Saturday, October 8, 2016

IBM OneExchange Medicare 2017 prescription drug (Part D) plan idiosyncracies

I am learning a few things about part D plans idiosyncrasies.  In a post last year I wrote quite a bit about the planfinder ( but there is ever more to learn.  It's important to use the government planfinder to look at the plan you think you want to buy because the description of it is more detailed than what's in OneExchange plan details. Here's a few things to consider:

Part D penalty (added 10/23/16):

Many times I've heard people say they don't need part D insurance because they don't take any drugs.  It's your choice to not buy a part D policy but you will pay a penalty if you change your mind AND you can only enroll in a part D plan during fall open enrollment to have the insurance in January of the following year. The penalty is 1% per month of the average plan premium for every month you don't have a part D plan.  It adds up and the average plan premium is reset (higher) every year.  My recommendation, buy the cheapest plan available in your zip code and maybe pick one that doesn't have a deductible.  This way, if you do need to fill a one off prescription you won't have to meet the deductible.  It might be worth paying a higher premium.

Tier 1 Generic Drugs:
Medicare rules to drug insurance companies require there be NO copay for a drug classified as Tier 1 Generic.  A drug insurance plan can classify a drug into any tier they want.  Many now have Tier 1 Preferred.  Thereby, they put the drug in a category such that they can charge a copay.  Pay attention to how your drug plan classifies your drugs.  I found a plan for someone that had a deductible but the person's drugs were all Tier 1 Generic so there were no copays and therefore no deductibles come into play unless it applies to a new prescription not in that tier.
Deductibles (updated 10/23/16):

If you need regular prescriptions, and not a lot of one off prescriptions, the only reason to worry about deductibles is if you have a cash flow problem.  Otherwise, pick the plan that has the lowest annual cost.  It's rather sad that people who can least afford it because of cash flow issues end up paying more for their drug plans.  Government subsidies are available if your income dips below about $24,000/year for a married couple and you have few assets (ala cash in the bank).  If you tend to have a lot of one off prescriptions in addition to your regular medications then you might want to consider picking a plan with no deductible.

Search options:

In planfinder you can filter out plans that do not cover all your drugs by clicking on the "Drug options" on the left side of the screen and selecting that option.  That feature is available to you just before you continue to plan results.

Drug entry:

Make sure all the drugs you take are for FDA approved conditions.  In an earlier post I explained what this means.  If you are taking a drug (like Adderall) it won't be covered unless you are under 18 years old because that is the demographic the FDA approved.  There is no sense entering that drug and it may be misleading because the cost of that drug is included in the results but Medicare won't allow it to be covered by the drug insurance company unless it meets the on-label criteria. Also, don't enter drugs into plan finder that no plan will cover.  For example, Medicare does not allow coverage of hair growth drugs.  Plan finder will include the cost of those drugs in the results but I think it is misleading.  Any drug you buy which is excluded will not count toward the doughnut hole calculation.

Zip Code Drug Tiers (added 10/13/16):

If you are selecting a drug plan for a relative, make sure you enter the right zip code.  This is important for a couple of reasons.  Drug insurance plans are sold by zip code.  That means a plan might be available for purchase in New York City, but not in Syracuse.  Even if a plan looks like it is available in two different cities, it may not be structurally the same.  The drug costs of what I thought was the same plan turn out to be different for San Francisco than for New York City.  The insurance company put exactly the same prescriptions in different tiers.  In San Francisco the prescriptions were in tier 1 generic which has no copay.  In NYC they were in tier 1 preferred which has a copay.  It is bad enough that the tier a drug is assigned to varies widely from plan to plan.  Drug insurance companies also vary it from zip code to zip code.

One Exchange website plans (added 10/23/16):
The list of plans you see on the One Exchange website might not include all the plans they sell.  I know this is true for their Medicare Supplement plans particularly regarding AARP UHC plans.  If there is a part D plan on that is a better plan for you but doesn't show up on the One Exchange website, call and ask if they sell the plan.  This is also true for Medicare supplemental plans and for Medicare Advantage plans.  My guess is they show the plans on their website that provide the most commission to them.

Deductibles and Doughnut hole 2017 coverage changes (added 10/23/16)

The deductible plans are allowed to increase deductibles from $360 to $400 in 2017.  Not all plans have deductibles but that just means they make up the difference with higher copays. An Affordable Care Act (aka Obamacare) provision is gradually lowering until 2020 the copay cost in the coverage gap.  The 2017 percentage you will pay for brand name drugs in the gap drops to 40% (down from 45% in 2016) and the percentage you will pay for generic drugs drops to 51% (down from 58% in 2016).  Plan finder will reflect those changes in the plan cost calculations. Reminder, the ACA target copay for 2020 for both drug categories is 25% unless congress modifies the ACA.

I'll keep updating this list as I learn more.

Sunday, September 18, 2016

IBM Medicare spouse access to HRA funding

People have asked me recently whether there is any advantage to using One Exchange services to buy insurance for their Medicare eligible spouse. The reason to do it is to more quickly spend your HRA money and/or make sure your spouse has easy access to the funds if you predecease your spouse.

The products you buy through One Exchange are EXACTLY the same products you buy when you search on  The only difference is shows you ALL the products you can buy in your zip code.  One Exchange shows you a SUBSET of  products because they only show products for which they get a commission.  One Exchange is an insurance agent. IBM requires you to buy at least one product from One Exchange to access your HRA. IBM is forcing you to use an insurance agent to get the money.

If you get an allotment of money every year from IBM it is highly likely you will use up that allotment for a given year just on yourself for part B, part D premiums, medigap premiums, dental, glasses and coinsurance payments.  If your allotment is a one time amount you received at retirement (via an FHA), you spend that money until the account is depleted which may take a number of years. In the first case, once the annual allotment is spent out, you're done with One Exchange until the next year.  In the second case, you're done with One Exchange when your HRA is depleted.

Case 1:  The retiree gets an annual allotment.  He spent the entire allotment on himself for the past 2 years.  His wife is now turning 65.  He did not opt to have his benefit reduced to pass some money to his wife if he does not survive her.  The only reason for his wife to buy any of her Medicare insurance through One Exchange is because the retiree might expire before the annual allotment is spent. The spouse will be able to spend the rest of the funds until the end of that year. After that year, there is no more allotment and therefore no reason for the spouse to use OneExchange and have reduced insurance choices (and I am not sure the spouse is even allowed to use the services).

Case 2: The retiree gets an annual allotment.  He/she did opt to have a reduced amount to pass on the benefit to the spouse.  The retiree might want the spouse to buy one product within the One Exchange system in case the retiree expires during the year so that it is setup and the remaining money is easily available to the spouse plus have an easier transition for the next year allotment.

Case 3: The retiree gets a fixed amount HRA at retirement through FHA funding to spend until it is depleted and it may take a number of years to do it.  The retiree might want the spouse to buy products within the One Exchange system to more quickly spend down that FHA/HRA account (as there is no guarantee it will be available until it is depleted) and also for the same reason as Case 2  - that is to make the transition easier for a surviving spouse by already having established access to the HRA funding.

Wednesday, August 24, 2016

IBM evaluating 2017 Medicare health insurance choices

The time of year to reevaluate your Medicare health insurance options is rapidly approaching.  Between October 15 and December 7 you have the opportunity to switch to another plan.  In September, insurance companies that offer Medicare Advantage plans will mail out 2017 plan information to current recipients as well as do intense marketing to try to get people to switch to their plans. The TV ad campaign is almost as intense as it is for the presidential election!  Be sure to READ and KEEP the information you receive from your current insurance providers.

Don't wait until the end of November to consider your choices.

First and foremost - remember that you only need to buy ONE medical plan from OneExchange to get your IBM health insurance benefit.  It has to be a medical plan - dental and vision don't qualify as health insurance.  Medicare Advantage plans, Medicare Supplemental plans (aka medigaps) for original Medicare users, and Medicare prescription drug insurance plans (part D plans) are what they mean by medical plans.

Secondly, Medicare Advantage plans and part D plans CHANGE their plans from year to year.  They cannot change the medical procedures they will cover (that is dictated by the government) but they can change who provides services. Medicare Advantage plans add or delete doctors, specialty clinics and change copay amounts.  Part D plans add or remove drugs they will cover and/or change the tier pricing for the drugs they cover. MAKE SURE you know what your coverage will be and switch if you don't like their 2017 changes.

I continue to believe original Medicare, a Medicare supplemental (medigap) plan and a separate part D plan offer maximum flexibility.  You can go to any doctor or specialty clinic anywhere in the USA.  You can pick a drug plan that best matches your prescription needs.  If you want to switch away from a Medicare Advantage plan to original Medicare and a medigap plan it is important to know whether you can get medigap coverage in your state without underwriting for preexisting conditions or premium adjustment for preexisting condtions.  States like New York and Connecticut don't allow such stuff.  Contact your state agency for more information:

Insurance companies are going through a lot of reorganization and consolidation to maximize their profit to stakeholders. For example, Aetna is a FOR PROFIT company.  You may have heard the news coverage about them. They are loudly wailing about how much money they've lost providing Obamacare insurance plans in rural areas.  That doesn't mean they aren't making profit.  They are still very profitable.  However, it appears (from the volunteer work I do) they are now squeezing all their plan holders (Medicare or otherwise) by routinely denying claims for obscure reasons to try to make up for what they've "lost" in rural coverage costs.  Make sure you not only understand your insurance provider coverage, but also look at the Medicare star ratings and the online chatter about the service of your insurance provider.  The nice thing about original Medicare is it is the government insurance pool.  There still is pressure to reduce cost (by congress) but there are no stakeholders looking for maximium profits.

Wednesday, June 29, 2016

IBM Medicare prescription drug insurance off label drug coverage

Every year - EVERY YEAR - it is really important to reevaluate your prescription drug insurance plan coverage to ensure you are getting the best coverage at the least annual cost during Medicare Fall Enrollment which occurs October 15 to December 7.
I recently listened to a Medicare recipient bitterly complain about how much work it is to manage her IBM Medicare insurance options, claims and enrollment.  She said she was retired and she wanted IBM to take care of this stuff for her!  I must admit it was irksome.  Even when IBM provided us with Medicare group health insurance, it was always important to evaluate the options they presented and determine the "best fit" choice.  So, as the slogan dictates, JUST DO IT!  If you ignore it, it can and will come back and bite you.  If you need help doing it, involve your relatives or find support organizations through Department of the Aging in your state to get advice.
The 2016 Medicare Fall enrollment session is right around the corner and will give you the opportunity to consider your plan choices for 2017.  This year has been a rough prescription drug coverage year for a lot of Medicare users whether the drug insurance coverage was provided through a Medicare part D stand alone insurance policy or a Medicare Advantage plan.  Beginning January 2016, prescription drug insurance companies were instructed by Medicare to clamp down on prescriptions prescribed for "off label" use and were told to deny such coverage.
What is "off label"?  All prescription drugs go onto the market because the pharmaceutical company proved the drug worked to treat a given condition.  Sometimes, the drug is only useful for that condition.  As an example, as far as I know, insulin's purpose is to treat diabetes.  That's the use which has been approved by the FDA.  If your doctor decided to prescribe insulin to treat some other condition, no matter how effective it might be, it would be an "off label"  use.

There are a lot of drugs that are only approved for a specific use or for a specific population.  For example, drugs used to treat Attention Deficit Disorder such as Adderall are FDA approved for CHILDREN meaning they are not approved for people older than 18.  Drug companies did not prove the usefulness for adults.  But adults can have the condition.  If the drug is prescribed it will be DENIED because of the instructions Medicare gave to the insurance companies. The only exception is if the disease being treated is cancer.
Why does Medicare have this power?  Medicare subsidizes private insurance companies.  Simply said, the government gives private insurance companies money every time you use a drug.  If you never use drugs then the insurance company does not get the subsidy (they just get your premium).
Why is all this blah, blah, blah relevant to you?  Just because a prescription drug plan has a drug on its formulary, it doesn't mean they will cover the drug.  The drug is only covered by insurance if it is used for the FDA approved condition.  There is no sense entering that drug when you do your plan selection in October unless you get a written guarantee from the drug insurance company that it will be covered.  Fat chance with that but maybe you want to try to get it for non-cancer related conditions.  You will highly likely have to pay full cost for the drug or try to find other discount options by asking the pharmaceutical company.

The bottom line is to pick a plan to cover your "on label" drugs unless the drug is used to treat cancer.
This post is long enough so I'll end it here.  Just a quick reminder - OneExchange sells a SUBSET of the prescription insurance plans available to you in your zip code.  If you are using original Medicare, AND you buy a Medicare Supplement through OneExchange, look at all the part D insurance options on to make the best choice.

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.