Appealing denial of coverage

When you are denied coverage for a medical procedure or a prescription drug it is important to do an appeal with your insurance company.  If you have a Medicare sanctioned plan the appeals process is governed by Medicare law.  Sometimes it takes a couple of iterations to get to an independent group (that is - not the private insurance provider) to get a fair assessment.

I just wanted to remind you that IBM secondary insurance and Aetna Integration insurance is not governed by the Medicare appeal process laws because it is not government sanctioned medigap or secondary insurance.  For those insurance policies if you are not satisfied with the decision they render you have to complain to the department of insurance in your state.  It is unlikely doing that will change the decision but it is important to complain because those departments track complaints and put pressure on insurance companies that are generating a lot of complaints.

I don't know what the appeals process is for IBM's prescription drug insurance plan.  Although it is a "creditable" plan, I am not sure if the company (CVS Caremark) is required to have the same appeals process as a government sanctioned prescription drug plan (PDP).  If you are choosing the IBM prescription insurance plan you should ask the question.  If it does not conform then your appeals are totally handled by CVS - which means there is no independent review and your chances of reversing a decision are slim.  If someone has an answer please post a comment.

Aetna Integration A detailed description

There is a brochure on the Aetna website that provides details about the Integration plan.  It is a good summary of the plan.  Unfortunately, I can't link to it because you need a user id to get to the site and you can only get one if you are enrolled.  If you are considering getting the insurance I suggest you call and ask Aetna to email you a copy of the brochure.  Here is the table of contents:

Table of Contents

Preface ........................................................................1

Important Information Regarding Availability of

Coverage

Coverage for You .....................................................1

Health Expense Coverage.......................................1

Treatment Outcomes of Covered Services

When Your Coverage Begins............................2

Who Can Be Covered ..............................................2

Retirees

Determining if You Are in an Eligible Class

Obtaining Coverage for Dependents

How Your Medical Plan Works........................5

Common Terms........................................................5

About Your Comprehensive Medical Plan...........5

Using the Plan

Cost Sharing

Emergency and Urgent Care...................................6

Coverage for Emergency Medical Conditions

In Case of an Urgent Condition

Coverage for an Urgent Condition

Non-Urgent Care

Follow-Up Care After Treatment of an

Emergency or Urgent Medical Condition

Requirements For Coverage.............................8

Clinical Review Criteria Requests

What The Plan Covers ......................................10

Comprehensive Medical Plan .................................10

Wellness......................................................................10

Routine Physical Exams

Preventative Health Care Services Expenses

Routine Cancer Screenings

Early Intervention Services

Bone Mineral Density Measurement or Test,

Drug and Devices

Vision Care Services

Limitations

Hearing Exam

Primary and Preventive Obstetric and

Gynecological Care

Physician Services .....................................................13

Physician Visits

Surgery

Anesthetics

Hospital Expenses ....................................................14

Room and Board

Other Hospital Services and Supplies

Outpatient Hospital Expenses

Coverage for Emergency Medical Conditions

Coverage for Urgent Conditions

Alternatives to Hospital Stays.................................16

Outpatient Surgery and Physician Surgical

Services

Birthing Center

Ambulatory Care

Home Health Care

Hospice Care

Other Covered Health Care Expenses .................19

Acupuncture

Ambulance Service

Diagnostic and Preoperative Testing ....................19

Outpatient Diagnostic Lab Work and

Radiological Services

Outpatient Preoperative Testing

Durable Medical and Surgical Equipment (DME)

.....................................................................................20

Experimental or Investigational Treatment .........21

Pregnancy Related Expenses..................................21

Prosthetic Devices....................................................22

Hearing Aids

Benefits After Termination of Coverage

Short-Term Rehabilitation Therapy Services.......23

Cardiac and Pulmonary Rehabilitation Benefits

Outpatient Cognitive Therapy, Physical Therapy,

Occupational Therapy and Speech Therapy

Rehabilitation Benefits

Reconstructive or Cosmetic Surgery and Supplies

.....................................................................................24

Reconstructive Breast Surgery

Specialized Care........................................................24

Chemotherapy

Radiation Therapy Benefits

Outpatient Infusion Therapy Benefits

Diabetic Equipment, Supplies and Education.....26

Treatment of Infertility............................................26

Advanced Reproductive Technology (ART)

Benefits

Enteral Formulas......................................................28

Treatment of Mental Disorders and Substance Use

.....................................................................................29

Treatment of Substance Abuse

Oral and Maxillofacial Treatment (Mouth, Jaws and

Teeth) .........................................................................30

Medical Plan Exclusions .........................................31

When Coverage Ends..............................................31

When Coverage Ends For Retirees

Your Proof of Prior Medical Coverage

Continuation of Coverage.......................................32

Continuing Health Care Benefits

Extension of Benefits ..............................................33

COBRA Continuation of Coverage......................33

Continuing Coverage through COBRA

Who Qualifies for COBRA

Disability May Increase Maximum Continuation

to 29 Months

Determining Your Premium Payments for

Continuation Coverage

Prescription Drug Coverage 2013

I am sorry I have not been able to write much this year and the deadline for making your decisions is only a few days away.  Hurricane Sandy visited Westchester, New York and turned a forest into a meadow.  Happily, not so much changed from last year so most of what I wrote applies. 

I just took a quick look at the rules that are being "upgraded" for the IBM's prescription drug plans.  The sentence saying that more than 250 drugs will require prior authorization in 2013 was not great to see.  What the provider will likely do is ask you to try alternate comparable drugs before they approve your prescription.  It is called step therapy.  That can range from annoying to life threatening as sometimes those alternate drugs don't work at all and can impact your health.

Once again, I decided to go with Aetna Integration A which meant I cannot use IBM's drug plan and had to select a separate private prescription drug plan (PDP) from a non-IBM provider.  I used the plan finder on the medicare.gov website to be sure I picked a PDP that has been sanctioned by medicare.  I also enrolled directly through the medicare.gov site as it is the quickest way to enroll and I have a record of the enrollment in case the private insurer makes a mistake and denies I was enrolled. 

The list of PDP providers available in your zip code can be daunting.  There are a lot of factors to consider when selecting a drug insurance plan such as -  where you will be able to fill prescriptions, whether or not step therapy will be required for your particular drug, deductibles (which cannot be higher than $350) and copays. Some plans also provide insurance in the "donut hole" but of course the premium for those policies will be higher.  All of these factors are important to consider when you pick a plan - not just premium price. 

My personal experience: this past year is the PDP plan I picked was cheap but it was not the best decision.  I could not use mail order and had to go to Target to pay the least for my prescription. However, they let me do 90 day refills so it wasn't too bad. The plan then decided not to cover my drug in 2013 so in September they stopped allowing 90 day supply refills.  I now have to go back to the pharmacy every month to get a refill.  It is annoying.   They also did not directly tell me the drug would not be covered in 2013.  They just said there were changes in their formulary and I should check their formulary. 

 

October 2012 - choices for 2013

I quickly looked at the IBM package this morning for the first time.  I don't see much change but the prices for some of the options.  People who need to cover their medicare eligible spouses are really getting slammed if they pick anything but Aetna Integration plan or the PPO plans and buy a separate Medicare part D prescription drug plan (which can be as cheap as $20/month) for the Integration plan.  People who need to cover their non-medicare eligible spouses seem to be hit the hardest if they want to get drug coverage.

I will provide more analysis after doing more reading but wanted to do a quick post because there is not much enrollment time this year.  The only thing I wanted to focus on for this post is that the Medicare Advantage plans IBM offers (the PPO and HMO plans).  For those plans:

• Make sure your doctors and local hospitals will accept the plan
• Make sure your drugs are on their formulary and if they require step-therapy
• Consider the fact that you will not be covered at specialized clinics like Cleveland Clinic or Sloan-Kettering if needed (most of those clinics do accept original Medicare)