Unlike private health insurance, Medicare is a government owned and managed health insurance system. Even when you used IBM group health plans IBM offerings for primary coverage (that is, original Medicare or Medicare Advantage plans) were still regulated by Medicare law. What that means is congress passes laws that dictate what coverage a doctor or supplier is able to provide. Medicare Advantage (aka private plans) are bound by that coverage law - they can only fiddle with who provides services or whether they think the medical procedure is necessary for your treatment. This sounds onerous and sometimes it is. If healthcare professionals break the law the government can prosecute them. Some examples will demonstrate how laws impact your medicare coverage.
Suppose you need to be on an oxygen support system. Choose wisely because once you pick an equipment supplier you have to keep that same supplier for 5 years. That's because there is a law that was passed in 2006 to lower Medicare costs. It is structured to have Medicare provide the supplier with monthly payments for 3 years for the equipment. After 3 years the supplier is only paid for maintaining the equipment. At the end of 5 years you can get a new oxygen support system from a different supplier. If you want more modern equipment or to switch suppliers any time during the 5 years you have to pay for it totally out of pocket.
There are a myriad of rules and regulations regarding fees and billing. Doctors are not allowed to bill you for services over and above 5-15% (percentage depends on the state) of what Medicare says is the approved amount for that service. If the provider tries to charge you more that is Medicare fraud. Medicare Advantage plans are also required to cap fee for services at the same rate as original Medicare - but are allowed to vary your copay so they can have higher copays for specialty services and lower copays for routine services.
Another important rule pertains to using a skilled nursing facility to recuperate from an illness. You MUST go to the facility from the hospital and need to have been in the hospital for at least 3 days. Otherwise Medicare will not cover it. It is the law. Nor will your private primary (e.g., Medicare Advantage) or secondary (e.g., medigap) medical insurance cover it - because it will have been denied by Medicare. Just as with any law - ignorance of the law does not absolve you from suffering the consequences. These laws are constantly changing or being amended. Each time you face a given situation you have to ask questions before you agree to anything - do research to determine what rules currently apply.
How can you possibly know all the rules surrounding Medicare healthcare? You can't. Even healthcare professionals regularly give out wrong information. Unless you see it in writing don't believe it. Sadly, even the government infromation hotline 1-800-MEDICARE is not foolproof - they give a lot of wrong answers. The burden is on the patient and the family to do research for a given situation. It can take a great deal of time but the payback for knowing the rules can save you a great deal of money.
There are a number of agencies - both government and non-profit - that will help you find answers. Make sure the agency is legitimate as there are also a lot of scams around. What follows is a list of some resources:
- 1-800-Medicare and/or http://www.medicare.gov/
This is the government official hotline and website for Medicare. The hotline people are good - but overwhelmed (and with the boomers coming along will likely be more overwhelmed) so their answers are as brief as possible. It is a 24 hour service (to cover Hawaii and Alaska) and the best time to call is late at night to get better service. The website is really excellent but complex. There are many reference documents on the site that are excellent but you have to search to find them. Take the time to learn the site.
- CMS centers for Medicare and Medicaid - http://www.cms.gov/
This is the government agency that ADMINISTERS Medicare and Medicaid. The actual services are provided by regional private agencies that the government hires to do the paper work. You get your quarterly Medicare medical statements from CMS. There is a huge amount of information on the website as well as data bases that detail Medicare coverage and fees. Many "white papers" detail specific situations such as "Who Pays First" which is about when Medicare is secondary insurance (e.g., if you work past 65 and have employer coverage). There is also something call "local coverage determinations" that details what procedures have been approved by regional administrators. That information is hugely helpful if you are appealing an insurance plan denial. But it is hard to navigate and typically you need experts to help you find the right information - such as the Medicare hotline agents.
- State Health Insurance Assistance Program - http://www.shiptalk.org/
This is a national program to help seniors navigate the Medicare world. It is a federal mandate that each state must have the agency and typically the states setup the agencies within the Department of Aging. This is an important resource because the rules about how Medicare medigap insurance is administered differs from state to state. There are also some special setups such as Medigap Select programs that states have setup. They will also know about state unique assistance programs, clinics and charities designed to help seniors. Generally the agencies are referred to as state SHIPs. However, states have a habit of giving agencies unique names - for example in Florida the agency is call "SHINE", in New York City it is called "HICAP". Some states have great agencies and others ... well ... they staff with mostly volunteers that are not well trained. If you are getting mediocre assistance press the agency to give you someone better to work with. They will do it if you make noise. The site above will provide the phone number of the agency in your state.
- State Pharmaceutical Assistance Program - part D insurance help
About 40 states have programs to help low income seniors cover their drug costs. You can find the program in your state by going to www.medicare.gov . It is unlikely IBM retirees will meet the income eligibility requirements but there is some useful Medicare D information on the site. You also should look into getting a prescription discount card in case your Rx is denied by your current insurance and you lose an appeal. Sometimes the state offers one. There is a non-profit that offers one at www.needymeds.org - you might also want to price your drugs using the prescription discount card versus your insurance as sometimes you'll get a better discount. The negative side of doing that is the cost of the drug will not be included in the "doughnut hole" computation. If you use a lot of drugs it is likely unwise to use a prescription drug discount card.
- State health insurance information for consumers -
Most states have complaint data about health insurance companies and particularly about HMOs. Before selecting a Medicare Advantage or medigap program look at how they rate on your state insurance website ( in NY it is http://www.ins.state.ny.us/). There are also star ratings for Medicare Advantage plans in the Medicare publication "Medicare & You" that is specific to your state and you receive the boook every year.
- Medicare Rights Center 1-800-333-4114 http://www.medicarerights.org/ and http://www.medicareinteractive.org/
This is a national non-profit organization that provides advocacy and helpline support for Medicare questions, help finding part D plans, help understanding medigap and medicare advantage plans. The agency is not affiliated with the government but often testifies in congressional hearings as well as provides evidence of consequences of poorly structured laws. Occasionally case advocates will help clients navigate the appeals process if they feel you have been unjustly denied coverage. The helpline is mostly staffed by volunteers so the answer quality ranges however, the full time staff reviews all the call notes will call you back to try to remedy any bad answers. The regular staff does the case work and there are staff as well as volunteer lawyers that help. They will also help low income clients enroll in low income subsidy programs. The information search website (medicareinteractive.org) aggregates medicare information and provides links to other support sites. It is excellent
On another topic... I've been going round and round with Extend Health about the plans offered not being applicable to retirees who are living full time or part time, as we are, overseas. The plans offered are set up for local networks of doctors or medical facilities within the US. They have little or no provisions for coverage "out of network" and for extended periods of time. There must be hundreds, maybe thousands, of retirees who are living outside the US. Where are they looking for their health benefit coverage?
ReplyDeleteMedicare never was a non-USA health insurance plan. Medicare Advantage plans therefore offer very little by way of non-USA coverage. Policies that are secondary to Medicare --- aka medigap plans sometimes offer coverage. Some medigap policies will cover overseas emergencies if it occurs in the first 60 days of your travel and at an 80% rate. There is a $250 deductible and a lifetime limit of $50,000. But that's probably not what you are looking for. There might be USA insurance companies that do offer international policies. Maybe the Department of Insurance in the state where you live when you are in the USA would know. If such a policy is available it would have nothing to do with Medicare and EH only deals with Medicare related policies.
DeleteI guess my question is: Since IBM has decided to discontinue its Health Coverage for retirees and contract with Extend Health for Medicare related coverage, where do the retirees who live overseas look for continued health coverage?
DeleteI recognize that your blog is focused on Medicare issues but what options are offered to the contingent of retirees overseas? Have they been thrown to the wolves?
I am confused by your question. Even the group insurance IBM offered to retirees once they turned 65 was Medicare based insurance and as such was subject to Medicare law. IBM required 65+ aged retirees to enroll in Medicare. Either IBM offered secondary plans (e.g.,United Health care only paid if Medicare paid - I know because I tried to fight that one for non-Medicare doctor services) or they offered Medicare Advantage HMO or PPO plans like Kaiser or Aetna. Maybe I am wrong but I do not believe there was any IBM insurance for people over 65 that worked "overseas" beyond what I described in my last reply. Perhaps for retirees under 65 the IBM group insurance is "worldwide" insurance? If so, I think the under 65 insurance did not change for 2014 but you need to verify that with the IBM Service Center. After I saw your post I googled "health insurance for expats" and saw that there are companies that offer worldwide policies. If you live part of the year in the USA and you buy Medicare related insurance then you will have access to your HRA for that insurance coverage. If you don't get Medicare insurance when you pass 65, and you are maintaining your legal residence in the USA then you will pay a penalty of 10%/year for every year you do not buy Medicare insurance. It is unlikely you will be able to get other types of health insurance in the USA because most insurance companies won't sell you a policy - or, if they do it will require lots of disclaimers, the premiums will be huge and they can deny or drop you at any time because the ACA law does not apply to people over 65.
DeleteIn my online research I came across an IBM Q&A document that had the following exchange:
ReplyDelete"Q8. I live a portion of the year inside the U.S. and the other portion outside the U.S., and currently receive coverage through the IBM Medical Supplement Plan Option, which pays for my treatment outside the U.S. How will this affect my medical coverage?
[Answer:] If you are U.S.-based and currently pay for Medicare Parts A and B, then, you will be able to elect Medicare supplemental coverage. Medigap plans may cover some services outside of the U.S."
This is (was) precisely my situation over the past five years or more. It is (was) a great medicare supplemental coverage by United Healthcare and happily accepted claims from outside the US. Unfortunately it is not being offered by Extend Health.
OK - I understand - the IBM group secondary policy had extended benefits for retirees overseas. It's not so much that it is not being offered by Extend Health. It is that IBM decided not to negotiate anymore group health insurance for Medicare eligible retirees. They could have still had Extend Heath offer such policies but it would have cost IBM money to do so. Extend Health is just selling what is available in the individual insurance marketplace. Try calling United Healthcare through AARP and ask them if they will offer some kind of special policy to provide what you need as a companion to a traditional medigap.
DeleteI sent a note to the new IBM Support email address as to the composition of the group, and also asked if they were serious in fixing the Extend Health Issues and below is the answer I received.
ReplyDeleteDear Roger Meggyesy,
Thank you for taking time out of your day to write Extend Health, a Towers Watson Division, with your questions regarding the IBM email support group. We are a group of hand picked Senior Customer Service Reps who work for Extend Health. We have each received extensive and ongoing training concerning the IBM retirees and the issues they face, both nationally and internationally, concerning their Medicare coverage.
We track every email and provide daily and weekly reports on all issues, as well as verbatim comments from the retirees. These reports and comments are sent to both Senior Extend Health and IBM personnel. Additionally we have direct access to back office individuals within Extend Health, as well as the various insurance carriers, to get issues solved as quickly and efficiently as possible.
As you know this is a very high priority for both IBM and Extend Health and both have felt they could have their "fingers on the pulse" more effectively regarding potential issues, through this mechanism than through the phones. So far activity has been encouraging, though roll-out of this option has just started.
If you have any other concerns or questions please contact us at the number listed below or reply to this email.
Please feed you issues and concerns with an Email sent to the address below. IBMsupport @ extendhealth.com. Remove spaces around the @ for a valid Email address.
Roger
Sorry to hijack this thread, but I am wondering whether Patrician was able to find coverage for non-emergency medical care outside of the U.S.? We are in the same situation.
ReplyDeleteI just received a book from IBM called "About Your Benefits: Post Employment". By law, IBM must mail this out to us every 5 years. On page 169 In the middle of the page there is a section called "Special Considerations". The second bullet says the requirement to enroll in an EH health plan to get your HRA does not apply and you will be eligible to use your subsidy to enroll towards your Plan coverage. I don't know what "Plan" means but wonder if they are trying to say the IBM Medical Supplement is still available to you because you live outside of the USA. I suggest you call the IBM Service Center (1-800-796-9878) and ask to talk to the Plan Administrator to get clarification on what they are trying to say.
DeleteThank you.
ReplyDeleteHi--thanks so much for taking the time to post this great information on this blog. I've passed the resources you list above on to some folks who aren't affiliated with IBM who are having trouble with their parents' transition to new health plans and long time physicians who won't accept the new coverage.
ReplyDeleteI'm the daughter of a retiree. My dad is deceased, but my 86 year old mom is receiving benefits. We are fortunate that she is in great health and has been able to opt for less expensive coverage, but feel really misled by Extend Health on the prescription plan. She only has about 4 prescriptions she takes on regular basis, but one is an expensive osteoporosis drug: Atelvia. We were very clear with Extend Health about precisely which drugs she took and that she preferred name brands, but they steered her to the Humana Walmart plan, which is charging her almost full freight for this drug: $150/month versus the $50 she previously paid.
You are absolutely correct, as a consumer, it is overwhelming trying to figure out how to make the best choice and now she is stuck for the next year. As a matte of full disclosure, I'm a lawyer, and still have found this very difficult because I never practiced in the area of Medicare and these very cumbersome regulations are not user friendly. In addition, I thought we could rely on Extend Health to provide us with accurate information. My mistake, made to my mother's detriment.
If you have any suggestions about the best way to address this with Extend Health--who to email or write to--I would appreciate it. Or if this is something IBM should be made aware of--or even cares about. I would hope IBM would care, since they are paying these folks to provide accurate information, but I do know this is not the company my father went to work for in 1950.
Thank you again for what you are doing. Barbara
Unless your mother is really low income or the state she lives in has a state pharmaceutical program for somewhat low income people, she is not allowed to make a change to her plan until October 2014 open enrollment for 2015. You can complain to Extend Health but what I just described is Medicare law so they cannot change it. Your mother should look into using a prescription card from needymeds.org. It costs nothing. She'd use the card rather than her prescription plan to fill her prescription. They may give her a better deal. The only down side is whatever she will pay will not count toward the Medicare "doughnut hole". I do believe it is worthwhile to send an email to IBMsupport@extendhealth.com to complain about the advice that was given to your mother. Also, in October when she picks a new Rx insurance plan - look on medicare.gov and use planfinder on the site to find the best plan. They show plans by least expensive to most expensive in her zip code. She can also get that information by calling 1-800-MEDICARE. Thank you for your feedback. I am glad the blog is helpful.
DeleteThank you. It's interesting. Afte this post, I went back to their site and ran her prescriptions through the comparison again and sadly, it turns out that she is on the least expensive plan. It's just such a dramatic change from what the retirees were receiving previously.
ReplyDeleteIs she filling her prescription at a Walmart or Sam's pharmacy. Those are the "preferred" pharmacies for Humana and will give her the lowest cost for that plan. Network pharmacies do not give the lowest price unless they are preferred.
DeleteOops. Typing snafu. I also wanted to add that I'm really surprised at the dramatic loss in buying power for this very large group of retirees. Not being in the health care field, I don't understand precisely how the pricing of prescription drugs works and how the negotiation for the pricing works, but for my mother to go from paying $50 to $150 per month for one drug is a very dramatic increase. I also researched this drug at several places, including Costco and Canada Pharmacy, who were selling it for $176 and $182, respectively. So, it appears that one of the great losses for the IBM retirees is their buying power as a large group. With that type of increase, I don't see how it can be being managed well.
ReplyDeleteWhen IBM Medicare retirees used IBM's Rx insurance plan I believe they were getting the benefit of a group insurance negotiation that included all employees and retirees. As such IBM was probably able to negotiate formulary prices that benefitted Medicare eligible retires. The plans we are now buying are strictly individual Medicare insurance plans where each insurance company has to negotiate with a drug company for formulary prices. Our wonderful legislators FORBID the government from negotiating prices as a Medicare group for part D plans. The pharma lobby was very strong in passing that law. Although what IBM did was a pity - congress isn't any better. In Canada the government negotiates prices with pharma companies. That's why their citizens have better prices.
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