood the money is theirs and to not mess with it. 
This latest action by IBM has moved the whole "transition" into the realm of being a ten act play in the Theatre of the Absurd.

Thursday, December 5, 2013

IBM Medicare Extend Health --- Where to get HELP beyond going to IBM or Extend Health

I posted this entry in 2009 but I think people are not looking at old entries so I am reposting because the IBM Service Center and Extend Health are not doing a good enough job helping people through this complex transition.  IBM retirees did not typically need to know all the ins and outs about Medicare because IBM provided some great plans.  Sadly, that is ending and the burden is on us to become educated.  I hope the following information helps you begin to understand and navigate the world of Medicare:
Unlike private health insurance, Medicare is a government owned and managed health insurance system. Even when you used IBM group health plans IBM offerings for primary coverage (that is, original Medicare or Medicare Advantage plans) were still regulated by Medicare law.  What that means is congress passes laws that dictate what coverage a doctor or supplier is able to provide. Medicare Advantage (aka private plans) are bound by that coverage law - they can only fiddle with who provides services or whether they think the medical procedure is necessary for your treatment. This sounds onerous and sometimes it is. If healthcare professionals break the law the government can prosecute them. Some examples will demonstrate how laws impact your medicare coverage.
Suppose you need to be on an oxygen support system. Choose wisely because once you pick an equipment supplier you have to keep that same supplier for 5 years. That's because there is a law that was passed in 2006 to lower Medicare costs. It is structured to have Medicare provide the supplier with monthly payments for 3 years for the equipment. After 3 years the supplier is only paid for maintaining the equipment. At the end of 5 years you can get a new oxygen support system from a different supplier. If you want more modern equipment or to switch suppliers any time during the 5 years you have to pay for it totally out of pocket.
There are a myriad of rules and regulations regarding fees and billing. Doctors are not allowed to bill you for services over and above 5-15% (percentage depends on the state) of what Medicare says is the approved amount for that service. If the provider tries to charge you more that is Medicare fraud. Medicare Advantage plans are also required to cap fee for services at the same rate as original Medicare - but are allowed to vary your copay so they can have higher copays for specialty services and lower copays for routine services.
Another important rule pertains to using a skilled nursing facility to recuperate from an illness. You MUST go to the facility from the hospital and need to have been in the hospital for at least 3 days. Otherwise Medicare will not cover it. It is the law. Nor will your private primary (e.g., Medicare Advantage) or secondary (e.g., medigap) medical insurance cover it - because it will have been denied by Medicare. Just as with any law - ignorance of the law does not absolve you from suffering the consequences. These laws are constantly changing or being amended. Each time you face a given situation you have to ask questions before you agree to anything -  do research to determine what rules currently apply.
How can you possibly know all the rules surrounding Medicare healthcare? You can't. Even healthcare professionals regularly give out wrong information. Unless you see it in writing don't believe it. Sadly, even the government infromation hotline 1-800-MEDICARE is not foolproof - they give a lot of wrong answers. The burden is on the patient and the family to do research for a given situation. It can take a great deal of time but the payback for knowing the rules can save you a great deal of money.

There are a number of agencies - both government and non-profit - that will help you find answers. Make sure the agency is legitimate as there are also a lot of scams around. What follows is a list of some resources:
  1. 1-800-Medicare and/or
    This is the government official hotline and website for Medicare. The hotline people are good - but overwhelmed (and with the boomers coming along will likely be more overwhelmed) so their answers are as brief as possible. It is a 24 hour service (to cover Hawaii and Alaska) and the best time to call is late at night to get better service. The website is really excellent but complex. There are many reference documents on the site that are excellent but you have to search to find them. Take the time to learn the site.
  2. CMS centers for Medicare and Medicaid -
    This is the government agency that ADMINISTERS Medicare and Medicaid. The actual services are provided by regional private agencies that the government hires to do the paper work. You get your quarterly Medicare medical statements from CMS. There is a huge amount of information on the website as well as data bases that detail Medicare coverage and fees. Many "white papers" detail specific situations such as "Who Pays First" which is about when Medicare is secondary insurance (e.g., if you work past 65 and have employer coverage). There is also something call "local coverage determinations" that details what procedures have been approved by regional administrators.  That information is hugely helpful if you are appealing an insurance plan denial.  But it is hard to navigate and typically you need experts to help you find the right information - such as the Medicare hotline agents.
  3. State Health Insurance Assistance Program -
    This is a national program to help seniors navigate the Medicare world. It is a federal mandate that each state must have the agency and typically the states setup the agencies within the Department of Aging. This is an important resource because the rules about how Medicare medigap insurance is administered differs from state to state.  There are also some special setups such as Medigap Select programs that states have setup. They will also know about state unique assistance programs, clinics and charities designed to help seniors.  Generally the agencies are referred to as state SHIPs. However, states have a habit of giving agencies unique names - for example in Florida the agency is call "SHINE", in New York City it is called "HICAP". Some states have great agencies and others ... well ... they staff with mostly volunteers that are not well trained. If you are getting mediocre assistance press the agency to give you someone better to work with.  They will do it if you make noise. The site above will provide the phone number of the agency in your state.
  4. State Pharmaceutical Assistance Program - part D insurance help
    About 40 states have programs to help low income seniors cover their drug costs. You can find the program in your state by going to . It is unlikely IBM retirees will meet the income eligibility requirements but there is some useful Medicare D information on the site. You also should look into getting a prescription discount card in case your Rx is denied by your current insurance and you lose an appeal.  Sometimes the state offers one.  There is a non-profit that offers one at - you might also want to price your drugs using the prescription discount card versus your insurance as sometimes you'll get a better discount.  The negative side of doing that is the cost of the drug will not be included in the "doughnut hole" computation.  If you use a lot of drugs it is likely unwise to use a prescription drug discount card.
  5. State health insurance information for consumers -
    Most states have complaint data about health insurance companies and particularly about HMOs. Before selecting a Medicare Advantage or medigap program look at how they rate on your state insurance website ( in NY it is  There are also star ratings for Medicare Advantage plans in the Medicare publication "Medicare & You" that  is specific to your state and you receive the boook every year.
  6. Medicare Rights Center 1-800-333-4114 and
    This is a national non-profit organization that provides advocacy and helpline support for Medicare questions, help finding part D plans, help understanding medigap and medicare advantage plans.  The agency is not affiliated with the government but often testifies in congressional hearings as well as provides evidence of consequences of poorly structured laws. Occasionally case advocates will help clients navigate the appeals process if they feel you have been unjustly denied coverage. The helpline is mostly staffed by volunteers so the answer quality ranges however, the full time staff reviews all the call notes will call you back to try to remedy any bad answers. The regular staff does the case work and there are staff as well as volunteer lawyers that help. They will also help low income clients enroll in low income subsidy programs. The information search website ( aggregates medicare information and provides links to other support sites. It is excellent

Wednesday, December 4, 2013

IBM Medicare Extend Health - More about Dental Plans

It is turning out to be way more difficult to find solutions for dental insurance than it was for health and prescription drug insurance.  Several people have been looking at various plans.  Here's what they have found out -----
The dental plans offered by Extend Health are just about the worst plans in the marketplace. Even some of the EH agents have told retirees what EH offers stinks! That's not to say other plans in the marketplace are much better. It seems the one AARP offers is the best of the lot but even then - the premiums are high and they will only cover cleanings and simple fillings for the first 6 months you own the policy. So, if a tooth fails you are SOL to have it fixed before June. And it caps at $1500 payout for the year. 12/6/13 - I just saw that EH added two plans offered by MetLife but I don't think these offerings are "offering" much.  It is also very frustrating that we find out what EH is selling by word of mouth or going onto their site.  Once enrolled, who'd  want to go back and keep checking the EH site to see what else is being sold!
Someone just told me about a group plan that is interesting ---- IF your dentist accepts it (mine accepts no plan). You pay Cigna a flat fee for the year (something like $130) to become a member of Cigna's dental insurance group. That entitles you to get the Cigna negotiated dentist rates from a dentist in their network. You pay the dentist whatever the negotiated rate is for a given procedure. For example, if a typical cleaning is $120 but the Cigna rate is $90 that's what you will pay the dentist - again, only if the dentist accepts the plan.
If you want to know more about the Cigna plan go to
There is another website that describes the myriad of dental insurance plans available to individuals but, as I said, none are particularly great ---
I already posted a blog entry about the VA dental plans available if you or your spouse are veterans.  They are the best plans I have seen so far because they are group dental insurance plans. It turns out they are available no matter what your income level as long as you served in the military and enrolled in the VA health system before 2004.  After that time, if you try to enroll the VA will not even let you register  in the VA health system if your income is too high (over approximately $50,000 annually - it depends on your zip code). There is also a dental plan for veterans of foreign wars who were in combat that does not appear to be income based.  However, you must prove you were in combat.
It's a pity that IBM wouldn't even give us the option to buy into the MetLife group plan since they had to know the individual dental plans stink.  I am not surprised - just continue to be disappointed in IBM.
I, personally, will skip buying dental insurance and basically self insure for as long as I can afford to use my existing dentist.

Sunday, November 17, 2013

IBM Extend Health Transition how to reach Dr. Rhee & the new VP of HR

I have posted in other places Dr. Rhee's email address but I thought I would make the information easier to find should you want to voice your concerns over this transistion:
Dr. Rhee  is at
The current VP of Human Resources is Diane Gherson.  Her email address is