It's been about a year that Towers Watson changed the name and it's obvious they did more than change the name, they changed the subcontracted provider that provides the customer interface. Time to give feedback on observations about it but my overall assessment is they are not good.
I did not have much interaction with the new services provider because most of my reimbursement are automatic. However, the few times I did submit claims, if they were routine, it worked. The two times I tried to submit claims that were "not routine" were not successful. They seem to not know how to handle claims from doctors who do not accept Medicare nor do they know how to accept claims for procedures that are not covered by Medicare (such as annual physical). In both cases I decided to not go on the war path because I knew I would be using up my HSA on other stuff. It wasn't worth the fight.
I truly hate the statements they send when they do a reimbursement. They are unintelligible. However, if I get the money, that's what really matters.
I also did not spend a lot of time on the website, given I don't need to make changes. I did call to change my medigap insurance in October and when I spoke to them, the agent tried to say I could not do it without underwriting until I reminded her I could do it whenever I want without consequence because I live in New York. She apologized for her mistake, but if I had not known I would have believed her. The quality of the service representatives seems to have degraded.
My next encounter happened when a friend told me he was advised, when he called, he could not file claims for part D IRMAA. For those that don't know, it is a Medicare income based assessment (don't call it a tax) imposed by Medicare for people with high incomes. He was told by Via Benefits it was not eligible for reimbursement. Of course, that was wrong. It is part of the part D premium but it is paid out of social security benefits or as a separate bill from Medicare.
I double checked it with Via Benefits via an inquiry on their site. The representative confirmed it was a legitimate recurring expense. Then he told me how to get a recurring expense form. Shock of shocks, he gave me the wrong information on how to find the form and I had to troll through the website until I figured it out. He directly sent me that answer to my email address. I do recommend putting inquiries in writing because it is less likely you will get a wrong answer. They don't want to have hard evidence of wrong answers.
Finally, I complained to Via Benefits via an inquiry message on their site that I no longer get email confirmations when I submit claims and could no longer find the setting on the website to double check it was still activated. This time, I got an email back telling me they had answered my question and it was posted on the site. It took me about 10 minutes to find where it was posted. I had to go to the reimbursements function and dig around until I found the message. There was no indication in the home screen that a message was pending. When I read the message, it said I could get a text, but no email confirmation. That's nuts twice. They could have put that in the email they sent to me telling me they had answered the question AND not everyone wants to give out their cell phone numbers so they can be texted!
Anyway, I guess we are lucky we still get HRA/FHA money. However, good luck figuring out all the Via Benefit quirks to be able to access that money to pay claims.
I wish you all a wonderful 2019 and a lot of patience and success getting claims paid. Complain, complain, complain if you have problems. It's the only way they will fix it.
Friday, December 21, 2018
Thursday, November 15, 2018
IBM Medicare Via Benefits Medicare Advantage Maximum Out of Pocket Cost
I write a lot about Medicare Advantage plans because they are complex but are presented as a comprehensive and simple one-stop shopping alternative to original Medicare.
This post is focusing on the MAXIMUM out of pocket (MOOP) cost you might pay using a Medicare Advantage plan if you are seriously ill. MOOP is an accumulation of all your payments, excluding premium payments, for a given year.
It is rare that this aspect of Medicare Advantage plans is mentioned or truly explained by the company or an insurance agent. It is often referred to as a cap and not MOOP. It needs to be an important part of your selection criteria if you are considering one of these plans.
The federal government determines the maximum MOOP number and it is current set at $6,700. However, your actual maximum can go as high as $13,400 a year. It is up to the insurance company where to set the MOOP but it never can be higher that $6,700 for in-network providers. To be fair, there are plans where the MOOP is $0. They are more restrictive plans such as HMOs where you cannot go out of network and in-network is a small set of doctors.
It is important to realize that if your plan does include an in-network and out-of-network option and you go to an out-of-network provider, your payment to the provider might not count toward an in-network MOOP. It depends on the insurance plan. Some plans have two numbers, meaning there is an in-network MOOP and an out-of-network MOOP.
I just saw a plan yesterday that had two categories and each category was set at $5000. That means if the policy holder was very sick, they could end up paying a whooping $10,000 out of pocket in 2019 plus pay a premium of $103/mo. Ergo, the MOOPs + premium cost could top out at $11,236/year!!!
How the blazes does that happen? When you are seriously ill, the cost sharing in Medicare Advantage plans changes. For example, your copay might be significantly higher than in original Medicare if you need home care. Insurance companies never talk about that.
Here is my bottom line on all of this.
A Medicare Advantage plan can be significantly more expensive than original Medicare if you get sick and has the potential of costing$13,400 in 2019 and you cannot buy a secondary insurance policy to cover that cost. There is no regulated MOOP for out-of-network services - see update below.
Original Medicare with my current F high deductible plan ($93/mo in my zip code) guarantees I will never pay more than $1116 in premiums and $2300 in F HD deductible in 2019. So my Original Medicare + FHD policy premium + FHD "MOOP" is $3,416. AND I can go to any Medicare doctor anywhere in the USA without needing a referral or worrying about networks.
I think that says it all.
Updated 5/31/2019
Today I helped someone who's parent had a Medicare Advantage PPO plan, was scheduled for cataract surgery as a hospital outpatient and was informed they had to pay a $1000 deductible and a $350 fee prior to receiving treatment.
The plan was structured to have very low cost (in copays and no monthly premium) as long as the person had minimal health issues. The parent didn't realize there was a $1000 deductible if she needed to use the hospital as an outpatient. When I looked at a more detailed description, there was a $675 deductible for inpatient admission (and nothing said about how often that deductible had to be paid such as one a year, once a quarter, for every admission and a $500/day copay after day 20. There was also a $6,700 in-network MOOP and a $10,000 out-of-network MOOP. Ergo the parent might face an annual cap of $16,700 because apparently the out-of-network MOOP is not regulated!
It's a pathetic decimation of the promise of Medicare insurance to protect the elderly from overwhelming medical cost and the federal government is enabling this by actively "pushing" Medicare Advantage plans.
This post is focusing on the MAXIMUM out of pocket (MOOP) cost you might pay using a Medicare Advantage plan if you are seriously ill. MOOP is an accumulation of all your payments, excluding premium payments, for a given year.
It is rare that this aspect of Medicare Advantage plans is mentioned or truly explained by the company or an insurance agent. It is often referred to as a cap and not MOOP. It needs to be an important part of your selection criteria if you are considering one of these plans.
The federal government determines the maximum MOOP number and it is current set at $6,700. However, your actual maximum can go as high as $13,400 a year. It is up to the insurance company where to set the MOOP but it never can be higher that $6,700 for in-network providers. To be fair, there are plans where the MOOP is $0. They are more restrictive plans such as HMOs where you cannot go out of network and in-network is a small set of doctors.
It is important to realize that if your plan does include an in-network and out-of-network option and you go to an out-of-network provider, your payment to the provider might not count toward an in-network MOOP. It depends on the insurance plan. Some plans have two numbers, meaning there is an in-network MOOP and an out-of-network MOOP.
I just saw a plan yesterday that had two categories and each category was set at $5000. That means if the policy holder was very sick, they could end up paying a whooping $10,000 out of pocket in 2019 plus pay a premium of $103/mo. Ergo, the MOOPs + premium cost could top out at $11,236/year!!!
How the blazes does that happen? When you are seriously ill, the cost sharing in Medicare Advantage plans changes. For example, your copay might be significantly higher than in original Medicare if you need home care. Insurance companies never talk about that.
Here is my bottom line on all of this.
A Medicare Advantage plan can be significantly more expensive than original Medicare if you get sick and has the potential of costing
Original Medicare with my current F high deductible plan ($93/mo in my zip code) guarantees I will never pay more than $1116 in premiums and $2300 in F HD deductible in 2019. So my Original Medicare + FHD policy premium + FHD "MOOP" is $3,416. AND I can go to any Medicare doctor anywhere in the USA without needing a referral or worrying about networks.
I think that says it all.
Updated 5/31/2019
Today I helped someone who's parent had a Medicare Advantage PPO plan, was scheduled for cataract surgery as a hospital outpatient and was informed they had to pay a $1000 deductible and a $350 fee prior to receiving treatment.
The plan was structured to have very low cost (in copays and no monthly premium) as long as the person had minimal health issues. The parent didn't realize there was a $1000 deductible if she needed to use the hospital as an outpatient. When I looked at a more detailed description, there was a $675 deductible for inpatient admission (and nothing said about how often that deductible had to be paid such as one a year, once a quarter, for every admission and a $500/day copay after day 20. There was also a $6,700 in-network MOOP and a $10,000 out-of-network MOOP. Ergo the parent might face an annual cap of $16,700 because apparently the out-of-network MOOP is not regulated!
It's a pathetic decimation of the promise of Medicare insurance to protect the elderly from overwhelming medical cost and the federal government is enabling this by actively "pushing" Medicare Advantage plans.
Tuesday, October 16, 2018
IBM Medicare Via Benefits Medicare Fall Enrollment for 2019
Medicare fall enrollment began yesterday. You have until midnight December 7th to make decisions about what, if anything, you want to change regarding your Medicare insurance. DO NOT wait that long if you have to call Via Benefits to change a policy you bought through them to another one they offer because it will take forever to get through to them.
YOU MUST buy at least one policy through Via Benefits to get to use your HRA/FHA. If you bought a plan such as a part D (PDP) that was not through Via Benefits then you can select a new PDP by going to www.medicare.gov to enroll or by calling 1-800-MEDICARE to enroll.
You'll get bombarded by mail and email from every insurance company selling Medicare Advantage plans and prescription drug plans (PDPs) in your zip code because this is the time of year you can change to those plans. It is also the time of year you can drop your Medicare Advantage plan and switch to original Medicare.
HOWEVER, it depends on the state you live in whether and when you can buy a Medicare Supplement plan to use with original Medicare. Call your State Health Insurance Assistance Program to find out the Medicare Supplement aka medigap rules for your state if you do not know them.
You can find your State Health Insurance Assistance program phone number at https://www.shiptacenter.org.
YOU MUST buy at least one policy through Via Benefits to get to use your HRA/FHA. If you bought a plan such as a part D (PDP) that was not through Via Benefits then you can select a new PDP by going to www.medicare.gov to enroll or by calling 1-800-MEDICARE to enroll.
You'll get bombarded by mail and email from every insurance company selling Medicare Advantage plans and prescription drug plans (PDPs) in your zip code because this is the time of year you can change to those plans. It is also the time of year you can drop your Medicare Advantage plan and switch to original Medicare.
HOWEVER, it depends on the state you live in whether and when you can buy a Medicare Supplement plan to use with original Medicare. Call your State Health Insurance Assistance Program to find out the Medicare Supplement aka medigap rules for your state if you do not know them.
You can find your State Health Insurance Assistance program phone number at https://www.shiptacenter.org.
Friday, October 12, 2018
IBM Medicare Via Benefits OneExchange ExtendHealth Disadvantage of Medicare Advantage
In the last few months the Department of Health and Human Services became the advertising agency for Medicare Advantage plans. This is supposed to be an unbiased organization that provides the oversight and administrative processing for Medicare recipients. It is now the unabashed tool of private insurance companies.
Updated 6/11/19
It's disheartening because Medicare Advantage plans have a lot of downsides that are hidden in the details and the sweet smile of insurance agents. This link to a Reuters news report confirmed it has been happening for a while, but the current government administration is over the top:
https://www.reuters.com/article/us-column-miller-medicare/medicare-advantage-plans-get-unfair-push-from-u-s-government-critics-idUSKBN1O621T
Updated 12/5/18
A few days ago this report appeared in the New York Times about how the Department of Health is "advertising" Medicare Advantage plans and the lack of pros and cons:
https://drive.google.com/file/d/1nOu51PEZhmaG9OUzDyblYQJSXIUVLUDM/view?usp=sharing
The best synopsis I have seen about that downside of Medicare Advantage plans is this description in Investopedia. I encourage anyone considering a Medicare Advantage plan to first read this article:
https://www.investopedia.com/articles/personal-finance/010816/pitfalls-medicare-advantage-plans.asp
Updated 10/15/18
The New York Times and a number of other publications recently did an article about Medicare Advantage Plans inappropriately denying claims such that 75 percent of appeals are successful at the first level of review. That means insurance companies are exploiting customers who are too overwhelmed to appeal either because they do not realize they can appeal or they don't have the wherewithal to do it. How ruthless!
Here is a link to a copy of the NYT article:
https://drive.google.com/file/d/1FUFTc8RhIvYkyhiS35jB_mSPPe1R8oJs/view?usp=sharing
If you want to read the full inspector general report here is a link to a copy of the report:
https://drive.google.com/file/d/1P0CUSXXlimKU3DlT4bVSCQ6EvNKYG-UX/view?usp=sharing
Updated 10/20/18
A couple of days ago I received and email from "Medicare" that was legitimately from the US government urging me to consider a Medicare Advantage Plan. I was so irate that the federal government is pushing private insurance over the traditional Medicare insurance pool that I sent a copy of the email to my local congressional representative to complain. This is beyond egregious. The federal government has no business hyping private insurance plans and looks like a violation of federal government ethics rules (Employees shall act impartially and not give preferential treatment to any private organization or individual).
Updated 10/30/18
I recently saw a program on PBS about how companies that offer Medicare Advantage plans have been pushing doctors in their networks to use more serious diagnosis codes so the insurance companies can increase the amount reimbursement they get from the federal government. Companies like United Healthcare are now being sued by the government for BILLIONS of dollars in over-payment of claims. Here is a link to the program: https://www.pbs.org/video/medicare-advantage-taking-advantage-aldeae/
Updated 11/13/2018
I just found the following recent quotes from the heads of HHS and CMS:
Updated 6/11/19
It's disheartening because Medicare Advantage plans have a lot of downsides that are hidden in the details and the sweet smile of insurance agents. This link to a Reuters news report confirmed it has been happening for a while, but the current government administration is over the top:
https://www.reuters.com/article/us-column-miller-medicare/medicare-advantage-plans-get-unfair-push-from-u-s-government-critics-idUSKBN1O621T
Updated 12/5/18
A few days ago this report appeared in the New York Times about how the Department of Health is "advertising" Medicare Advantage plans and the lack of pros and cons:
https://drive.google.com/file/d/1nOu51PEZhmaG9OUzDyblYQJSXIUVLUDM/view?usp=sharing
The best synopsis I have seen about that downside of Medicare Advantage plans is this description in Investopedia. I encourage anyone considering a Medicare Advantage plan to first read this article:
https://www.investopedia.com/articles/personal-finance/010816/pitfalls-medicare-advantage-plans.asp
Updated 10/15/18
The New York Times and a number of other publications recently did an article about Medicare Advantage Plans inappropriately denying claims such that 75 percent of appeals are successful at the first level of review. That means insurance companies are exploiting customers who are too overwhelmed to appeal either because they do not realize they can appeal or they don't have the wherewithal to do it. How ruthless!
Here is a link to a copy of the NYT article:
https://drive.google.com/file/d/1FUFTc8RhIvYkyhiS35jB_mSPPe1R8oJs/view?usp=sharing
If you want to read the full inspector general report here is a link to a copy of the report:
https://drive.google.com/file/d/1P0CUSXXlimKU3DlT4bVSCQ6EvNKYG-UX/view?usp=sharing
Updated 10/20/18
A couple of days ago I received and email from "Medicare" that was legitimately from the US government urging me to consider a Medicare Advantage Plan. I was so irate that the federal government is pushing private insurance over the traditional Medicare insurance pool that I sent a copy of the email to my local congressional representative to complain. This is beyond egregious. The federal government has no business hyping private insurance plans and looks like a violation of federal government ethics rules (Employees shall act impartially and not give preferential treatment to any private organization or individual).
Updated 10/30/18
I recently saw a program on PBS about how companies that offer Medicare Advantage plans have been pushing doctors in their networks to use more serious diagnosis codes so the insurance companies can increase the amount reimbursement they get from the federal government. Companies like United Healthcare are now being sued by the government for BILLIONS of dollars in over-payment of claims. Here is a link to the program: https://www.pbs.org/video/medicare-advantage-taking-advantage-aldeae/
Updated 11/13/2018
I just found the following recent quotes from the heads of HHS and CMS:
"Medicare Part D and Medicare Advantage demonstrate the successes possible when we harness consumer choice and private-sector innovation to improve care and lower cost," said Alex Azar, secretary of the Department of Health and Human Services.
CMS Administrator Seema Verma added: "The steps that the Trump Administration has taken to improve and drive competition in Medicare Advantage means more savings, more benefits, and lower costs for seniors."
Saturday, October 6, 2018
IBM Medicare Via Benefits OneExchange Extend Health Fall Open Enrollment 2019 choices
I have said several times in this blog that Via Benefits (aka Extend Health or OneExchange) does not sell all the Medicare plans available in your zip code. I decided to take a look at how many plans were available in my zip code on www.medicare.gov as compared to the plans offered by Via Benefits for 2019:
Plan Type zip code offerings Via Benefit offerings
Prescription 23 15
(PDP)
Medicare 28 21
Advantage
with Rx
Medicare 6 0
Advantage
without Rx
I made this chart to emphasize how important it is to look at all the plans available to buy as you might find a better plan in your zip code than in the subset of the plans offered by Via Benefits. If it turns out that is true for a Medicare Advantage plan, I suggest you call Via Benefits and ask them how you can get an exception to buying a plan from them because their offerings are inadequate for your medical needs.
As I wrote in my last post, I did change to a Medicare Supplement (aka medigap) F high deductible (aka F-HD or F+) plan. The K plan was okay but the maximum out of pocket protection in the case of a catastrophic illness was too high, particularly if I was incapacitated unable to switch to something better. I am learning as I age that I have to make insurance choices as simple as possible even if it means paying a higher premium.
I also wanted to harp on the fact that there is more and more propaganda as regards pushing seniors to Medicare Advantage plans. Now www.medicare.gov is doing it. This past week I was counseling a client who complained that some of the doctors she uses would not take her Medicare Advantage plan but would accept Medicare. When I asked her why she kept the plan, she said because the premium was cheaper than buying a part D and a medigap to use with original Medicare. For some reason, the out of pocket costs she paid to the doctors who wouldn't take her plan were not part of her cost calculations!
I have written this a bunch of times, but feel it is worth writing again. This is INSURANCE. You are buying insurance coverage but you hope like hell you never need to use it. You buy auto insurance in case you have an accident. If you never have an accident, it doesn't mean the auto insurance wasn't worth buying. It means you are lucky. Ditto house insurance and fires. Ditto health insurance!
Plan Type zip code offerings Via Benefit offerings
Prescription 23 15
(PDP)
Medicare 28 21
Advantage
with Rx
Medicare 6 0
Advantage
without Rx
I made this chart to emphasize how important it is to look at all the plans available to buy as you might find a better plan in your zip code than in the subset of the plans offered by Via Benefits. If it turns out that is true for a Medicare Advantage plan, I suggest you call Via Benefits and ask them how you can get an exception to buying a plan from them because their offerings are inadequate for your medical needs.
As I wrote in my last post, I did change to a Medicare Supplement (aka medigap) F high deductible (aka F-HD or F+) plan. The K plan was okay but the maximum out of pocket protection in the case of a catastrophic illness was too high, particularly if I was incapacitated unable to switch to something better. I am learning as I age that I have to make insurance choices as simple as possible even if it means paying a higher premium.
I also wanted to harp on the fact that there is more and more propaganda as regards pushing seniors to Medicare Advantage plans. Now www.medicare.gov is doing it. This past week I was counseling a client who complained that some of the doctors she uses would not take her Medicare Advantage plan but would accept Medicare. When I asked her why she kept the plan, she said because the premium was cheaper than buying a part D and a medigap to use with original Medicare. For some reason, the out of pocket costs she paid to the doctors who wouldn't take her plan were not part of her cost calculations!
I have written this a bunch of times, but feel it is worth writing again. This is INSURANCE. You are buying insurance coverage but you hope like hell you never need to use it. You buy auto insurance in case you have an accident. If you never have an accident, it doesn't mean the auto insurance wasn't worth buying. It means you are lucky. Ditto house insurance and fires. Ditto health insurance!
Sunday, September 23, 2018
IBM Medicare Via Benefits Fall Open Enrollment for 2019 insurance
Another year, another fall open enrollment. I just received the 2019 information for my part D plan. The premium went up about 30%! That stinks. More importantly, a brand name drug is no longer on their formulary. The only way it is covered is by the generic, which doesn't work as well. Double, that stinks. Once again, I beg you to check the 2019 coverage for your Medicare part D to be sure it is still covering your drugs.
If it's time to find a new part D prescription insurance plan, the prices and coverage for the 2019 plans should be loaded by October 1st in www.medicare.gov but enrollment won't be activated until October 15. Since I already have a medigap plan with Via Benefits, I can buy any part D plan available in my zip code and am not restricted to just the plans Via Benefits offers.
I am hoping Via Benefits has a suitable part D plan - even if it isn't the cheapest plan I can buy. It seems interacting with this new service provider is no thrill. Although I chose email notification when I submit claims (I fax in claims), they seem to use a random number generator to decide whether or not to notify me they got the claim. I am also hearing from people that they are making mistakes such as double paying a premium and/or not paying some premiums. My biggest complaint about the switch to Via Benefits is the statements they send when they reimburse. I thought it was just me, but a few people have said "what the hell".... They are unintelligible.
This year I am also going to switch my medigap policy to F high deductible. I've played with the K plan and it was fun, but it really didn't provide much benefit and I am tired of the game. Also, as I have said in the past, F high deductible is going away in 2020 because the F plan is going away. I want to get it now and stick with it until I see what happens with the G high deductible offering.
There are other changes happening in 2019 such as new Medicare Advantage structures. There is also a horrid proposal by HHS to change how doctor visits are paid. They want to pay the same rate whether it a visit to a primary care doctor or a specialist. If enacted, it might become more difficult to find a specialist that accepts Medicare. As I have written in the past, HHS is making many changes administratively and not as a result of legislation. That, in itself, is making it ever more difficult to object to the changes. Here's a link to an analysis of some changes and proposed changes by the Medicare Advocacy Center. It's hard to read. I just skimmed it and my eyes started to roll around in my head: http://www.medicareadvocacy.org/wp-content/uploads/2018/09/Report.-Summary-2019-Call-letter-and-C-D-Rule-1.pdf
There is something else happening that is rather distressing. It seems health care providers have decided to partner with insurance companies to "push" their Medicare Advantage offerings. A provider group I use for some of my medical needs offers seminars on such policies. I have spoken to people who thought they were talking to someone from the medical group about what insurance to use and did not realize they were talking to an insurance agent from the insurance company. I have also tried to help someone who was in an assisted living facility who couldn't understand why they could not use the physical therapists at the facility. They did not realize when they moved to the facility they also had to buy the Medicare Advantage policy sold by the facility to have access to PTs and Home Care providers provided by the facility. They were not real happy because the primary care doctor they used was not covered by that plan.
I am even noticing that AARP is skewing their advice toward their Medicare Advantage plans in their newsletters. That's sad because they've aligned with United Health Care for years but were really pristine about keeping their advice unbiased.
The final thing I have noticed which is extraordinarily distressing, is insurance agents are becoming more ruthless about coercing seniors into switching insurance plans. Perhaps because of the attacks on the Affordable Care Act, insurance agents see an opportunity to do it. Last week, a woman with cognitive difficulties told an agent 4 times that she did not want an HMO, she wanted a PPO. She signed a lot of papers but did not have the wherewithal to be able to read them. When she got home she slowly started to read all the papers she had signed and realized she had been put into an HMO. She was lucky, she got Medicare to change it. Some people don't realize it until they go to the doctor.
Hopefully, the advice Via Benefits provides is not skewed, but keep in mind that it is their best interest for you to buy all your insurance from them. Thereby they get more commission. Make sure if you are trying to pick a new plan, you are getting advice from an unbiased source. 1-800-Medicare is unbiased, your state SHIP is unbiased (you can find yours at https://www.shiptacenter.org) and there are many non-profits offering advice such as www.medicarerights.org.
Happy fall open enrollment.
If it's time to find a new part D prescription insurance plan, the prices and coverage for the 2019 plans should be loaded by October 1st in www.medicare.gov but enrollment won't be activated until October 15. Since I already have a medigap plan with Via Benefits, I can buy any part D plan available in my zip code and am not restricted to just the plans Via Benefits offers.
I am hoping Via Benefits has a suitable part D plan - even if it isn't the cheapest plan I can buy. It seems interacting with this new service provider is no thrill. Although I chose email notification when I submit claims (I fax in claims), they seem to use a random number generator to decide whether or not to notify me they got the claim. I am also hearing from people that they are making mistakes such as double paying a premium and/or not paying some premiums. My biggest complaint about the switch to Via Benefits is the statements they send when they reimburse. I thought it was just me, but a few people have said "what the hell".... They are unintelligible.
This year I am also going to switch my medigap policy to F high deductible. I've played with the K plan and it was fun, but it really didn't provide much benefit and I am tired of the game. Also, as I have said in the past, F high deductible is going away in 2020 because the F plan is going away. I want to get it now and stick with it until I see what happens with the G high deductible offering.
There are other changes happening in 2019 such as new Medicare Advantage structures. There is also a horrid proposal by HHS to change how doctor visits are paid. They want to pay the same rate whether it a visit to a primary care doctor or a specialist. If enacted, it might become more difficult to find a specialist that accepts Medicare. As I have written in the past, HHS is making many changes administratively and not as a result of legislation. That, in itself, is making it ever more difficult to object to the changes. Here's a link to an analysis of some changes and proposed changes by the Medicare Advocacy Center. It's hard to read. I just skimmed it and my eyes started to roll around in my head: http://www.medicareadvocacy.org/wp-content/uploads/2018/09/Report.-Summary-2019-Call-letter-and-C-D-Rule-1.pdf
There is something else happening that is rather distressing. It seems health care providers have decided to partner with insurance companies to "push" their Medicare Advantage offerings. A provider group I use for some of my medical needs offers seminars on such policies. I have spoken to people who thought they were talking to someone from the medical group about what insurance to use and did not realize they were talking to an insurance agent from the insurance company. I have also tried to help someone who was in an assisted living facility who couldn't understand why they could not use the physical therapists at the facility. They did not realize when they moved to the facility they also had to buy the Medicare Advantage policy sold by the facility to have access to PTs and Home Care providers provided by the facility. They were not real happy because the primary care doctor they used was not covered by that plan.
I am even noticing that AARP is skewing their advice toward their Medicare Advantage plans in their newsletters. That's sad because they've aligned with United Health Care for years but were really pristine about keeping their advice unbiased.
The final thing I have noticed which is extraordinarily distressing, is insurance agents are becoming more ruthless about coercing seniors into switching insurance plans. Perhaps because of the attacks on the Affordable Care Act, insurance agents see an opportunity to do it. Last week, a woman with cognitive difficulties told an agent 4 times that she did not want an HMO, she wanted a PPO. She signed a lot of papers but did not have the wherewithal to be able to read them. When she got home she slowly started to read all the papers she had signed and realized she had been put into an HMO. She was lucky, she got Medicare to change it. Some people don't realize it until they go to the doctor.
Hopefully, the advice Via Benefits provides is not skewed, but keep in mind that it is their best interest for you to buy all your insurance from them. Thereby they get more commission. Make sure if you are trying to pick a new plan, you are getting advice from an unbiased source. 1-800-Medicare is unbiased, your state SHIP is unbiased (you can find yours at https://www.shiptacenter.org) and there are many non-profits offering advice such as www.medicarerights.org.
Happy fall open enrollment.
Thursday, May 17, 2018
IBM Medicare Via Benefits the Disadvantage of Medicare Advantage Plans
There are two ways for the government to get rid of Medicare. The obvious way is to repeal the law enacting Medicare that was passed in 1965. That would be political suicide. The subtle way is to privatize it and then turn it into a voucher system. That effort has been in play since the mid 1980s and the process is accelerating in sneaky, stealth, legislative and non-legislative actions (by Health and Human Services).
The legislative actions to affect Medicare rarely come as direct "Medicare Legislation". The actions are buried in bills that have no hint of having anything to do with Medicare. The actions are buried in crazy places, like a farm bill or a budget bill. For example, in the Budget Act of 2018 (H.R.1892) bill there was a significant increase for higher income Medicare recipients' part B premium "tax", (but don't call it a "tax" call it something incomprehensible like IRMAA to disguise it). It's a sneaky way of attacking Medicare. Sometimes, journalists pick up on these changes and citizens are able to push back on the proposed actions. Mostly, it doesn't happen. Ergo, medigap plan F will no longer be available in 2020 even though it is a popular plan, because the legislative body decided people who have it go to the doctor too much. WHAT? Seriously, that is the reason.
The non-legislative actions are just plain stealth. They are harder still to find, follow and understand. These slow motion actions are also sinister because no journalist will have the tenacity to investigate and do ongoing reporting of the impact of negative changes dribbling out over years. The biggest changes that are not obvious are the elimination of many services like the closing of local Social Security offices making it more difficult for people to resolve problems when they sign up for Medicare or the reduced staffing and increasing turnover of 1-800-MEDICARE client service representatives because of low bid contracts, making the help available for complex problem resolution worthless. Even the website is deteriorating and has not been updated in 18 months because the contract to do any upgrades has been "held up" in the HHS bidding process.
The biggest non-legislative actions happen because insurance company lobbyists push legislators who in turn push HHS to expand the options available in Medicare Advantage Plans. There is currently a plan to expand those fringe options, such as adding acupuncture. There are already services included in Medicare Advantage Plans, such as dental coverage, that are not included in original Medicare even though the government is subsidizing both ways of getting coverage. Why add more?
If Medicare eligible recipients move to Medicare Advantage (MA) Plans then the government can get out of the insurance pool business. That is, get rid of original Medicare. The next step will then be to provide a fixed amount of money (aka vouchers) to Medicare recipients to buy MA policies and further disengage by gradually removing government oversight and pushing complaints back to the insurer to resolve. Better still, the voucher money will never increase (think IBM HRA), making the cost burden of Medicare shift back to the recipients and off of general tax payers. It thereby ends Medicare.
Maybe that's the most dire scenario. The less dire scenario is the government just pushes everyone onto Medicare Advantage Plans and kills original Medicare with a medigap. What's the big deal? Well, Medicare Advantage Plans are MANAGED CARE policies.
As some of you know, I do Medicare counseling. In the last month, I tried to help two people who were locked into Medicare Advantage plans. Neither could go to an advanced cancer treatment center, like City of Hope in California, to get treatment for rare forms of cancer. One policy holder had an HMO policy that did not allow out-of-network coverage, another had PPO coverage but could not afford the co-pays of out-of-network services.
Reminder, Medicare recipients who have original Medicare can go to any Medicare doctor or clinic anywhere in the country. Beware shiny objects being flashed by Medicare Advantage Plans. Having Silver Sneakers won't help you if you need to remedy a potentially life ending health crisis which requires treatment from a top notch specialist.
The legislative actions to affect Medicare rarely come as direct "Medicare Legislation". The actions are buried in bills that have no hint of having anything to do with Medicare. The actions are buried in crazy places, like a farm bill or a budget bill. For example, in the Budget Act of 2018 (H.R.1892) bill there was a significant increase for higher income Medicare recipients' part B premium "tax", (but don't call it a "tax" call it something incomprehensible like IRMAA to disguise it). It's a sneaky way of attacking Medicare. Sometimes, journalists pick up on these changes and citizens are able to push back on the proposed actions. Mostly, it doesn't happen. Ergo, medigap plan F will no longer be available in 2020 even though it is a popular plan, because the legislative body decided people who have it go to the doctor too much. WHAT? Seriously, that is the reason.
The non-legislative actions are just plain stealth. They are harder still to find, follow and understand. These slow motion actions are also sinister because no journalist will have the tenacity to investigate and do ongoing reporting of the impact of negative changes dribbling out over years. The biggest changes that are not obvious are the elimination of many services like the closing of local Social Security offices making it more difficult for people to resolve problems when they sign up for Medicare or the reduced staffing and increasing turnover of 1-800-MEDICARE client service representatives because of low bid contracts, making the help available for complex problem resolution worthless. Even the website is deteriorating and has not been updated in 18 months because the contract to do any upgrades has been "held up" in the HHS bidding process.
The biggest non-legislative actions happen because insurance company lobbyists push legislators who in turn push HHS to expand the options available in Medicare Advantage Plans. There is currently a plan to expand those fringe options, such as adding acupuncture. There are already services included in Medicare Advantage Plans, such as dental coverage, that are not included in original Medicare even though the government is subsidizing both ways of getting coverage. Why add more?
If Medicare eligible recipients move to Medicare Advantage (MA) Plans then the government can get out of the insurance pool business. That is, get rid of original Medicare. The next step will then be to provide a fixed amount of money (aka vouchers) to Medicare recipients to buy MA policies and further disengage by gradually removing government oversight and pushing complaints back to the insurer to resolve. Better still, the voucher money will never increase (think IBM HRA), making the cost burden of Medicare shift back to the recipients and off of general tax payers. It thereby ends Medicare.
Maybe that's the most dire scenario. The less dire scenario is the government just pushes everyone onto Medicare Advantage Plans and kills original Medicare with a medigap. What's the big deal? Well, Medicare Advantage Plans are MANAGED CARE policies.
As some of you know, I do Medicare counseling. In the last month, I tried to help two people who were locked into Medicare Advantage plans. Neither could go to an advanced cancer treatment center, like City of Hope in California, to get treatment for rare forms of cancer. One policy holder had an HMO policy that did not allow out-of-network coverage, another had PPO coverage but could not afford the co-pays of out-of-network services.
Reminder, Medicare recipients who have original Medicare can go to any Medicare doctor or clinic anywhere in the country. Beware shiny objects being flashed by Medicare Advantage Plans. Having Silver Sneakers won't help you if you need to remedy a potentially life ending health crisis which requires treatment from a top notch specialist.
Sunday, April 8, 2018
IBM Medicare OneExchange Via Benefits part D drug doughnut hole costs
Recently a few people have asked for help understanding the rules surrounding the part D doughnut hole costs, and what is meant by "closing" the doughnut hole. They have tried to work with their insurance plans to understand the computations but have not been able to get answers.
First off, I am no expert. It's really hard to find an expert who can simply explain part D coverage because it is so complex. I recently looked at Wikipedia and whomever wrote that description made some mistakes. The government's Center for Medicare Services even posted that it needs to be updated. That's a generous way of saying it is wrong. If you really want to understand the structure of the part D insurance it requires a lengthy history lesson of the machinations that the legislative body went through to arrive at providing prescription drug insurance coverage for seniors. The following link provides the history: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690175/
The explanations provided by Medicare to the public are moment in time descriptions. They do not go back in history to explain terms like "coverage gap" nor the legislation arguments. Mostly, it is general and skips the reasons why the computation is so convoluted. Some terminology meaning also morphed as the program was legislatively changed. Then there is the dilemma rarely discussed, that prices for drugs can change as often as every two weeks in medicare.gov plan finder. I am guessing that happens as each insurance plan renegotiates prices with pharmaceutical companies as their contracts renew throughout the year. Nowhere in plan finder do they issue a warning that the prices are not guaranteed for a calendar year.
With that as a back drop, there are two publications that might help you, the first of which is much easier to read than the above link:
Here's my crack at a simplistic part D description. First, there are, and will always be three phases to your part D insurance plan which are:
History helps you see why the second phase is currently called the coverage gap or doughnut hole.
In 2006, when part D insurance first became available, there was initial phase insurance but in the second phase, that is the doughnut hole, there was NO insurance assistance to a policy holder for prescription drug coverage until the policy holder's out of pocket drug cost exceeded $5000. Then insurance coverage would kick back in and provide catastrophic coverage. Ergo, the policy holder was responsible for 100% of the drug cost during the second phase or coverage gap.
In 2011, the ACA or Affordable Care Act or Obamacare legislation included gradually phasing in policy holder insurance coverage during the coverage gap such that, on average, in 2019, a policy holder might receive about the same insurance benefit as in the initial phase for brand name drugs. However, it would not have been politically expedient to change the name of the second phase until the ACA implementation is complete so it continues to be called the coverage gap.
Before 2011, part D insurers had almost no role in the second phase of coverage. The policy holder was paying 100%. The insurer was merely an administrator and jumped back in as insurer a little bit (at a 15% level) in the third phase.
Here's how it currently works.
The insurer is a major payer during initial phase of coverage (where the split between your copay and the insurance coverage is, "on average", 25% and 75% respectively for brand name drugs). In 2018, the initial phase lasts until the total cost of all your drugs (that is paid by both you the insurance company) equals $3750.
In the second phase (aka doughnut hole, aka coverage gap) your copay percentage increases and the insurance coverage drops. It pays about 15% which is the same percentage it has always paid in catastrophic coverage. However, the policy holder copay has been gradually declining since 2011. Reminder, before 2011 seniors paid 100% of the drug cost.
In 2018, in the coverage gap, you pay 35% and, as previously mentioned, your insurance pays 15% of the drug cost. Wait - that's only 50%! So who pays the other 50%? It's the pharmaceutical company who discounts the brand name drug 50%.
In 2019 the coverage gap copay percentage decline ends and the policy holder copay percentage will be 25% which is "on average" what it is in the first phase BUT the actual dollars you pay might be different. Hold on to that thought.
The third phase of coverage is the catastrophic coverage. You enter this phase when the sum of what you paid in the first two phases plus the drug company discounts in the second phase totals $5000.
In the catastrophic phase, the insurance company percentage is still 15%. However, the pharmaceutical company is no longer involved. Instead, the federal government becomes the major payer at 80% and your copay percentage drops to 5%. Actually, catastrophic level is the easiest level to understand and its structure has been the same since 2006.
First off, I am no expert. It's really hard to find an expert who can simply explain part D coverage because it is so complex. I recently looked at Wikipedia and whomever wrote that description made some mistakes. The government's Center for Medicare Services even posted that it needs to be updated. That's a generous way of saying it is wrong. If you really want to understand the structure of the part D insurance it requires a lengthy history lesson of the machinations that the legislative body went through to arrive at providing prescription drug insurance coverage for seniors. The following link provides the history: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690175/
The explanations provided by Medicare to the public are moment in time descriptions. They do not go back in history to explain terms like "coverage gap" nor the legislation arguments. Mostly, it is general and skips the reasons why the computation is so convoluted. Some terminology meaning also morphed as the program was legislatively changed. Then there is the dilemma rarely discussed, that prices for drugs can change as often as every two weeks in medicare.gov plan finder. I am guessing that happens as each insurance plan renegotiates prices with pharmaceutical companies as their contracts renew throughout the year. Nowhere in plan finder do they issue a warning that the prices are not guaranteed for a calendar year.
With that as a back drop, there are two publications that might help you, the first of which is much easier to read than the above link:
- This publication is from Medicare. It has some examples which are helpful. However, they do not truly explain the language that the geniuses decided to use to regarding the doughnut hole: https://www.medicare.gov/pubs/pdf/11493.pdf
- This publication is from Kaiser Foundation. They are NOT affiliated with Kaiser Health Insurance. They are a wonderful source of highly technical analysis of Medicare coverage. However, they are writing for the Medicare professional. The publication is difficult to read (at least for me) but worth a try: https://www.kff.org/medicare/fact-sheet/the-medicare-prescription-drug-benefit-fact-sheet/
Here's my crack at a simplistic part D description. First, there are, and will always be three phases to your part D insurance plan which are:
- initial coverage,
- "gap" coverage (albeit this name might change), and
- catastrophic coverage.
Again, THERE WILL ALWAYS BE THREE PHASES.
History helps you see why the second phase is currently called the coverage gap or doughnut hole.
In 2006, when part D insurance first became available, there was initial phase insurance but in the second phase, that is the doughnut hole, there was NO insurance assistance to a policy holder for prescription drug coverage until the policy holder's out of pocket drug cost exceeded $5000. Then insurance coverage would kick back in and provide catastrophic coverage. Ergo, the policy holder was responsible for 100% of the drug cost during the second phase or coverage gap.
In 2011, the ACA or Affordable Care Act or Obamacare legislation included gradually phasing in policy holder insurance coverage during the coverage gap such that, on average, in 2019, a policy holder might receive about the same insurance benefit as in the initial phase for brand name drugs. However, it would not have been politically expedient to change the name of the second phase until the ACA implementation is complete so it continues to be called the coverage gap.
Before 2011, part D insurers had almost no role in the second phase of coverage. The policy holder was paying 100%. The insurer was merely an administrator and jumped back in as insurer a little bit (at a 15% level) in the third phase.
Here's how it currently works.
The insurer is a major payer during initial phase of coverage (where the split between your copay and the insurance coverage is, "on average", 25% and 75% respectively for brand name drugs). In 2018, the initial phase lasts until the total cost of all your drugs (that is paid by both you the insurance company) equals $3750.
In the second phase (aka doughnut hole, aka coverage gap) your copay percentage increases and the insurance coverage drops. It pays about 15% which is the same percentage it has always paid in catastrophic coverage. However, the policy holder copay has been gradually declining since 2011. Reminder, before 2011 seniors paid 100% of the drug cost.
In 2018, in the coverage gap, you pay 35% and, as previously mentioned, your insurance pays 15% of the drug cost. Wait - that's only 50%! So who pays the other 50%? It's the pharmaceutical company who discounts the brand name drug 50%.
In 2019 the coverage gap copay percentage decline ends and the policy holder copay percentage will be 25% which is "on average" what it is in the first phase BUT the actual dollars you pay might be different. Hold on to that thought.
The third phase of coverage is the catastrophic coverage. You enter this phase when the sum of what you paid in the first two phases plus the drug company discounts in the second phase totals $5000.
In the catastrophic phase, the insurance company percentage is still 15%. However, the pharmaceutical company is no longer involved. Instead, the federal government becomes the major payer at 80% and your copay percentage drops to 5%. Actually, catastrophic level is the easiest level to understand and its structure has been the same since 2006.
The terminology of coverage gap and "doughnut hole closing" is, to put it bluntly, currently idiotic but politically expedient. What the creators were trying to describe by saying "the doughnut hole is closing" is that the "average" copay of 25% for a brand name drug will be the same in the initial coverage phase and in the second phase. Ergo, the average percentage of your copay in the initial coverage phase and in the "coverage gap" will be 25% and therefore the copay percentage in the first two phases will be equal in 2019 . That's what they mean. It's about PERCENTAGE, not absolute dollars. Clear as mud, right?
It turns out there is no "average 25%" copay for a brand name drug in the initial phase of part D plans. The insurance plans often put expensive brand name drugs in much higher tiers so your copay percentages can be significantly more than 25% . Insurers are allowed to define tier percentages and put brand name drugs in whatever tier they want. It is true that once you go to the second phase, your copay will be 25% but 25% of what number? Is it the same as the number in the initial phase? It depends on the price used in the second phase. Therefore, the actual dollar amount copay of a drug can be different in the second phase. It will depend on the price the pharmaceutical company uses to discount the drug which might be more or less than the price in the initial phase and/or you might have been paying more or less than 25% of the drug cost in the initial phase.
I will not try to explain more. I just wanted to help you understand the structure of the part D plan and try to get away the the idiotic terminology that surrounds it. I urge you to read the publications and also try to get your part D insurance to explain your costs (good luck with that).
I also urge you to keep badgering your elected officials to both simplify part D and to protect Medicare. Medicare has been a political football since its inception in 1965. In addition to legislative actions, there are many subtle HHS non-legislative actions being taken to cause Medicare to be substantially more expensive for seniors, by doing such things as increasing part B premiums and part A deductibles and co-pays. Over the last 10 years those costs have increased by about 40%. That, in turn, increases the premiums of Medicare Supplements (medigaps) and Medicare Advantage premiums or reduces MA plan in-network options. There is also conservative pressure to privatize Medicare by pushing seniors to Medicare Advantage plans which are managed care plans that limit access to a wide network of health professionals.
Wednesday, January 31, 2018
IBM Medicare Towers Watson, Extend Health, One Exchange, Via Benefits
This is cruel. Why does the organization name keep changing? Aren't human resources people supposed to be knowledgeable about how human memories work? Particularly, do they know NOTHING about senior humans? They have just guaranteed most older retired employees will not remember any name and will keep calling the IBM Employee Service Center to ask how to file claims - if they even remember to file claims.
Oh, wait, but this is such a memorable name! Via ... isn't that a road? This is the road to benefits? It's more likely the road to forgetting about benefits.
Maybe HR saw how successful they were getting people to forget SHAP - which stands for Special Health Assistance Provision. Isn't that descriptive? That's a benefit for IBM people who retired before 1997 and reimburses $900 of their Medicare part B premiums. It is so memorable that I personally know 5 people who did not realize they had the benefit and did not file claims for years. This might be HR's attempt to do the same thing for the HRA/FHA.
Write down the new organization name - Via Benefits. Say it 100 times. Then print it on a piece of paper and tape it to your forehead. That way you will remember, whenever you look in the mirror, who has your retiree health benefits money.
I couldn't help but write this brief post because it is too silly to let it alone.
Oh, wait, but this is such a memorable name! Via ... isn't that a road? This is the road to benefits? It's more likely the road to forgetting about benefits.
Maybe HR saw how successful they were getting people to forget SHAP - which stands for Special Health Assistance Provision. Isn't that descriptive? That's a benefit for IBM people who retired before 1997 and reimburses $900 of their Medicare part B premiums. It is so memorable that I personally know 5 people who did not realize they had the benefit and did not file claims for years. This might be HR's attempt to do the same thing for the HRA/FHA.
Write down the new organization name - Via Benefits. Say it 100 times. Then print it on a piece of paper and tape it to your forehead. That way you will remember, whenever you look in the mirror, who has your retiree health benefits money.
I couldn't help but write this brief post because it is too silly to let it alone.
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