Most IBM retirees use IBM secondary insurance instead of buying a medigap plan on the market. However, some of you might decide to buy a medigap plan instead. There are several reasons why you might do it. I won't go into those reasons right now.
Over the last several months I have helped a couple of friends pick a medigap plan and then they try to buy it. Notice, I said try to buy it. I just filed a complaint with the NYS Department of Insurance because it turns out that it is not easy always to get companies who are offering the plans to respond.
As I have mentioned in the past - there are at least ten varieties of medigap plans that are strictly defined by the federal government. The plan types are identified by letters like K, L, F, A and so on. There are some medigap plans that are "high deductible" meaning they don't kick in unless you are really sick. The offset to those plans are low premiums. For example, the medigap F high deductible plan has a $2010 annual deductible but the monthly premium can be as low as $50/month. If you are healthy, you'll end up spending way less in premiums and that will offset the part A &B deductibles and part B copay bills you will pay. It takes a lot of being sick to be worth paying a premium of, say, $200/month to have immediate coverage.
There is absolutely NO difference between one insurance company's K plan and another company's K plan. These plans are defined by law. There are no doctor networks associated with these plans. They simply work as secondary to Medicare so if the doctor takes Medicare then the doctor takes the medigap plan. That means the logical thing to do is to buy the cheapest offering in your zip code. The premiums can vary as much as 200% from one company to another. How do you know who is the cheapest? Sometimes your state's department of insurance has the rates. New York State publishes the rates. How do you know who sells a policy in your zip code? Either call 1-800-MEDICARE or go onto medicare.gov to find out.
Why did I file a complaint? Because the insurance companies with the lowest premiums are very, very difficult to reach or insist you must be contacted by an insurance agent in order to buy the policy. I know this will shock you - the agent will then try to up-sell you to a Medicare Advantage plan or a no deductible medigap plan. Many times the insurance companies did not even return phone calls when the buyer insisted they wanted a high deductible medigap. In one case - the agent hung up on a buyer when she insisted she wanted an F+ plan. Some insurance companies (like AARP United Healthcare) won't even sell a high deductible plan (which is perfectly legal) but won't tell you that you can get one - just not from them. Why don't they sell the plan? Because they don't make much money on it.
If you decide you want a high deductible medigap plan - be persistent. If the insurance company with the lowest premium is not responding COMPLAIN to the state department of insurance that they are doing bait and switch selling.
Sunday, July 21, 2013
ACA Insurance Pools and Medicare
Several people have asked me if they can participate in the ACA individual policy provider insurance pools instead of being on Medicare. The short answer is no. Once you are over 65 years old most private insurance companies do not want to sell you insurance unless it is a Medicare Advantage or a medigap policy. If you can find a company that will see you an individual policy still be very wary of doing so as it is highly risky on two fronts. First, they can drop you at any time and tell you to go onto Medicare. That often happens when you get really sick. I know this because 65+ people think they can stay on COBRA plans when they are terminated because it is offered. The insurance companies take the premiums until they get sick and then say WHOOPS you are too old to be on this plan. And you cannot just go onto Medicare whenever you want - you have to wait for an enrollment window to enroll. Second, you will pay a Medicare premium penalty of 10%/year for every year you are not on Medicare which is a forever penalty and is calculated using the current year Medicare premium. That means, as yearly premiums go up so does the cost of your penalty.
As the ACA begins insurance pool implementation I predict there will be a lot of erroneous reporting. Do a lot of fact checking before you believe what you read.
As the ACA begins insurance pool implementation I predict there will be a lot of erroneous reporting. Do a lot of fact checking before you believe what you read.
Monday, April 15, 2013
Reading about Medicare overhauls might be bad for your health
There is much being reported about how our law makers propose to change Medicare in various budget proposals and sequestration cuts - making it very difficult to ignore and it is nerve rattling. There is no way to predict what will actually happen and much of the reporting is either over hyped or just inaccurate. If you want to really understand the implications of various congressional proposals go to the Medicare Rights Center and sign up for their news letters. They provide excellent analysis: http://www.medicarerights.org/.
The Medicare Rights Center is a private, non-profit organization not affiliated with any government agency or corporate insurance company. The reason I learned as much as I know about Medicare is that I have been a volunteer on their Medicare Helpline for about four years. The organization has researchers, analysts, lawyers and a front line view of how hard it is for seniors and the disabled to figure out Medicare by answering over 14,000 helpline calls per year. The phone calls I find the hardest to handle are from people in their eighties and older who are easily confused, at the mercy of their Medicare Advantage plans or medical providers, and haven't a clue about how to resolve problems. These calls have shown me how lucky I am to have access to IBM insurance options and to still be able to figure things out for myself. I dread the day I cannot and hope Congress will simplify Medicare insurance before then and that IBM will keep its promise to provide retirees with healthcare options. It's a lot to wish for.
The Medicare Rights Center regularly does analysis on those helpline calls and the impact of various government proposals. They provide feedback to Congress on the current construct of Medicare, the private insurance industry providing Medicare Advantage and part D plans as well as the various congressional suggestions to revamp Medicare. As an example, there is a notion held by some of our legislators that people who have secondary private insurance (aka medigap plans) go to the doctor more often than people who do not and thereby drive up overall Medicare costs. So, the genius legislative thinking is those secondary plans should be "taxed". The analysis of real data shows that is a wrong notion. I, for one, do not enjoy going to a doctor no matter what insurance covers. Turns out I am a good representative of the majority of people! Hopefully, USA citizens will be informed enough to put pressure on legislators to act rationally. It's a lot to wish for.
The Medicare Rights Center is a private, non-profit organization not affiliated with any government agency or corporate insurance company. The reason I learned as much as I know about Medicare is that I have been a volunteer on their Medicare Helpline for about four years. The organization has researchers, analysts, lawyers and a front line view of how hard it is for seniors and the disabled to figure out Medicare by answering over 14,000 helpline calls per year. The phone calls I find the hardest to handle are from people in their eighties and older who are easily confused, at the mercy of their Medicare Advantage plans or medical providers, and haven't a clue about how to resolve problems. These calls have shown me how lucky I am to have access to IBM insurance options and to still be able to figure things out for myself. I dread the day I cannot and hope Congress will simplify Medicare insurance before then and that IBM will keep its promise to provide retirees with healthcare options. It's a lot to wish for.
The Medicare Rights Center regularly does analysis on those helpline calls and the impact of various government proposals. They provide feedback to Congress on the current construct of Medicare, the private insurance industry providing Medicare Advantage and part D plans as well as the various congressional suggestions to revamp Medicare. As an example, there is a notion held by some of our legislators that people who have secondary private insurance (aka medigap plans) go to the doctor more often than people who do not and thereby drive up overall Medicare costs. So, the genius legislative thinking is those secondary plans should be "taxed". The analysis of real data shows that is a wrong notion. I, for one, do not enjoy going to a doctor no matter what insurance covers. Turns out I am a good representative of the majority of people! Hopefully, USA citizens will be informed enough to put pressure on legislators to act rationally. It's a lot to wish for.
Monday, November 12, 2012
Appealing denial of coverage
When you are denied coverage for a medical procedure or a prescription drug it is important to do an appeal with your insurance company. If you have a Medicare sanctioned plan the appeals process is governed by Medicare law. Sometimes it takes a couple of iterations to get to an independent group (that is - not the private insurance provider) to get a fair assessment.
I just wanted to remind you that IBM secondary insurance and Aetna Integration insurance is not governed by the Medicare appeal process laws because it is not government sanctioned medigap or secondary insurance. For those insurance policies if you are not satisfied with the decision they render you have to complain to the department of insurance in your state. It is unlikely doing that will change the decision but it is important to complain because those departments track complaints and put pressure on insurance companies that are generating a lot of complaints.
I don't know what the appeals process is for IBM's prescription drug insurance plan. Although it is a "creditable" plan, I am not sure if the company (CVS Caremark) is required to have the same appeals process as a government sanctioned prescription drug plan (PDP). If you are choosing the IBM prescription insurance plan you should ask the question. If it does not conform then your appeals are totally handled by CVS - which means there is no independent review and your chances of reversing a decision are slim. If someone has an answer please post a comment.
I just wanted to remind you that IBM secondary insurance and Aetna Integration insurance is not governed by the Medicare appeal process laws because it is not government sanctioned medigap or secondary insurance. For those insurance policies if you are not satisfied with the decision they render you have to complain to the department of insurance in your state. It is unlikely doing that will change the decision but it is important to complain because those departments track complaints and put pressure on insurance companies that are generating a lot of complaints.
I don't know what the appeals process is for IBM's prescription drug insurance plan. Although it is a "creditable" plan, I am not sure if the company (CVS Caremark) is required to have the same appeals process as a government sanctioned prescription drug plan (PDP). If you are choosing the IBM prescription insurance plan you should ask the question. If it does not conform then your appeals are totally handled by CVS - which means there is no independent review and your chances of reversing a decision are slim. If someone has an answer please post a comment.
Aetna Integration A detailed description
There is a brochure on the Aetna website that provides details about the Integration plan. It is a good summary of the plan. Unfortunately, I can't link to it because you need a user id to get to the site and you can only get one if you are enrolled. If you are considering getting the insurance I suggest you call and ask Aetna to email you a copy of the brochure. Here is the table of contents:
Continuation Coverage
Table of Contents
Preface ........................................................................1
Important Information Regarding Availability of
Coverage
Coverage for You .....................................................1
Health Expense Coverage.......................................1
Treatment Outcomes of Covered Services
When Your Coverage Begins............................2
Who Can Be Covered ..............................................2
Retirees
Determining if You Are in an Eligible Class
Obtaining Coverage for Dependents
How Your Medical Plan Works........................5
Common Terms........................................................5
About Your Comprehensive Medical Plan...........5
Using the Plan
Cost Sharing
Emergency and Urgent Care...................................6
Coverage for Emergency Medical Conditions
In Case of an Urgent Condition
Coverage for an Urgent Condition
Non-Urgent Care
Follow-Up Care After Treatment of an
Emergency or Urgent Medical Condition
Requirements For Coverage.............................8
Clinical Review Criteria Requests
What The Plan Covers ......................................10
Comprehensive Medical Plan .................................10
Wellness......................................................................10
Routine Physical Exams
Preventative Health Care Services Expenses
Routine Cancer Screenings
Early Intervention Services
Bone Mineral Density Measurement or Test,
Drug and Devices
Vision Care Services
Limitations
Hearing Exam
Primary and Preventive Obstetric and
Gynecological Care
Physician Services .....................................................13
Physician Visits
Surgery
Anesthetics
Hospital Expenses ....................................................14
Room and Board
Other Hospital Services and Supplies
Outpatient Hospital Expenses
Coverage for Emergency Medical Conditions
Coverage for Urgent Conditions
Alternatives to Hospital Stays.................................16
Outpatient Surgery and Physician Surgical
Services
Birthing Center
Ambulatory Care
Home Health Care
Hospice Care
Other Covered Health Care Expenses .................19
Acupuncture
Ambulance Service
Diagnostic and Preoperative Testing ....................19
Outpatient Diagnostic Lab Work and
Radiological Services
Outpatient Preoperative Testing
Durable Medical and Surgical Equipment (DME)
.....................................................................................20
Experimental or Investigational Treatment .........21
Pregnancy Related Expenses..................................21
Prosthetic Devices....................................................22
Hearing Aids
Benefits After Termination of Coverage
Short-Term Rehabilitation Therapy Services.......23
Cardiac and Pulmonary Rehabilitation Benefits
Outpatient Cognitive Therapy, Physical Therapy,
Occupational Therapy and Speech Therapy
Rehabilitation Benefits
Reconstructive or Cosmetic Surgery and Supplies
.....................................................................................24
Reconstructive Breast Surgery
Specialized Care........................................................24
Chemotherapy
Radiation Therapy Benefits
Outpatient Infusion Therapy Benefits
Diabetic Equipment, Supplies and Education.....26
Treatment of Infertility............................................26
Advanced Reproductive Technology (ART)
Benefits
Enteral Formulas......................................................28
Treatment of Mental Disorders and Substance Use
.....................................................................................29
Treatment of Substance Abuse
Oral and Maxillofacial Treatment (Mouth, Jaws and
Teeth) .........................................................................30
Medical Plan Exclusions .........................................31
When Coverage Ends..............................................31
When Coverage Ends For Retirees
Your Proof of Prior Medical Coverage
Continuation of Coverage.......................................32
Continuing Health Care Benefits
Extension of Benefits ..............................................33
COBRA Continuation of Coverage......................33
Continuing Coverage through COBRA
Who Qualifies for COBRA
Disability May Increase Maximum Continuation
to 29 Months
Determining Your Premium Payments for
Continuation Coverage
Sunday, November 11, 2012
Prescription Drug Coverage 2013
I am sorry I have not been able to write much this year and the deadline for making your decisions is only a few days away. Hurricane Sandy visited Westchester, New York and turned a forest into a meadow. Happily, not so much changed from last year so most of what I wrote applies.
I just took a quick look at the rules that are being "upgraded" for the IBM's prescription drug plans. The sentence saying that more than 250 drugs will require prior authorization in 2013 was not great to see. What the provider will likely do is ask you to try alternate comparable drugs before they approve your prescription. It is called step therapy. That can range from annoying to life threatening as sometimes those alternate drugs don't work at all and can impact your health.
Once again, I decided to go with Aetna Integration A which meant I cannot use IBM's drug plan and had to select a separate private prescription drug plan (PDP) from a non-IBM provider. I used the plan finder on the medicare.gov website to be sure I picked a PDP that has been sanctioned by medicare. I also enrolled directly through the medicare.gov site as it is the quickest way to enroll and I have a record of the enrollment in case the private insurer makes a mistake and denies I was enrolled.
The list of PDP providers available in your zip code can be daunting. There are a lot of factors to consider when selecting a drug insurance plan such as - where you will be able to fill prescriptions, whether or not step therapy will be required for your particular drug, deductibles (which cannot be higher than $350) and copays. Some plans also provide insurance in the "donut hole" but of course the premium for those policies will be higher. All of these factors are important to consider when you pick a plan - not just premium price.
My personal experience: this past year is the PDP plan I picked was cheap but it was not the best decision. I could not use mail order and had to go to Target to pay the least for my prescription. However, they let me do 90 day refills so it wasn't too bad. The plan then decided not to cover my drug in 2013 so in September they stopped allowing 90 day supply refills. I now have to go back to the pharmacy every month to get a refill. It is annoying. They also did not directly tell me the drug would not be covered in 2013. They just said there were changes in their formulary and I should check their formulary.
I just took a quick look at the rules that are being "upgraded" for the IBM's prescription drug plans. The sentence saying that more than 250 drugs will require prior authorization in 2013 was not great to see. What the provider will likely do is ask you to try alternate comparable drugs before they approve your prescription. It is called step therapy. That can range from annoying to life threatening as sometimes those alternate drugs don't work at all and can impact your health.
Once again, I decided to go with Aetna Integration A which meant I cannot use IBM's drug plan and had to select a separate private prescription drug plan (PDP) from a non-IBM provider. I used the plan finder on the medicare.gov website to be sure I picked a PDP that has been sanctioned by medicare. I also enrolled directly through the medicare.gov site as it is the quickest way to enroll and I have a record of the enrollment in case the private insurer makes a mistake and denies I was enrolled.
The list of PDP providers available in your zip code can be daunting. There are a lot of factors to consider when selecting a drug insurance plan such as - where you will be able to fill prescriptions, whether or not step therapy will be required for your particular drug, deductibles (which cannot be higher than $350) and copays. Some plans also provide insurance in the "donut hole" but of course the premium for those policies will be higher. All of these factors are important to consider when you pick a plan - not just premium price.
My personal experience: this past year is the PDP plan I picked was cheap but it was not the best decision. I could not use mail order and had to go to Target to pay the least for my prescription. However, they let me do 90 day refills so it wasn't too bad. The plan then decided not to cover my drug in 2013 so in September they stopped allowing 90 day supply refills. I now have to go back to the pharmacy every month to get a refill. It is annoying. They also did not directly tell me the drug would not be covered in 2013. They just said there were changes in their formulary and I should check their formulary.
Monday, October 29, 2012
October 2012 - choices for 2013
I quickly looked at the IBM package this morning for the first time. I don't see much change but the prices for some of the options. People who need to cover their medicare eligible spouses are really getting slammed if they pick anything but Aetna Integration plan or the PPO plans and buy a separate Medicare part D prescription drug plan (which can be as cheap as $20/month) for the Integration plan. People who need to cover their non-medicare eligible spouses seem to be hit the hardest if they want to get drug coverage.
I will provide more analysis after doing more reading but wanted to do a quick post because there is not much enrollment time this year. The only thing I wanted to focus on for this post is that the Medicare Advantage plans IBM offers (the PPO and HMO plans). For those plans:
I will provide more analysis after doing more reading but wanted to do a quick post because there is not much enrollment time this year. The only thing I wanted to focus on for this post is that the Medicare Advantage plans IBM offers (the PPO and HMO plans). For those plans:
- Make sure your doctors and local hospitals will accept the plan
- Make sure your drugs are on their formulary and if they require step-therapy
- Consider the fact that you will not be covered at specialized clinics like Cleveland Clinic or Sloan-Kettering if needed (most of those clinics do accept original Medicare)
Sunday, December 18, 2011
Options to change your insurance in 2012
Obviously, the IBM enrollment period is over but I wanted to remind you that you do have a "window" provided by Medicare law (it has nothing to do with IBM) called the Medicare Advantage Disenrollment period and it is January 1- Feburary 14, 2012. During that period you can switch from IBM's Medicare Advantage plan to original Medicare. So, if, for example, you decide you hate Aetna's HMO or PPO you can switch to original Medicare during that period. You won't be able to get IBM supplemental nor IBM prescription drug insurance because the IBM enrollment period is close. However, you will have the ability to buy a Medicare approved prescription drug plan (and you should buy one to avoid a penalty even if you don't need it). You also MIGHT have the ability to buy a medigap plan for secondary insurance. It depends on the state laws whether or not the private insurance companies have to sell it to you.
Another change you can make any time during 2012 is to switch (one time) from your IBM Medicare Advantage plan to a "5 star" rated Medicare Advantage plan. Ditto for the Prescription Drug Plan. Once again, it is a change you can make that has nothing to do with IBM but once you make the change you cannot use IBM's offerings for the rest of 2012. The wrinkle in this option is there has to be a 5 star plan in your zip code. The way you find out if you have one is to go to plan finder on medicare.gov.
None of the above is relevant to people who are buying insurance for their non-medicare eligible spouses unless you no longer need to cover your spouse because once you switch, IBM will stop providing your spouse's insurance too.
Another change you can make any time during 2012 is to switch (one time) from your IBM Medicare Advantage plan to a "5 star" rated Medicare Advantage plan. Ditto for the Prescription Drug Plan. Once again, it is a change you can make that has nothing to do with IBM but once you make the change you cannot use IBM's offerings for the rest of 2012. The wrinkle in this option is there has to be a 5 star plan in your zip code. The way you find out if you have one is to go to plan finder on medicare.gov.
None of the above is relevant to people who are buying insurance for their non-medicare eligible spouses unless you no longer need to cover your spouse because once you switch, IBM will stop providing your spouse's insurance too.
Monday, November 28, 2011
No Aetna Offering Details!!!
I just spent about 40 minutes trying to get a detailed plan description for the Aetna A Integration plan. It is not available to me until I am enrolled! I called Aetna and asked for the details and they said everything that is available was already sent to me. I called IBM and the representative said the details would be available in January if I am enrolled in the plan.
I registered a complaint with IBM. It is outrageous that detailed information is not available for people who want to do detailed comparisons. I urge you all to similarly complain. How are we to make informed decisions unless we know exactly what is and is not covered?
I registered a complaint with IBM. It is outrageous that detailed information is not available for people who want to do detailed comparisons. I urge you all to similarly complain. How are we to make informed decisions unless we know exactly what is and is not covered?
Sunday, November 27, 2011
Full program descriptions
I had a little time tonight to try to find a full program description for the Aetna Integration A plan. I thought I would be able to easily find it on the website providing by Aetna which is ibmrhabenefits.aetnamedicare.com (password=IBM65). I just wanted you to know that I was wrong because I thought full plan details were on this site. The website says (in small print) that it is a marketing website. If I want a full plan description I need to call Aetna. That's really annoying. Even IBM's medical plan is fully documented in the resource library at netbenefits.com. I am probably going to give them a call tomorrow to get the complete plan description just because I want to see what they say.
It doesn't change my decision because I know enough to know I want to try this plan in 2012 but it really does make me feel like they are trying to hide the details of this plan. If you are considering their HMO or PPO offerings don't just go by their "marketing" brochures. The detailed documents are really important. I know this because I volunteer on a medicare helpline and a large number of the "issues" callers have are because of denials of coverage or billing problems they have with medicare advantage plans.
Someone commented that if your spouse is not medicare eligible you only have 4 choices and have to use the IBM medical and prescription coverage plans. It's true but at least you do have choices. A friend tried to get coverage for his spouse separately and the best he could find was a private plan for $17,000/year for his spouse and that didn't include drug coverage. What IBM offers may not be as good as you want but it sure is better than anything else you can buy - assuming you can even buy a plan. If Obamacare sticks the problem might go away in 2014. It's up to the Supreme Court now.
I also wanted to mention that this year I decided to try the vision plan coverage because it is so inexpensive. It seems to me it sort of pays for itself since they pay $35 for a doctor when the doctor is out of network and the prescription glasses discount coverage is better that the free vision card offering. I needed new glasses next year and the provider I like to use is included in the plan so I am giving it a try.
It doesn't change my decision because I know enough to know I want to try this plan in 2012 but it really does make me feel like they are trying to hide the details of this plan. If you are considering their HMO or PPO offerings don't just go by their "marketing" brochures. The detailed documents are really important. I know this because I volunteer on a medicare helpline and a large number of the "issues" callers have are because of denials of coverage or billing problems they have with medicare advantage plans.
Someone commented that if your spouse is not medicare eligible you only have 4 choices and have to use the IBM medical and prescription coverage plans. It's true but at least you do have choices. A friend tried to get coverage for his spouse separately and the best he could find was a private plan for $17,000/year for his spouse and that didn't include drug coverage. What IBM offers may not be as good as you want but it sure is better than anything else you can buy - assuming you can even buy a plan. If Obamacare sticks the problem might go away in 2014. It's up to the Supreme Court now.
I also wanted to mention that this year I decided to try the vision plan coverage because it is so inexpensive. It seems to me it sort of pays for itself since they pay $35 for a doctor when the doctor is out of network and the prescription glasses discount coverage is better that the free vision card offering. I needed new glasses next year and the provider I like to use is included in the plan so I am giving it a try.
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