Monday, May 2, 2016

IBM Medicare Retiree Ombudsman for help

Until recently, Roger Meggy, an IBM retiree, has been helping people with a variety of OneExchange problems. He has had a good success rate in helping people resolve issues as well as inspiring OneExchange to improve their websites and documentation. Towers Watson and IBM management agreed to have Roger serve as an ombudsman when this transition first occurred in 2013 so he developed a unique and unfettered access to support people within those organizations for problem resolution. 
Roger can no longer do it but is passing the baton to Ron Linton who will now be a liaison.  Ron can be reached at  If you are at wits end on how to navigate OneExchange or how to remedy a problem, contact Ron. He is also seeking volunteers to help produce a hints and tips guide for IBM retirees.  
Although Roger is no longer able to do it , he can be reached at for those who want to wish him well.

Sunday, April 3, 2016

IBM Medicare & Obamacare (Affordable Care Act aka ACA)

There is still a lot of confusion about insurance options for people turning 65.  I believe this because of the questions I hear during Medicare counseling as a volunteer and for friends.

  1. Over 65 employed:
    People who are over 65 and employed are able to continue to use their employer health insurance plans (if the company offers it and is larger than 20 employees). You CANNOT use ACA insurance - you can only use employer insurance.  Generally, it is recommended those people should enroll in Medicare part A (hospitalization coverage) because there is no premium for that part of Medicare.  Then, part A would act as secondary insurance.  In most cases it doesn't provide more than employer insurance but there may be instances where it is useful such as when Medicare will cover a procedure as inpatient whereas the employer insurance will require it to be outpatient. For IBM insurance it is fine to enroll in part A. Sometimes employer insurance won't allow part A enrollment so be sure to check on it.  If the employer offers prescription drug insurance that is creditable then it is fine to also use the employer drug insurance plan. IBM drug insurance is creditable.  If your drug insurance is not creditable (which is determined by Medicare) then you will face a drug insurance penalty of 1% per month of the national average drug insurance premium for every month you use an inadequate drug plan when you try to enroll in a part D plan.  That penalty almost never goes away.
  2.  Over 65 retired with working spouse:
    People over 65 who are retired are able to obtain insurance coverage through a working spouse (working for a company larger than 20 employees). Once again, you CANNOT use ACA insurance.  It has to be employer insurance.  If the spouse's company is less than 20 employees then you must register for Medicare part A and part B to have adequate health insurance.  If you do not  - no matter the reason - and continue, for example, to use spousal insurance coverage, that insurance coverage automatically changes to being SECONDARY insurance to Medicare when you turn 65.  That means the insurance will only cover co-pays and deductibles. If the spousal prescription drug insurance is creditable you can continue to use it but make sure you keep proof of having that coverage for when your spouse stops working.
  3. Turning 65 retired & using ACA marketplace insurance:
    Sometimes retired IBMers decide to use ACA marketplace insurance rather than IBM retiree insurance prior to turning 65.  If you are not collecting Social Security you will not automatically be notified that you must sign up for Medicare.  Worse still, sometimes the private insurance company that is providing the ACA insurance policy doesn't pay attention to your birthday. They cannot cover you when you turn 65 (by law). The moment you turn 65, that insurance policy (once again) becomes secondary insurance. There is legislation in process to notify people not collecting Social Security about this but it is not yet implemented.  
  4. ACA impact to Medicare:

    There is a great deal of mis-information about ACA legislation as regards Medicare.  The implication typically is that ACA insurance is financed off the back of Medicare and therefore Medicare coverage is being severely cut back.  In fact, not one medical procedure covered by Medicare insurance has been affected.  No doctor fees have been reduced because of ACA. Sequestration lowered doctor fees. That was done by the legislative body because of the budget fights.  
  5. Here's what has changed in Medicare because of ACA:
    The prescription drug insurance doughnut hole is being closed (Hooray!).

    Medicare Advantage plans were paid 15% more than the part B premium collected from people using those plans (which meant taxpayers were financing the 15%).  It is being phased out.  It is rather outrageous private plans were being subsidized by the government.
    There is a big effort to eliminate Medicare fraud cost and eliminate prescription drug insurance coverage for off label use of drugs when the condition is not cancer related. The off label problem occurs because pharmaceutical companies don't prove to the FDA the efficacy of a drug for conditions where it might be useful. Many drugs are only modestly useful for off label conditions and wouldn't be approved.  People don't realize Medicare is subsidizing the cost of prescription drugs by providing payments to part D plans.  As such, Medicare wants to be sure the drug is effective. Such efforts are substantially reducing the cost of Medicare - far more for fraud than off label use.


Tuesday, December 8, 2015

IBM Medicare 2016 other enrollment periods

Yesterday was the last day of the Medicare Fall Open Enrollment which is the time to make changes to Medicare health insurance for 2016 coverage.  In addition to this time, some people will be able to modify their choices during 2016.

  • Medicare Advantage Disenrollment Period: January 1 - February 14, 2016

If you have a Medicare Advantage insurance plan, you are allowed to disenroll from the plan and use original Medicare during this period of time.  Some people use this option because they did not realize they were automatically enrolled in a new Medicare Advantage plan because their old plan terminated.  They will often realize the change when they go to the doctor in January and are told the doctor does not accept their current plan.  It's possible this might happen to some  IBMers who were automatically enrolled in the individual Aetna plan because the IBM group Aetna plan terminated.
Although it is a nice option it can get complicated.  If you had a Medicare Advantage plan that did not include an Rx insurance plan, you cannot switch to a new Rx plan.  If you want to buy a Medicare Supplemental plan to have secondary insurance for original Medicare, the rules governing that purchase are determined by your state.  Finally, if you have something called a Medicare Medical Savings Account plan you cannot switch.  If you are able to switch, original Medicare will be effective the beginning of the next month.

  • Medicare General Enrollment Period:January 1 - March 31, 2016

If you miss the initial sign up window for Medicare after you turned 65 and are not working (which is 3 months before through 3 months after your birthday), then you must wait for the General Enrollment Period (GEP) to sign up unless you can prove you were misinformed by a Medicare employee. There will likely be penalties assigned for every year you did not use Medicare and definitely be penalties for every month you did not buy Rx insurance.  That's irritating all by itself but then add to that your insurance coverage will not begin until July 1st of 2016. The most frequent cause for making this kind of mistake is for people who are over 65 and get laid off.  They buy the COBRA insurance and think they are covered by COBRA (per an earlier post, they really are not covered).  When COBRA ends it is usually after their Special Enrollment Period (SEP) to enroll in Medicare which is 8 months.  At that point, they must wait for the Medicare GEP to enroll.

  • Unique Special Enrollment Periods: Any time during 2016 if you are eligible

As I just described, when you stop working and are over 65 you have 8 months to enroll in Medicare insurance.  There are other ways you are also be eligible for an SEP.  Just to name a few:

  • If you move from one state to another
  • If you have a state pharmaceutical assistance program which includes a one time SEP
  • If you go into or come out of a nursing home
  • If you can prove marketing fraud for the insurance plan you currently have 

Hopefully, none of the above applies and you will have a happy Medicare 2016 year!


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.