IBM Medicare supplemental medigap VICTORY

Holy cow ... sometimes being unwilling to "let it go" pays off!
   
I got the mail tonight and the cheapo medigap insurance company capitulated!!!  They paid the claims they were supposed to pay.  Unfortunately, they paid the providers (who had already been paid) so we'll have to wait for the providers to refund us the money.  BUT ... they paid!!!  And it was more than I thought it was ... about $1,500. 
 
I think the magic words I used in my last letter to them was that what they were doing was Medicare fraud and I would be filing agency complaints.  What a pity that it took such words to push them into action. 
 
Meanwhile, there are others out there that are being cheated and they don't even know it.  I sure hope the agencies I complained to will not treat this as a "closed case" and still investigate this company.
 
I also hope I have helped someone who is reading this blog to learn how to deal with insurance companies.  Keep reading the statements they send to you.  You have to work at understanding the statements and if it doesn't add up ... challenge the company.  Use the threat of involving state and federal agencies to support your case.
     
Clearly, if I had been wrong about their processing of the claims they wouldn't have paid them.  
Here's the crazy part ...  no explanation, no apology ... just a bunch of processing forms arrived that showed they paid a bunch of doctors money.  How guilty is that? 
     
Beware ... insurance companies are ruthless.
 
Update:  The cheapo insurance company sent a letter on December 24, 2014 explaining what happened.  They said they made a "clerical error".   They said they provided a more detailed explanation to the NYS Department of Insurance and have recalculated the deductible. Those rascally clerical errors and incompetent clerks just cannot be trusted.    

IBM Medicare OneExchange Medicare Supplemental story continues

It's been a couple of weeks since I wrote about my medigap hijacking story and I am sorry to say nothing has improved.  The company refuses to acknowledge my spouse hit the medigap F deductible and therefore should be paying the coinsurance claims. They sent a bunch of crap information back that basically was smoke and mirrors. It amazes me how they just stonewall the complaint no matter how much information I provide to prove the case. 
 
I am also amazed how long it is taking for State's Department of Insurance to respond to my complaint.  I filed the complaint in the middle of November and when I look on their website they still have not assigned it to an investigator.  That says a lot about the state services provided.  They must have two investigators to support millions of consumers.
 
Last week I found another state insurance department - a fraud department.  It wasn't obvious that it existed.  I Google searched to find it.  I sent in a request for a fraud investigation of the insurance company. Who knows if that will result in any action.  Even if it does result in an investigation, it doesn't mean we'll get money back from the insurance company.
   
I suspect this is how this insurance company makes money on medigap F high deductible plans.  They tell policy holders they haven't hit the deductible until there is way more coinsurance paid than the actual deductible amount and it's highly likely the policy holder will never notice it.  If the policy holder does notice but doesn't pay the providers the providers will send bills to collections so we had no choice but to pay the providers.  The goat rodeo that follows to try to get the insurance company to back pay to the actual deductible is impossible.  There is no intervening agency that will force them to pay or lose their license to sell policies.  All I can do at this point is take them to small claims court.  Even then, they can stonewall the payout.  Most small claims court awards never get paid. 
 
I will also try to get the Medicare federal inspector general to investigate the company.  However, I am pessimistic that the agency will even read my complaint much less do anything about it.  There have been many cutbacks at the state and federal level to agencies that support advocacy for consumers because lobbyists keep demanding more "cuts to bureaucracy". 
 
Once again, I lament what IBM did by throwing us into this den of insurance provider wolves.  Losing IBM's power to advocate and get insurance companies to behave is a huge loss for us.  Just a huge loss.

IBM Medicare OneExchange Medicare Supplemental Plan (medigap) experience

I've written a lot about Medicare Supplemental insurance and I thought I knew a lot about this insurance.  However, I have discovered I still have a whole lot to learn.  Oh, I know about the structure of the plans, how they are defined by law, and how an "N" plan is an "N" plan no matter who sells it and to "do the math".  I learned all about that stuff on medicare.gov and a myriad of other websites that describe types of medigaps.  However, none of those sites ever said a thing about the caliber of the insurance provider.  That's where my knowledge was (and is) woefully lacking.
 
It is true that the Medicare Supplemental policies are all the same.  However the insurance company services are certainly not the same. No one from medicare.oneexchange.com/ibm or anyplace else will tell you these things because it would make insurance companies very unhappy and most advisers have relationships with those companies:

• Buying a policy:  The standard advice about buying a medigap policy is to buy the cheapest one sold for the letter category you have selected.  So, I went to the department of insurance website for my state to find the list of who sells what type of medigap and at what price.  I was so excited when I saw the cheapest premium for the medigap plan I wanted was almost 50% less than the next higher price insurance company.  I tried everything but stand on my head to get that "cheapest" company to respond to my request to buy a policy.  I called them.  I emailed them.  I complained to the department of insurance that they were unresponsive and I said I suspected they only sold the policy if you bought other policies from them (which is illegal).  Nothing worked. There was no buying that cheapest policy.  So, I went to the second "cheapest" insurance company to buy the policy. I'll call them cheapo. They insisted the only way I could buy their policy was by having one of their insurance agents VISIT MY HOUSE.  So, I endured multiple visits from their agent and a dreary sales pitch about all the products they offered.  I begged her to stop, telling her all I wanted was a medigap.  She felt bad but she pressed on.  I finally was able to buy the policy. A couple of months later they fired her.  I guess she wasn't pushy enough. 
  
        
• Paying premiums for a policy:  I hate, hate, hate for any company to automatically take premiums out of my bank account.  It has been my experience that it is a nightmare to get them to stop and then forever to recoup any premiums they take after the policy is canceled. However, this "second cheapest" aka cheapo company insisted it is how they keep their costs down.  So, I relented and let them do it.  I must say, they never miss a beat when it comes to collecting the premium.  I cringe over how hard it is going to be to get them to stop when I cancel the policy at the end of this year.
      
• Paying the doctors (the medical providers):  In order for this cheapo insurance company to get a claim the doctors and the hospitals have to be very precise about how they file the claim with Medicare.  If they do not put exactly the right information about this medigap in the claim then it will not be sent by Medicare to the medigap via MAIL.  That's because this cheapo company will not implement automatic electronic crossover.  I never thought to ask them about that when I bought the policy.  I thought everyone did crossover.  So, one provider screwed up and didn't put the right information into their claims.  I didn't realize it because I don't get benefit from the plan until I meet a deductible.  Fixing that has turned out to be highly irritating and the provider is mad at me because they did it wrong! Even when it is done right, it seemed odd to me that it sometimes takes at least two months before I get bills from a doctor.  It turns out even when the doctor properly processes the claim, they cannot bill me until the cheapo company processes the claim and tells them I haven't yet met the deductible.   That's the law. They are not exactly speedy in their processing.  It's no wonder some doctors tell people with medigap insurance they want to be paid "up front" because it might take months for them to get money out of this insurance company even when they do it right. Make sure when you get a bill from your doctor or hospital that they have sent the claim to your medigap.  It will show it as a line item on the bill even if they get $0 from the medigap.  If you don't see the line item call the provider and ask them to file a claim with the medigap. 
   
• Tracking out-of-pocket costs for a deductible policy:  I am miserable about this issue and freaking out that I never thought about it as an issue.  One would think the cheapo insurance company would do this and automatically make coinsurance payments to doctors when I hit the deductible.  One would think.  Wait, it gets better.  How about, one would think the running total the cheapo company puts on the EOB tallying the YTD deductible is accurate.  One thinking that would be very wrong. I got at least 15 statements from the cheapo company.  But I never added up the expense amount across those 15 claims.  I just kept looking at the YTD total.  I am a total idiot to not have done the math myself until this week.  I'm about $900 over having met the deductible.  All I could say is HOLY $#@# and hold my head in my hands for being so stupid. It's going to take forever to get them to pay me that money back.  I just know it.
     
• Update 3/17/15: Ask for a sample EOB statement:  We just received an EOB (Explanation of Benefits)  statement from the new Medicare Supplemental plan.  It is one of the easiest to read statements I have ever seen.  It's better than the Aetna EOB Integration statements we used to get.  If you are considering changing to a new Medicare Supplemental insurance company, ask them to give you a sample EOB statement before you make the change. The quality of the statement says a lot about the caliber of the company.
       
• Providing customer service:  Want to guess the caliber of customer service provided by the cheapo company to try to resolve this problem?  I just loved arguing with the call center representative who insisted I was wrong until I went through several claims with her.  Then she said ... we'll check into this and get back to you.  Fat chance they will do that with just a phone call.  I knew I would have to start a letter writing campaign.
   
• Seeking resolution of a problem:  I don't know how long this is going to take but I don't have a good feeling.  I already sent in a written complaint to their claims department and their home office.  I also complained to the department of insurance (again) but this time I might get their attention because this is "fraud". It took me several days to compile the information and try to accurately describe the situation.  I'm sure I aged a couple of years trying to do it. 
    

So, I am war worn from this experience and will switch to a different medigap insurance provider in 2015.  When I started looking at the third cheapest company that sells the policy type I currently have, I went online to look at consumer complaints.  It wasn't pretty. I'm not going anywhere near that mess as it sounds worse than what I just described.  So, I am switching to a "K" plan only because I can buy it from a reputable insurance provider.  I'm not thrilled to buy "K" but it's the best option I can find for a "deductible" plan that is sold by a reputable insurance company.  I hope someone else can learn from my saga.  No one should have to deal with a disreputable insurance company but it's crueler still for old people to have to beat their way through this swamp.

IBM medicare.oneexchange.com/ibm Website and Conversation

I finally called OneExchange a few days ago to confirm part D insurance enrollment and to ask to be dis-enrolled in a vision plan that we had selected through OneExchange. They never fail to disappoint. 
 
First, the OneExchange website is still a mess. I looked at the plans available in my zip code and they still do not display the AARP UHC plans on the website - to find out that information  you must call OneExchange.  Then, I checked our enrollment information to verify our plans. The information for my part D plan is correct.  However, for my spouse, the information showed he was enrolled in TWO part D plans.  Now, that's not possible (by law, Medicare will not allow it) but it was not clear what they were trying to describe.  Last year there was a problem with the first part D plan, so my spouse had to switch to a different plan.  The website displays both plans but does not have any indication of which plan is active.  There was also no way to use the OneExchange website to dis-enroll from the vision plan. 
 
Next, I called OneExchange.  Similar to my experience last year, I was placed on hold for about 25 minutes before I spoke to a client representative.  I asked to representative (who was very nice) to confirm our part D enrollments and to explain why two part D plans were showing on the website for my spouse.  She put me on hold for about 10 minutes two times to try to get a logical answer for the two part D plans issue.  She finally said she was told it is because the website is showing enrollment history.  Ergo, there is no logical answer.  She did confirm our enrollments for our respective part D plans.
 
I then asked her to dis-enroll us from the vision plans for 2015 as we no longer wanted them.  She promptly said OneExchange cannot do it and I must call the insurance carrier to dis-enroll.  Now, that's also not logical.  An insurance agent (which OneExchange certainly is) can most certainly handle a dis-enrollment for these kinds of plans.  It's just not a service they provide. 
 
Although it is rather hateful to do it, I continue to encourage everyone to make sure to call OneExchange before December 7 and confirm all 2015 plan enrollments.  Make sure to record the date, time and agent name when you call just in case you need to do a Medicare appeal in 2015.  I also went to www.medicare.gov and verified our  respective  part D enrollments.  OneExchange is still too clumsy to trust.
 
 

IBM OneExchange HRA/FHA 2015 Disbursements

A recent mailing from OneExchange about Medicare part B premium recurring reimbursements couldn't have been more confusing in both the content and the timing.  There is no explaining why they chose to send out that mailing now.  It seems to me they could have done it months ago. People are confused enough right now about whether or not they need to do anything for enrollment.
  
Here's the deal on HRA reimbursements.  You can get reimbursements two ways.  It can be recurring or you can file for them yourself.  You can get reimbursed for bills such as your insurance premiums, your copays (aka coinsurance), doctor bills for doctors that do not take Medicare.  Medicare part B premiums are just "insurance premiums".
 
In an earlier post I mentioned that people who could afford to "pre-pay" insurance policy premiums for an entire year and then submit the claim to OneExchange to be reimbursed were able to very quickly "drain" their HRA accounts and were done with any reimbursement paperwork by February. However, you cannot do that with Medicare part B premiums.  The federal government is not setup for "prepay"!
  
Reminder for those people who retired before 1997 and get SHAP reimbursement for part B premiums up to a maximum of $900 - you can only apply for reimbursement from OneExchange for the remaining amount of part B payments you make ($358.80 if your part B is $104.90 in 2014).
 
  

IBM OneExchange Medicare 2015 Enrollment Directions

The emails and USPS mailings from IBM and OneExchange over the last week that couldn't be more confusing.  It's easy enough for me to confuse myself - I really don't need any more help.
 
There is an implication that we must "do something" to keep getting the IBM HRA/FHA.  If you already enrolled in a medical or prescription drug plan through OneExchange aka ExtendHealth  in the last 12 months then you don't need to "re-enroll" in the plan if it is still an active plan.
 
Here's when you need to "do something" regarding OneExchange enrollment: 

• The Medicare Advantage or prescription drug plan you use will not be offered in 2015.  Then you need to find a new medical or prescription drug plan.
• Your Medicare Advantage or prescription drug plan (PDP) will change in 2015 and you don't like the changes.  For example, the premium is increasing, the formulary is changing or the Medicare Advantage plan is changing their doctor network and excluding your doctor.

Although you don't need to contact OneExchange and do anything - I suggest you call them to verify you don't need to do anything.  Make notes on when and who you talked with and what they said.  That is just a little preventative medicine in case you need to file a complaint with Medicare because OneExchange screws up.  Remember ... OneExchange is an insurance agent to Medicare.  As such, if you find they have screwed up your enrollment and put you in a wrong plan or dis-enrolled you can appeal to Medicare that you were misled by an insurance agent and get it fixed.  But you need names and dates to make a good case for it.   If OneX screws up and denies access to your HRA you need that information to file an appeal with the IBM Plan Administrator that you were misinformed. 
   
I also want to keep reminding you that Medigaps aka Medicare Supplemental insurance policies for participants who use Original Medicare are not part of the Medicare Fall Enrollment process.  There are very specific rules for when/if you can enroll/dis-enroll in Medigaps.  You MUST look at your state rules for those policies. DO NOT make any changes until you know the full consequences of those changes.

Sorry to say - you have to have an advocate to be sure this stuff is done correctly.  I keep trying to educate my children on Medicare and my IBM HRA just in case I can't be my own advocate as I get older. They mostly ignore me but I know some of it is sinking in.

IBM OneExchange Medicare Supplement F High Deductible Experience

I'll start with a lament.  I still hugely miss IBM's retiree group plan for Medicare secondary insurance provided through Aetna Integration plan.  It offered such great coverage that went beyond what is provided by the government sanctioned Medicare supplemental plans and was so easy to use. It was a big, big take away.  End of lament.
     
I've written in early posts how I opted to stay with "Original Medicare" because I wanted maximum flexibility to be able to go to any doctor or clinic who would take Medicare anywhere in the country ( http://ibmmedicare.blogspot.com/2013/09/ibm-extend-health-why-i-like-original.html).  Another small reason I chose original Medicare is political.  Our federal government is using additional tax payer dollars to subsidize enrollees in Medicare Advantage plans versus enrollees in original Medicare.  Ergo, the government is subsidizing private insurance companies - another example of corporate welfare. The Affordable Care Act is trying to eliminate those extra payments but there is a slow phase out. 
   
Anyway, original Medicare is good insurance but medical copayments and deductible payments are limitless and can become exorbitant for catastrophic diseases.  Supplemental (aka medigap) insurance policies (offered by private insurance companies) provide insurance coverage for the copayments (known as coinsurance) and deductibles and thereby cap out of pocket costs. However, they offer no additional medical coverage (e.g., visits to an acupuncturist as was in Aetna Integration) and will only cover deductibles and copays for claims approved by original Medicare.
 
I decided my spouse and I would get  medigap F high deductible (F-HD) plans because the premiums are really low.  These plan do not provide any benefit at all until the client pays $2140 of copays and deductibles in a given year.  If those payments do exceed the $2140 the insurance then kicks in and  pays all deductibles and copays for the rest of the year. The counter resets every January.
    
This has been a complex medical year for my spouse. Even so, the total cost of copays and deductibles still hasn't even come close to $2140 so the medigap F-HD insurance has provided no benefit at all.  HOWEVER, the policy premiums are so low ($87/month - which is low for NY) that we are financially still way ahead by hundreds of dollars compared to buying a higher premium policy (e.g., medigap N) for a different kind of medigap that would have paid copays and deductibles immediately. We'll stay with F-HD plans for 2015.
   
As with any insurance coverage - car, house, boat ... the insurance premium paid goes up the more coverage you want.  Medicare Advantage plans sometimes obscure the fact that you are getting less (e.g., restricted doctor networks) for your premium payment - which might just be your part B premium.  Medigap plan premiums are high if you want copays and deductibles immediately covered.  During this fall enrollment time - I once again urge you to "do the math" and make sure your premium is worth the benefit you are receiving.
 
Updated 9/20/14:  I should have added to this post that you should check from time to time on your state's department of insurance website (in New York https://myportal.dfs.ny.gov/web/guest-applications/medicare-monthly-premiums) or call your state health insurance assistance agency  (www.shiptalk.org lists the phone number) to find out if there are new providers of  Medicare Supplemental plan offerings or if there have been premium changes for existing providers.  The state health insurance agency (aka SHIP) will also know the state rules for when or if you can switch to a different medigap plan.

IBM Medicare OneExchange 2014 fall open enrollment

For those of us already enrolled in Medicare, October 15 - December 7, 2014 is the annual open enrollment period.  This, by law, is the federal government's time of year when it allows Medicare recipients to make changes for Medicare Advantage plans and Medicare prescription drug plans to be effective for 2015.  It is NOT an official enrollment time to make changes to Medicare supplemental plans (aka medigap plans).  Medigap plans are regulated by state laws and your state determines when and whether you can switch from one medigap plan to another.  For example, in New York state you can change medigap policies any time you want to be effective the beginning of the next month.  It's called continuous enrollment.
 
What does all this have to do with OneExchange?  You are required to purchase at least one private insurance policy from OneExchange to get your HRA subsidy.  If you bought a Medicare Advantage plan or a drug plan and you are happy with the plan then you don't need to make any changes for 2015 and don't need to talk to anyone at OneExchange.  HOWEVER, you must RELOOK at your plan to be sure it will continue to provide the benefits you want in 2015 and take action if the plan is no longer meeting your needs.
 
This is the time of year private insurance plans make changes to benefits and to formularies (the list of drugs they will cover) for the plans they offer.  Your current plan should send you a notification of changes by the beginning of October.  I suggest that the best way to find out which prescription drugs your plan will cover is on the Medicare website (www.medicare.gov).  Plan updates will be posted on that website by October 15, 2014. That's when to do the "plan finder". Enter your drugs and look at available plans in your zip code that provide the best coverage.
 
If the medical or drug plan you currently have through OneExchange is no longer suitable, you will need to switch to a better OneExchange plan and you MUST make Medicare Advantage or part D insurance plan changes before December 8th since there is no special enrollment period for IBMers this year. The Medicare dates of Oct. 15 - Dec. 7  apply to make those changes. Again, it does not apply to Medicare Supplemental/medigap policies.  You need to talk to your state first to find out the rules for making those changes before you change anything with OneExchange. Unfortunately, switching means going through the OneExchange enrollment process again.
 

IBM Medicare HRA Claims for Uninsured Doctor or Dental Bills

I have been trying to get claims processed for two health provider bills that are not covered by my insurance.  It took several months, multiple denials and conversations with four different OneExchange agents before I got the right answer. It turns out there can be absolutely no reference to "insurance" anywhere on the provider bill.
   
In the case of the doctor services, I tried to submit evidence of doctor service and fees by using a uniform insurance form my doctor has always given to me.    He does not "accept" any insurance and requires payment by the client.  However, he does provide a bill on this form with diagnostic codes so the client can submit a claim to insurance for reimbursement (should it be a covered service).  Since he accepts no insurance - he obviously has opted out of Medicare. Because I provided that form to OneExchange as evidence of my doctor bill they immediately denied the claim. The claim denial said they wanted to see a copy of the insurance denial. They wanted a "pure" doctor bill on the doctor's stationary to remove that requirement.
    
I found this out because I recently submitted a bill from my dentist.  The dentist forgot I no longer had insurance and sent the claim to MetLife.  Of course, it was denied.  Then the dentist sent me a bill showing a claim had been sent to MetLife and $0 had been paid.  That line item caused OneExchange to deny my dental reimbursement claim because they again wanted to see the dental insurance claim denial.  When I called OneExchange to complain, the agent told me there can be no reference to insurance on the bill.  So, I whited out the line about MetLife and resubmitted the dentist statement.  Voila.  The claim was paid.
    
I complained to the agent that there was no way for me to know this "rule".  The agent said it is on the website.  Mea Culpa. I didn't read the entire website before submitting claims.  Of course, the denial reason couldn't explain that the reference to potential insurance coverage is the reason for the denial.  I mean, that is a lot to ask.
 

IBM Medicare HRA setup for IBM retiree couples

Yesterday a customer service representative at OneExchange further explained the account setup for married couples who have both retired from IBM.  I have never seen any documentation about why and how they setup those accounts.
  
The account is setup in the name of the person who is oldest.  In my case, that is my spouse.  The HRA subsidy for both people is put into one account.  Because we each have power of attorney for the other we are both able to access the account. 
 
The rep said there is huge benefit to having one account.  The amount of money in the account is available to cover the bills and premiums of either person to whatever amount is in the account.  So, it is possible to spend the entire account on just one person.
 
The rep went on to said if the accounts were separated then each person could only spend their own HRA money limit.  The couple would not have access to each other's money -  meaning if one underspent the HRA benefit the other could not tap into that remaining balance.
 
I have not seen that explanation written anywhere.  All I knew is when the account was setup it was one account in my spouse's name.  One customer service rep told me  I could split it apart when I questioned it earlier this year but did not tell me the ramifications.  I was concerned about what would happen when one of us dies but decided to not do a thing about it until next year. 
 
This customer representative told me they will settle it out when one of us dies and it is no issue. 
 
I haven't yet applied my rule of "ask 3 times" to be more confident that the answers provided are correct.  Maybe later in the summer I will ask again.

IBM Medicare part D Drug Insurance Formulary Exception Request

One of the aspects of losing the group health and prescription drug plans provided through IBM is we lost the help of the IBM HR employees that were assigned to shepherd us through various negotiations with insurance company claim denials.  We are now on our own to figure out the myriad Medicare appeals processes.
      
My spouse's doctor just wrote a prescription for a new drug.  When we took it to the pharmacy we were told it was denied because the brand name version of the drug is not on their formulary.  The doctor was very specific - he wants the brand name version.  As it happened, the brand name version of the drug was actually on the formulary until a couple of months ago.  You may not know this, but part D insurance plans can change their formularies whenever they "want".  Yes, they have to file paper work but then they can drop a drug they formerly covered "mid stream" in the plan year.  Our illustrious congress passed laws in 2006 allowing them to do so.  They also passed laws forbidding the government from negotiating with pharmaceutical companies to get drug discounts.  The insurance lobby and pharma lobby are strong lobbies.
     
Anyway, what that means is even if you bought a part D plan that covers your drug - the insurance company can decide during 2014 to adjust their formulary any time they want and drop your drug from their list.
     
Because my spouse's plan dropped coverage for the brand name drug this year - they are required (by law) to provide a 30 day "transition refill" even though this is a new prescription for my spouse.  If the drug were not on their 2014 formulary they would have just outright denied the drug.  OK - so now what? In our case - the first step is to request an exception and ask that the brand name drug be covered for the rest of the year.  The doctor had to write a letter for such a request to be even considered by the insurance company.
   
How do I put this politely?  The letter the doctor wrote sucked.  It didn't provide a compelling argument for why my spouse must take the brand name drug.  I didn't tell the doctor it sucked as it would have been truly obnoxious - but I do believe the request will be denied because it was truly a lousy letter.   
   
If the exception request is denied we will then need to go through the formal part D appeals process.  If so, I will try to get the doctor's office to write a "better" letter at the next step.  This might turn out to be a multi-step denial/appeal process.  The truth is you do not get a fair decision until you get to the independent review board appointed by Medicare to review denials which will be the after the "3rd denial" for us.  Insurance companies bet most people will give up after the first or second denial.  DON'T DO IT.  At least 50% of the time denials are overturned when they get to the independent review board.
     
How come I am so smart as to know a lousy doctor letter?  Only because of the volunteer work I do at the Medicare Rights Center.  Otherwise I would think it was just fine.  Yesterday, ironically, I urged a caller to go back to her doctor to get a better letter for the next level of her appeal because the letter she read to me for her first appeal was truly lousy too.  The Medicare Rights Center has a sample doctor letter:
     
 http://www.medicarerights.org/fliers/Rights-and-Appeals/Part-D-Appeals-Packet.pdf?nrd=1
          
You would think doctors know how to write these letters - sorry to say - they don't.  The compelling argument has to be that there are significant health (and cost) implications to using a generic version of a drug.  What is interesting is doctors might even tell you those implications but when it comes to writing appeal letters they go brain dead.
    
So the bottom line of this post - we've lost IBM advocates to help us with an onerous appeals process created by our legislators that make the navigation of the Medicare maze very difficult.  It doesn't matter what your party affiliation might be.  Congress acts as one when it comes to satisfying lobbyists and maintaining campaign contributions.  You have to become your own navigator and expert.  It's not easy but it will save you a lot of anguish and money so -  just do it.
  
5/28/14 Update: A pleasant surprise!  The exception request was granted!  The insurance company left a message implying they talked to the doctor after getting the request so the letter wasn't an issue.  My compliments to Express Scripts for making it so easy.  The exception expires in May 2015 so we'll have to get another prescription plan in October to cover the drug unless Express Scripts is willing to extend the exception for all of 2015.  At least we know it is covered for the rest of 2014.  Nice.

IBM Medicare and OneExchange HRA claims payment processing saga

HRA payment process seemed to settle down for me after a few blips in January and February.  Unfortunately, it didn't last and today I spent 45 minutes on the phone with the claims payment department trying to resolve two claim denials.
 
I file my claims by filling out the OneExchange form and then faxing the form and documentation to them.  I set up an email conformation of the fax. To set that up -  go to the PayFlex site and select the notification option. I use faxes so that I will have a complete picture of what I have submitted every month.  I attach my fax to the payment documentation when I receive checks to have a complete picture.  It was invaluable to have this information for today's call because I could quickly reel off dates and payments.
 
The confirmation email tells me what has been processed and what is denied before the check arrives.  This month they denied two claims.  One was for our proof of medigap F premium payments.  I provided a checking account statement I generated online  showing the premium payment deductions from our account.  It is exactly the same statement I have submitted for the same claim for the 3 prior months and all those claims were paid.  This time OneExchange said there was not enough proof. The second denial was for a claim for a payment to a doctor that doesn't take Medicare. There was no proof it was not paid by Medicare.
  
The first representative I spoke to said she would stay on the line and bring in a funding department representative for a 3 way call.  As soon as the funding representative came on the line the inital representative was gone!  The funding representative said the medigap insurance problem was that I didn't provide a copy of the bill from the medigap insurer.  I don't get a bill.  She said I needed to get one.  I said - but it was paid for the prior 3 months without a submitting a copy of a bill. She said the claims were never paid.  I countered that they were paid and gave exact dates when the claims were paid.  Then, she said she didn't know why those claims were paid but still insisted I needed a bill this time. 
 
For non-Medicare doctor fee claim, the denial said I needed an EOB showing the claim had been denied. As an aside - I don't get EOBs - I am in original Medicare so I get MSNs.  But I am quibbling. I told the representative the doctor doesn't accept Medicare so he is not going to even submit a claim to Medicare.  Then, the representative said what I needed was a letter from the doctor saying he does not participate in Medicare. At that point I felt like she was making up answers.
 
I then asked to talk to a supervisor.  The supervisor's analysis of the denials was completely different.
    
 The supervisor said the claim denial for  medigap premium  was because the online bank printout I provided didn't include my name.  The online generated statement only shows the last 4 digits of our checking account and does not show our names.  I told her that the prior claims were paid.  I also said the first time I submitted a premium claim I provided a copy of a check I wrote to the insurance company to pay the January premium and it did  include both our names and account number.  Nonetheless, she is now, in May, saying it may not be enough to generate a printout that has the last 4 digits of the same account that was shown on the January check for the follow-on months claims to be paid.  She said maybe they were wrong to even pay for 3 months. She said she would send the May denial back to claims processing for a review. 
 
The supervisor said for the non-Medicare doctor claim I needed to write on the doctor bill that he does not accept Medicare.  I did write it on the bill but it was at the bottom.  Apparently their fax machine cut off the bottom of that page.  She could see some of the writing but didn't get it all.  She said write it at the top of the bill and retransmit it. 
  
I don't trust that she is right about the non-Medicare doctor claim solution.  So, just in case, I went online to medicare.gov and got the form to submit the claim to Medicare myself and get an MSN denial.  I am truly annoyed to have to do so - the IRS rules for HRA are quite clear - you just have to show you paid the doctor for the employer to reimburse the fee. If I am trying to cheat the system I will be the one liable - not IBM.
 
I continue to be underwhelmed by the knowledge and helpfulness of the OneExchange call center representatives. I feel they  "make up answers" and want to just to get us off the phone.  I suggest that if your claims are denied, when you call to resolve the problem don't trust the answers you are getting and, if it is at all complicated,  ask to talk to a supervisor.

5/20/14 Update: The supervisor was right about the medigap F premium reimbursement.  I resubmitted a different printout - a screen shot of the payment from my checking account that also showed my name.  The claim was paid. However, she was wrong about the non-Medicare doctor claim.  I did what she said but it was denied again with the same reason -- they want an "EOB" denial.  I sent in the claim to Medicare so I'll get a denial MSN from Medicare in a couple of weeks and then I'll try to submit the claim again. I feel really lucky that I know what to do - OneExchange is absolutely clueless about giving Medicare administrative advice. I also get really aggravated that we have to jump through hoops to get our health benefit.
 
5/28/14 Update:  OneExchange almost got the medigap F premium reimbursement right.  They reimbursed one premium for May.  However, the second premium was tagged as a duplicate even though they were the ones who setup an account to handle TWO people.  I called yesterday and even the customer representative was baffled as to why the second premium was tagged as a duplicate.  He said the easiest way to fix it was to just setup recurring premium reimbursement and sent me the forms to do it.  I was perfectly happy submitting all my claims each month so I could easily track what I had filed.  At this point - I just want to get it fixed.
  
6/7/14 Update:  I continue to have trouble getting reimbursement for claims paid when the medical services are not covered by insurance.  This time my claim was denied for dental services.  They wanted to see an insurance statement because my dentist's bill showed he'd submitted the claim to MetLife and it was denied (of course).  And, of course, I threw out the MetLife denial statement.  Anyway, the answer du jour is doctor/dentist bills not covered by insurance can have NO reference to insurance on them.  So, now I need a new bill from the dentist without the reference to insurance. 

IBM Medicare and OneExchange - Know Your Rights

Several months ago IBM mailed out a thick manual titled "About Your Benefits: Post-Employment Summary Plan Description". The terms of this document were effective January 1, 2014.  THIS IS AN IMPORTANT DOCUMENT.
  
Most of what is in that manual is not applicable to IBM Medicare eligible retirees and you may have not bothered to even open the manual. However, there are several sections that are very important to Medicare eligible retirees.  Start from page 165 and try to read all the way through to the end of the manual.
 
In the Legal Information the manual describes the appeals process if your claims are denied by Towers Watson (page 227).  It's important to know that process because there are timelines associated with appealing denied benefits claims.  Basically, it is a 60 day window from the time of denial for you to appeal.
  
In the world of Medicare - it is also important to know the appeals process for all your claims handling.  If your insurance denies a claim there are also timeframes within which you must appeal or you can be denied again just based on the fact that you appealed "too late" even though your appeal was improperly denied and you would have succeeded in overturning the ruling had you done it on time.  Timeframes depend on the kind of insurance you have - Original Medicare or Medicare Advantage.
  
The net of this post is that we now have to know the process of how to appeal when an insurance company denies a claim - Towers Watson does not handle that.  And we also have to know the process of how to appeal when Towers Watson denies a reimbursement. 
 
Each time a claim is denied by an insurance company they are required to legally tell you the process.  The same does not apply to Towers Watson denying reimbursement claims. Dig out that IBM manual and put it in a place where you can reference it so you know what to do if you have a problem with Towers Watson claims. 
  

IBM Medicare OneExchange - Use the IBMsupport.OneExchange@TowersWatson.com email address

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

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

  

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

If you are using Original Medicare and have a secondary medigap supplemental insurance policy the medigap usually will have a crossover agreement with Medicare to get your claims from Medicare. How the crossover agreement works will depend on the secondary insurance company that issued your policy. Automatic crossover claims processing is really easy.  After I set it up,  I never had to file any claims with Aetna.  Medicare automatically sent claims to Aetna.  Do not assume your new medigap insurance company will do the same.
 
I have a user account on www.medicare.gov so I can see claims filed by doctors and also see my insurance profile without having to call Medicare or wait for a Medicare Summary Notice (aka MSN) which is mailed out once a quarter.  I looked at my secondary insurance profile on www.medicare.gov  today and it still showed Aetna as my secondary insurance.  There is no capability for a Medicare recipient to change that field.  Only insurance companies are authorized to notify Medicare of changes and it takes approximately 6 weeks for a change to be implemented.
  
If you have a medigap policy, your secondary insurance company may be willing to work with both the old IBM plan and Medicare to make the change. Call your insurance company and ask if they will do it or if they have already done it. When I first used Aetna Integration, it took one call to them and they worked with both Medicare and United Heath Care to make the change. 
   
This time, my insurance company would not do changes because of how they do crossover. It is not automatic.  I am paying a really low premium for a medigap F high deductible insurance plan so  I had low expectations. Also, Aetna did not notify Medicare that my 2013 policy terminated which is sort of crazy because it means Medicare would keep sending claims until Aetna told them to stop.  Aetna would have to keep denying those claims -- all of which has to have some administrative cost. Anyway, I called Aetna to have them notify Medicare my plan terminated.  Then I called my new insurance company to find out how their crossover works. 
 
By way of example, this is how my company does it - which is not great but worth the low premium:
 

• I ask the doctor's office to put the insurance company code on the Medicare claim form (in position 9D).  That code tells Medicare to fax or mail a copy of the claim to the insurance company. If there are Medicare employees involved in the process, I bet it doesn't work very well but it's worth trying.
      
• If the doctor's office cannot, I could ask if them to fax or mail a copy of the Medicare insurance claim directly to the insurance company. Since that does require human action, I won't ask.
      
• If the doctor's office cannot put the code on the claim,  then I will fax or mail a copy of the MSN to the insurance company when I get it. That is the official copy.  Print out of a claim from the medicare.gov website is not an "official" copy.
       

Even if there were automatic crossover, an F high deductible plan doesn't start paying until your out-of-pocket is $2110 for Medicare deductibles and copays. I will keep track of my Medicare deductibles and copays because I will submit them to Extend Health for HRA reimbursement. I'll also track it to be sure my insurance company starts paying if I hit the $2110 (and I sure hope that doesn't happen).  Even the IBM medical supplemental insurer United Heath Care was not good about keeping track of my out-of-pocket amounts (it was $4000 last time I used that plan) and made mistakes.

IBM Extend Health Reimbursement Account Rebate Process

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

IBM Medicare 2014 Remaining Enrollment Options for Extend Health Transition

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

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