IBM Medicare Via Benefits IBM Supplemental Drug & Medical Benefits

When IBM stopped offering Medicare eligible retirees Medicare group health insurance and moved to a "premium reimbursement" model, they also announced two benefits for Medicare eligible retirees that are separate from HRA funding.

A couple of days ago I looked at those two benefits again.  Although I hope to never need these benefits from IBM, it is nice to know they are available.  Both of these benefits are in addition to HRA funding and would come into play during a catastrophic situation:

1. IBM Supplemental Drug Benefit:
    
   The purpose of this benefit is to help retirees with the cost of a very expensive drug where part D insurance isn't doing much to defray the cost.  The help comes into play when the total cost of the drug exceeds $100,000.  Before you gasp, that total cost is computed by adding what you pay, what your insurance plan pays, what the pharmaceutical company pays by discounts and what Medicare pays when you are in catastrophic coverage for your part D plan.  I'll use a simplistic example, but please realize the phase dollar numbers I use are fictitious (the percentage numbers are accurate).  Also, pay attention to how I defined "total cost" in this paragraph.
    
   First off, remember there are 3 phases to a part D plan.   Phase 1 (total cost less than $4000) is when you pay a copay decided by the plan and the insurance company pays the rest.  Phase 2 (entered when total cost exceeds $4000) you pay a copay of 25% of the cost of the drug and the pharmaceutical company covers the rest.  Phase 3 (entered when total cost exceeds $6000)  you pay 5% of the cost of the drug and Medicare covers the rest.  There is more innuendo involved than what I described but this is the essence of how a part D plan works.
   
   You've been prescribed drug XYZ in January.  The drug is $12,000/mo. before insurance kicks in. In the first month, you will blow right through the first phase AND second phase because the drug cost is so high.  Your copay will be about $4,500 of that $12,000.  Boom, you are in  Phase 3 (aka Catastrophic coverage) .  Month 2 your copay is $600/month (5%) for the drug UNTIL month 9.  At that point the total cost of the drug exceeds $100,000 and IBM will pick up the rest of your copays until the end of the year.  So, your cost for the year is $4,500 +  $4,800 (8*600) = $9,300 and IBM will cover $2,400 of the yearly cost. It's not a huge benefit but it is something.
     
2. IBM Supplemental Medicare Benefit
   
   This benefit is a bit easier to explain.  It's about private nursing and home care so there are no phases.  First off, if you did not already know this, Medicare DOES NOT cover private nursing care when you hire a full time nurse to help you.  Medicare does cover some home care, but it has to be related to a medical problem where the patient has been discharge home and now is home bound and needs someone to come to the house, such as an aid to change a feeding tube, and while there they can bathe you or do other simple chores. You have to use a Medicare authorized agency for the services and the amount of time you get for home care is a few hours a week (about 20) unless there is something dire in the beginning of the treatment where the doctor requires a nurse to come every day.  But that cannot go on for more than a couple of weeks. Medicare absolutely does not cover long term home care.
        
   Here's where IBM comes into play. Sometimes you absolutely do need more services than Medicare will cover so you start paying for services even though you know it will be denied by Medicare. Maybe it's something like needing an overnight nurse to help you in the first few days after you come home from the hospital to make sure you don't fall during the night. Even though the doctor prescribes it - Medicare will certainly deny the claim because it doesn't relate to your specific medical problem! (I know, it's stupid because if you fall you will end up back in the hospital which will be a lot more expensive than a night nurse.)
      
   When you have paid out-of-pocket $6,500 for denied private nursing or home care then IBM will cover the cost of denied services for the rest of the year. Reminder, a Medicare Advantage plan or a Medicare Supplemental plan will cover some claims so this is only about denied claims for services.  Of course, IBM will want to review the situation before they commit to do it, including information from your doctor showing medical necessity and evidence that Medicare denied the coverage.  Still, it seems to me that this could be a significant benefit for very ill people.

There are a few more detail about these benefits in the "About Your Benefits" book I mentioned in earlier posts.  In order to get that document you need to logon to www.netbenefits.com.  I posted the 2019 version https://drive.google.com/file/d/1j1OX3l3l_0xsnXYDtCDCjBcE4p3bfWlP/view for easier access, but it is already obsolete because IBM eliminated the Life Planning benefit.  The description of the above benefits starts on page 184.

      

The most important thing is don't forget these benefits exist!!!