Choices, choices, choices

Either I am getting confused more easily or this year it was harder to sort through the choices.  Probably it is a bit of both.  I took another look at the Aetna Integration offering and there is a summary sheet on one of the brochures that had several items regarding what is not covered that were a bit disconcerting:

• No coverage for Durable Medical Equipment. That means if you need something like a wheel chair there is no copay.  A lot of DME items are big ticket items so this will mean you have to do a lot of comparison shopping before buying equipment. Make sure you buy from a supplier that sticks to Medicare's fee limits so you really are only stuck paying  20% of the cost.
• No coverage for experimental procedures.
• A blanket statement that they only cover what is in the plan documents for medical and hospital services.  How do you get the document? You have to go to the Aetna website.
• No coverage for preventative benefits beyond Medicare at no additional cost.  I honestly don't know what that means.  A big part of my annual checkup is the blood work.  Medicare doesn't cover those tests.  IBM supplemental medical did.  I don't know if Aetna Integration does. 

I haven't gone to the website to find the specific plan document for Aetna Integration to get more information.  It won't change my decision to try the plan in 2012.  A number of friends have been very satisfied with the plan so I am going with that assessment.  However, if you do have significant medical problems it is important to find that document and then compare what is covered to the specific plan document for IBM medical coverage because there are differences in the two plans.

I spent a great deal of time verifying that we had selected the right prescription drug plans.  Although Medicare.gov had good planfinder tools it, I kept jumping from plan finder to formulary finder to compare plans to make sure I got a complete picture of the plans I was selecting. It took a lot of time.

It looks like Aetna is pushing the PPO plan pretty hard.  I cannot emphasize enough that if you go that route you will have to use their doctor and hospital network to get the full benefit of the plan.  If your doctors and hospital are already in the network then it is worth considering.  Just remember, the participating health providers can decide to drop out any time during the year but you cannot change health plans until January 2013. 

Oh, one more thing.  If you are selecting a PDP do it soon as it is best to enroll via Medicare to be sure that your records are updated (versus enrolling via the private insurance company and having them notify Medicare).  Medicare is advising on Medicare.gov that it takes up to 10 days to get the verification that you are enrolled.  That means you will be close to the enrollment deadline when you get your verification if you enroll this week.  Do it now!

More 2012 Analysis

I spent a few hours going through the new plan offering and I still feel like I don't know enough.  I did learn a few things.  The switch to CVS Caremark is not great for me as they will not cover three of my drugs AFTER next year and they will make my husband go through step therapy for one of his drugs.  Ugh.  I decided it was time to pick a Medicare part D plan (also called a PDP or Prescription Drug Plan) and not use IBM's prescription offering. 

I did look at the Aetna PPO offering because someone told me they heard you can go to any out of network doctor that accepts Medicare and you'll still pay 20%.  Well, that's not quite true.  I finally found it on the PPO fact sheet.  You can go to any out of network doctor that accepts medicare AND agrees to accept the PPO.  That makes more sense because that is how PPOs usually work. I've had a few health problems this past year and am really glad I was not confined to specific doctor networks or having to contend with having a doctor agree to take both Medicare and the PPO plan. It's enough of a hassle to find a doctor that will accept Medicare.

The HMO offerings are even more restrictive. However, the positive aspect of an HMO is you will have access to all the doctors who are part of the HMO.  They cannot tell you they are no longer accepting patients.  And if they quit the HMO you will be assigned to another doctor.  If a PPO doctor decides to no longer be with a plan it is up to you to go hunt for another doctor in the PPO network - and even if they are in the network I believe they can stop accepting new patients - it is something to ask of Aetna.  If you live in a remote area that might mean your replacement doctors are not nearby.  I tried to figure out whether you could get coverage if you wanted  multiple opinions in the HMO or PPO plans (something I needed to do this year as I was getting conflicting opinions).  I couldn't find it and since it is not what I will choose I gave up looking.  In original Medicare you can get as many opinions as you want.  I am not sure I see a lot of advantages to the PPO unless the drug coverage suits your needs.  I do believe that HMOs are effective at containing your medical costs.  Just realize the trade-offs. 

So, I decided to switch from IBM's supplemental medical/drug plan to Aetna's Integration plan A.  I can do that because both my husband and I are Medicare eligible.  I am doing it because I know I will have several doctor visits next year and there is a small chance I may need to go to the hospital.  The Medicare deductibles and copays will be covered by Integration A making the plan a real winner for me.   If your spouse is not Medicare eligible then you are stuck with IBM's supplement plans and the switch to CVS unless you can buy spousal coverage some other way. The Health Care Reform Act provides insurance exchanges in 2014.  Not much help for 2012.

I spent quite a few hours on medicare.gov looking for a PDP for me and a PDP for my husband.  It turns out he can get a PDP with Medco for $36.80 a month and they cover all his drugs. Since he has had a good experience with them and there is no step therapy involved he is using them.  The annual cost and the consumer ratings are good.  His drugs will cost more but I believe that the cost savings from Integration plan A will counterbalance that.  I need to go with a different PDP because Medco will not cover one of my drugs (which is interesting as they covered it as an IBM provider) and found one for $30.10/month that has a good rating.

At first I tried to look for drug plans that have robust formularies but decided they were too expensive.  It just wasn't worth the monthly fee.  If we have to take different drugs next year we will change plans in 2013.  If we are prescribed a drug that is not on the formulary of the plans we are selecting in 2012 we will appeal the decision to not cover the drug.  Sometimes the plan will cover the drug on an exception basis until you can switch to a different plan the next year.  Also, if a drug is not covered on your plan the drug company might work with you to get the drug at a lower cost until you can switch to a different plan in 2013.  It's worth the risk to try this approach.

As best I can tell, all the analysis I did in 2010 and 2011 still applies so if you want more information read through the rest of the blog. There are suggestions on websites to use for more information.  I also urge you to go to the websites for the 2012 IBM plans, ask what-if questions, make sure your doctors and drugs are covered by the insurance.  Do the math.  You are buying insurance.  The insurance company wants to make money and you want to not have to spend money!  Try to find a solution that is a win-win.

IBM Prescription drug coverage for 2012

I just took a quick look at the IBM medical coverage selections for 2012 so my observations are going to be brief. I will try to provide better insight later in the week.

I was surprised to see that Medco will no longer be the prescription drug plan provider. It is changing to CVS Caremark. It is really important to determine if CVS will cover your drugs if you decide to use IBM for your drug coverage. It was similarly important to do that if Medco continued to be the provider but at least Medco would have notified you about the change if they would no longer cover your drugs. Also, some of the issues with the donut hole are continuing to ease because of the Health Care Reform act so it is worth the analysis to decide if it is time to get a separate drug plan and not use IBM's offerings. Medicare.gov has a spectacular plan finder.

I also wanted to reiterate that if you decide to use a Medicare Advantage PPO or HMO be sure you really understand ALL the potential costs of that plan. The literature mostly describes coverage for hospital and doctor visits. All these plans are required to cover whatever original Medicare covers but they sometimes pay less than original medicare for a give procedure such as an ambulance. Do the detailed comparison!

Finally, there is an aspect to Medicare for Durable Medical Equipment (DME) that is important to understand. Medicare does not set limits for what a DME provider can charge for, say, a wheel chair. It only sets limits for what the reimbursement level will be. So, make sure to understand how DME works with your HMO or PPO should you decide to go that way. If the PPO makes you go specific suppliers you will be stuck with what they charge and cannot shop around.

More to come as I study the options for 2012

IBM Medicare choices for 2012

Open enrollment for Medicare coverage in 2012 began on October 15, 2011 and closes on December 7, 2011. This is a change from previous years. Unfortunately, IBM is not showing us their offerings in detail until November 2, 2011. That is too bad because it gives us less time to consider our options.

However, the brochure we just received does list what our choices are going to be even though the brochure is all about "Creditable Coverage" for prescription drug plans. If you don't see your current plan listed that means they are not going to offer it in November so it is a heads up.

There is a lot of language in the brochure about "Creditable Coverage" and penalties for not having proper prescription insurance coverage. They never provide details about the penalty which makes it seem more onerous. It is not a terrible penalty. It is 1% of the base monthly premium established by Medicare law. The base premium is established by the government every year. It is approximately $31 in 2012. That means if you don't have creditable drug coverage you will pay a 30 cents per month penalty (deducted from your social security) for every month you didn't have a drug plan IF you change your mind and decide to have a drug plan. So, if you didn't have a drug plan for a year you'd face about a $3.60 penalty IF you change your mind and decide to buy a drug plan in the future. There is NO penalty if you never buy a creditable drug plan. And some people don't do it. They say they do just as well buying drugs through Cosco or Walmart plans. Each person has to determine what is right for them.

The impact of not having creditable coverage is an important aspect to consider for non-Medicare eligible retirees buying insurance for Medicare eligible spouses. It might be worth it for you to take a non-creditable option and pay the penalty when you do move to a creditable plan. As I have said in the past ... you have to do the math.

In the past I did not consider choices for people who are trying to cover non-Medicare eligible spouses. I will try to do that in this enrollment period. It is a little difficult for me to do it because I don't see those options in the information I receive. However, there is a lot of very detailed information on netbenefits.com that everyone can see. You should look at the resources in netbenefits.com as well as the private insurance websites (e.g., Aetna) to be sure you understand the details of each plan. The IBM summary brochure is just that ... a summary.

So, happy 2012 enrollment period.

2011 Health Care Reform for Part D plans

If you decide to use the Aetna Integration Plan as you supplemental medical coverage then you will need to buy a Part D prescription drug plan from a private insurer. You HAVE to buy a drug plan to maintain continuous coverage. If you don't have a drug plan there will be a penalty applied of 1%/month for every month you are not covered by a part D plan if you change your mind. It is not a huge penalty because the monthly premiums are low and it is based on the national average which is about $33/month ... but it will cost about $4 per year for every year you are not covered and can add up. The penalty doesn't goes away (unless you fall below the poverty line and qualify for low income programs.) Some people who don't really want a drug plan buy the cheapest plan they can find in their zip code to avoid the lifetime penalty. Some premiums are as low as $15/month.

In 2011 there are changes to Part D that can lower your out of pocket costs if you do get into the doughnut hole. The old rule was that once you were in the doughnut hole you paid the entire bill for your drugs until you hit an out of pocket limit (about $4000). Granted you pay the insurer's discount rate for the drug - but the insurance companies have not been too good at negotiating discounts. Starting in 2011you will pay 50% of the insurer discount rate and also "get credit" for 100% of the cost toward getting out of the doughnut hole. For generics you only get a 7% break - I will guess because generics are much cheaper.

All of these pricing features are in the "configurator" planfinder on medicare.gov. Use it to determine your total cost for a given drug plan.

AARP "insurance"

I hear a lot of people talk about AARP as if it were an insurance company. It is not. In reality all that is happening when you see AARP as part of a name of a health or drug insurance plan is the private insurance company paid AARP a fee to use the logo. For many, the AARP "stamp of approval" means a lot. I don't have a clue how AARP vets those offerings nor what kind of fees they charge to use the logo. That is why the names of all the AARP plans are complex. For each offering the name has to be unique to the insurer and each insurer has several offerings.

I do know that the underlying insurer - whether United Healthcare, BlueCross/BlueShield and so on - does have a rating so the best thing to do when deciding what plan you want to buy is to evaluate the reputation of the insurer. There are a few ways to do that. In the "Medicare and You 2011" book at the back of the book there are ratings associated with the plans they profile. Your state SHIP (State Health Insurance Assistance Program) also has user ratings associated with plans offered in your state. You can find the phone number on medicare.gov. Also, ask your friends and your doctors what insurer they prefer. Sometimes an insurer is slow to pay or onerous about processing claims. The doctor's accounting office usually has strong opinions about who they prefer.

Comparison pricing is essential whether you are picking a medicare advantage, drug or a medigap plan. I strongly urge you to look at medicare.gov planfinder to do the comparison. It is the best example I have ever seen of your tax dollars at work to give you great information.

IBM medical plans are NOT medigap plans

Buried in an earlier posting I talk about medigap vs. IBM medical offerings but it is worth repeating because it is very confusing. If you are using original medicare there is government defined secondary insurance available for purchased from private insurers typically referred to as medigap insurance to cover your deductibles and the copays. There are 12 different types of plans defined by the government and each is designated by a letter A,B,C, M, N and so on. A private insurer offering plan "M" must structure it according to "M" components. Sometimes the private plans are called supplemental insurance. To find out what companies offer medigap plans in your zip code go to medicare.gov. Incidently, it makes no sense to pay more for a given plan - pick the cheapest private insurer for the plan you want. The plans offered through AARP (which are usually United Healthcare plans) are often priced well but not always so do comparison shopping!

NONE of IBM medical insurance options are medigap plans. That is why IBM medical plans are often referred to as secondary insurance. By law, you are only allowed to buy one medigap plan. Since IBM medical insurance is NOT a medigap plan you can buy IBM's medical/prescription drug coverage and also buy a medigap plan. Do this if you want IBM's drug plan but want better medical coverage than IBM's medical plan. It is unlikely that the IBM medical component of the coverage will be used but it can happen. There are services like acupuncture that are covered by IBM but not covered by a medigap plan.

Do not believe the IBM service center if they tell you that you cannot buy a medigap plan if you buy an IBM medical plan. It is not true.

2011 Enrollment

By now, you probably received the IBM selection package. It looks to me like not much has changed except the prices on some of the offerings and Aetna withdrew one of their Medicare Advantage offerings (PFFS). As an aside, I will speculate that they did not have a very good doctor network and the new regulations from the government to provide network specifics pushed them to shut it down.

I still don't think there is any "best choice". Each offering has advantages and disadvantages. The Medicare Advantage plans are as good as the doctors and hospitals they require you to use. If you want to go to an expert doctor or institution such as Sloan-Kettering you might not be able to do it. Make sure the plan gives you access to the doctors and hospitals you want to use.

The Aetna Integration Plan A is really tempting for those of us who use Original Medicare. It looks like a medigap insurance plan but at a fraction of the cost. It is NOT a medigap plan. Last year I went to their website to look at the detailed coverage and mapped it to a "popular" medigap plan to see how it compares (for example, details like skilled nursing coverage). The booklet you get from IBM does NOT provide sufficient information to let you do a comprehensive comparison. Since the Integration Plan A is not a medigap plan there is no governmental agency overseeing an appeals process. Again, I don't think that is a big deal. It is just part of doing a comparison.

All said, I personally was really tempted to sign up for the Aetna Integration Plan A. I decided not to do it when I looked at medicare.gov and got estimates from plan finder for my out of pocket costs on a non-IBM prescription drug plan. I estimate I would have to spend about $2000 more for my drugs with a non-IBM plan. Given that - I will take the bet (essentially a $2000 bet) that I will be healthy in 2011. (I lost that bet this year and reached the Out Of Pocket for the medical plan - $4000.) Still, I am staying with the IBM Medical/Prescription Drug Supplement plan. I know I need the drug coverage, I don't know if I will need the medical coverage, and I am an optimist.

I used myself as an example just to show the kind of work you have to do to pick the plan that is best for you. In the end it really is gambling. IBM is betting it can make money on you and you are betting you will have lower medical costs.

Appeal, appeal, appeal claim denials

Both medicare and UnitedHealthcare have an appeals process if a medical claim is denied.

The Medicare appeals process is dictated by the government and there are 3 levels of appeal. At the first level you are basically still dealing with administrative personnel. At the second level you are finally reaching medical professionals. When you appeal a claim you will need supporting information from your doctor as to why the procedure was necessary which can make it a little bit of a hassle to appeal. Some doctors have staff that help with appeals. It is a cost overhead headache and no wonder medical professionals are opting out of treating medicare clients given the fee structure is pathetically low. Even if your doctor is not much help - still gather your evidence and appeal! For example, Medicare routinely denies screening tests (e.g, EKG or blood tests). If you had those tests as a prep for surgery then submit copies of the bills showing the surgery. Of course, the logical assumption is Medicare would have realized you had surgery since they pay that claim as well. Don't get logical. Do appeal.

For UnitedHealthcare there is also an appeal process. However, because the IBM supplemental plan is not a government sanctioned medigap plan the appeal process is strickly a UHC process. It is perhaps a reason why you might want to consider buying a legit medigap plan. If you have a medigap plan then your appeal is going through government agencies at the second and third level. For IBM's supplemental plan if UHC denies the appeal your recourse it to complain to your state health insurance agency. It is a harder process and the chances of UHC being overturned are likely lower but those complaints are "registered" against UHC to help the state agency to look for patterns. So, use the UHC appeal process and the state complaint process. It may also be worthwhile to lodge a complaint with IBM if you think UHC is being unreasonable.

There is also an appeal process for drug plans. If the IBM plan (Medco) is denying coverage for a drug use the appeal process if the drug is not on Medicares "never cover" list. Don't waste your time appealing drugs on the "never cover" list. Most of them fall into the category of barbituates. You can get a list of those drugs from Medicare. Often times, coverage is also denied if the drug is being used "off label". That appeal argument is easier to win.

2010 IBM Enrollment Period

It's that time of year again. Lucky us. Some of you asked why IBM delayed the enrollment and why weren't they changing the offerings for retirees. I am guessing about why they delayed enrollment. Healthcare reform starts to kick in next year and impacts more about current employees than retirees. IBM HR is probably looking at what they need to do to comply such as perhaps offering supplemental IBM employees health insurance and/or negotiating with insurance companies on how the reforms will affect premiums. Again, it is my guess that is what is causing the delay.

There is nothing in heathcare reform that affects IBM retiree medicare offerings. Notice, they did not say they were keeping the price of offerings the same - just the offerings itself. They are probably negotiating with private insurance companies on the price of the Medicare Advantage offerings (eg, HMO and PPO offerings). The government is not going to reduce the "extra" subsidies for these plans in 2011 but is also not going to increase them either - as was done in previous years (and is an outrage that taxpayers should have been screaming about). Nonetheless, private insurance companies are raising their premium rates and blaming it on healthcare reform. How ethical.