IBM Medicare Via Benefits Medicare Advantage Analysis

Yesterday there was an article about Medicare in the Sunday New York Times Business section.  Unfortunately, it was not on the front page.  Everyone needs to read it!
     
It was, yet, another sad story about the misery of Medicare Advantage insurance and also captured the strategy of the current administration to dismantle Medicare by pushing it into a Medicare Advantage insurance delivery system. 
 
Please take time to read the article and tell anyone and everyone you can how these plans are only good for healthy people. When someone on that kind of plan gets really sick, they discover their plan's limitations and have no recourse but to live (or die) with those limitations.

https://drive.google.com/open?id=1Fo7Nw6JwBMhS2N7KHWDfO9F5WmzHv4Rb

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!!!

IBM Medicare Via Benefits HRA Reimbursement Tactics

Several people I know try to interact with Via Benefits reimbursement as little as possible.  It's a  strategy for some but might not be easy for people to do from a cash flow perspective.
 
They are paying a year's worth of their part D and Medicare Supplement premiums in January and then submitting claims to Via Benefits to be reimbursed.  Some insurance companies even offer a discount if you do it.
 
There is no guarantee Via Benefits won't mess up the claim, but it's a one time haggle instead of the recurring aggravation of needing to monitor for reimbursement mistakes and deal with the mistakes when they occur.

There is an aspect about using that strategy that is a little morbid.  It may be difficult to recoup advanced payment of premiums from the insurance company if something happens. Maybe that's a small issue compared with the difficulties of dealing with Via Benefits!

IBM Medicare Via Benefits Reimbursement Problems and Errors for 2020

Something is amiss with Via Benefits Reimbursements.  Make sure your recurring premium reimbursements and your claims are being properly processed. It seems they are messing up!

My problem relates to recurring premium reimbursement.  I did not change my insurance plans in 2019 and had purchased the policies through Via Benefits in 2018.  What is supposed to happen is automatic premium reimbursements continue into 2020 without any action on my part.  That's what happened in previous years.

I noticed about a week ago the auto reimbursement for the Medicare Supplement policies for me and my spouse didn't happen. When I looked on the website there was still the information showing auto reimbursement but no funds had been dispersed. However, the part D insurance reimbursement looked to be working okay.

I used the "Help" function in the reimbursement services function to open a ticket to complain about the Medicare Supplement premiums.  They fixed it and "closed" the ticket without any explanation. The way I knew it really was fixed was by not only checking on the website but also looking for the direct deposit of the premiums for January 2020.

Then, I looked again at the part D auto reimbursement payment.  They display that disbursement in a strange way.  It's not worth explaining but it is confusing - at least for me. On second look,  I realized they reimbursed automatically for the part D January insurance premium for me but had not done it for my spouse's part D insurance.  Again, I used "Help" to open a ticket.  Again, it was fixed and closed without any explanation. When I checked it again, they showed the premiums were reimbursed on 1/1/2020 BUT they did not deposit the reimbursement in my account, nor did they reduce the HRA account by that amount.  I generated another help ticket.  What a mess!

Although I don't like the way the "Help" works, I think it might still be better to use than trying to call them, if you have a claims problem.  It seems calling them is a nightmare no matter what you need - whether it is changing insurance or resolving a claim problem. Unfortunately, you have to call them if you want to change your insurance provider because they have to record your voice when they make the change.
   
To use their online system to file a reimbursement complaint, sign on to the website and click the reimbursements link to get to it. "Help" is at the top of the HRA funds and reimbursement web page. Don't use the "Help" function on the main web page you see when you first log on.  You must click the reimbursements link to see the Help associated with reimbursements.

Doing it online not only eliminates talking to incompetent representatives, it will also provide clear documentation on your complaint interactions in your account and provides a reference if you are forced to call them.

What follows is a comment posted by a reader a couple of days ago who is having a miserable time with Via Benefits and did try to resolve it by calling them. The moral of this post is pay close attention to what Via Benefits is doing and be sure your claims are properly processed!!!
   
 
To get reimbursed for the part of my Medicare part B premium that is not covered by the SHAP $900, I send in a Reimbursement form in January of the next year, after the previous years last quarter SHAP has processed. I include a copy of my SS letter showing what the Medicare Part B premium will be for that previous year, a copy of the 4 quarterly payments by SHAP for the previous year, and ask for the balance not paid by SHAP, on reimbursement form. I sent all this data for 2019 in in early January 2020, expecting the balance to be taken out of my 2019 HRA. VIA Benefits treated it as a recurring premium reimbursement for 2020,divided the balance due by 12, and took the first months(January 2020) payment out of my 2020 HRA. After spending an hour on the phone with VIA Benefits(half of it when rep put me on hold to talk with someone else), I was told they would try to straighten it out. I would need to call back in about 10 days to see if it got straightened out. I asked if they could email or txt me to tell me the status, but no, I would have to call back after 10 days. Since you never talk to the same person twice, I imagine I will have to go through the whole thing again with the new rep. Omaha worked much better for claims than El Paso does.

IBM Medicare Via Benefits Medicare Insurance Change Still Possible

Although the Fall Open Enrollment Period ended in December.  There are still opportunities to make changes to your Medicare insurance during 2020. 
     

1. Medicare Advantage Open Enrollment Period: January 1 - March 31, 2020
        
   If you are enrolled in a Medicare Advantage plan, you are allowed to change to a different Medicare Advantage plan during the first three months of 2020.  If you find your current plan doctor network has significantly changed or the drug costs have significantly increase, you have options!  You can switch to another Medicare Advantage plan or you can drop into Original/Traditional Medicare (OM) and get a stand alone Prescription Drug Insurance plan (PDP).  The OM & PDP option might not be feasible in many states because there are varying rules from state to state on whether an insurance company is required to sell you a Medicare Supplement plan (aka medigap).  OM without a medigap that caps your out of pocket costs is a risky proposition.  Medical costs can rapidly escalate if you have a significant medical problem.
        
   
2. Medicare Plan Finder problems Special Circumstance Enrollment:  All year long
        
   Medicare, as in the government agency (aka CMS), has quietly issued a very significant admission statement in www.medicare.gov.  They know there were huge problems with their new plan finder program and have posted information on the website about allowing recipients to change their plans per the following link: https://www.medicare.gov/sign-up-change-plans/when-can-i-join-a-health-or-drug-plan/special-circumstances-special-enrollment-periods
        
   There is an important notice on that page titled "note":
        
   If you believe you made the wrong plan choice because of inaccurate or misleading information, including using Plan Finder, call 1-800-MEDICARE and explain your situation. Call center representatives can help you throughout the year with options for making changes.
        
   It's easy to overlook that note but the significance of it is huge!
           
3. There are other special enrollment conditions described on that same web page that can be life saving.  For example, if you move to a different zip code, you get a chance to totally change your insurance down to maybe being able to buy a medigap (check with your state to be sure of your options) because you are moving to a new zip code area.
        

My wishes for 2020 is you need none of the above and have the best Medicare insurance to meet your medical needs in 2020.  Happy New Year!

IBM Medicare Via Benefits part D structure 2020 & Kaiser Foundation & Medicare part D brochure information

In January 2020 the "doughnut hole" closes for generic drugs.
 
That means that in the second stage of drug plans, you will pay a 25% copay for the negotiated price of your drugs.  That might be more or less than you pay in the first phase.  The terminology for the second phase of "doughnut hole" has no meaning.  It started with there being NO coverage in the second phase in 2006 and that condition has gradually been remedied to where the second phase now provides policy holders with part D co-insurance coverage that approximates the first phase.
   
The pharmaceutical companies must still absorb the rest of the cost of the drug cost in the second phase.  For brand name drugs, they are not likely to do much negotiation with the insurance carrier to discount the drug because they will only be paid something less than 25% of the drug cost.  It depends on how many middlemen are involved that must also be paid.
 
There are two references in this post that will help you know more about drug plans and how they are structured.  The first, from Kaiser Foundation is a great analysis and also explains why there is such a big jump in out of pocket costs as policy holders move through the different phases.  There were provisions in the Affordable Care Act (ACA) aka ObamaCare that held down those costs.  Those provisions lapsed in 2019 and were not renewed by the current administration.
 
The second brochure is Medicare's attempt to explain the cost structure without getting too wonky.  It's a decent explanation.
 
https://www.kff.org/medicare/fact-sheet/an-overview-of-the-medicare-part-d-prescription-drug-benefit/
   
https://www.medicare.gov/Pubs/pdf/11109-Your-Guide-to-Medicare-Prescrip-Drug-Cov.pdf

IBM Medicare Via Benefits Extend Health Medicare's new plan finder is a mess

If you are using www.medicare.gov to find a better drug plan to use in 2020, do not rely on the results you get from the government application.  It is riddled with bugs, returns unpredictable results and by default presents an ordered list of plans with the lowest premiums.  Low premium results are only useful for people who take NO drugs.  Obviously, that's a low percentage of Medicare eligible users.

If you call Medicare to ask them to help you find a plan, know that they are using the same application so the results they give you might not be accurate. Via Benefits has its own plan analysis application, albeit for their subset of prescription drug insurance policies. That's what they are searching at to help you find a plan.  I don't know how accurate their application is but my guess is it is better than the new plan finder on medicare.gov.

Updated 11/25/19:  I just found this news report about the new plan finder....Oh, boy:
https://www.propublica.org/article/the-11-million-dollar-medicare-tool-that-gives-seniors-the-wrong-insurance-information

What do you do for 2020 if you need to find a better part D plan? You have no option but to run the application on medicare.gov to figure out who is selling plans. It appears that at least the formularies are accurate.  If you run the application here are some tips:

1. Make sure you choose the sort option (on the left side of the screen) for results that orders plans by the annual cost of drugs + premium
2. Enter your prescription amounts as 1 month supplies.
3. When you look at the results for a specific plan, be sure to look at the details to find out if all your drugs are covered.  That means you have to scroll down to the BOTTOM of the plan details. Reminder, if a drug is not covered by a plan, then the cost is not used for the  calculation of when you get into the coverage gap nor catastrophic coverage.
4. Pick a couple of plans that you are considering and ... gulp ... CALL THE INSURANCE COMPANIES to verify ALL the results you got.  You'll also need to call the insurance companies to find out their list of preferred in-network pharmacies.  That information is not in plan details and those pharmacies won't show up in the "pick your pharmacies" step if they are more than 10 miles away.  If you weren't able to run plan finder using a preferred pharmacy, ask the insurance company what the annual cost is at a preferred pharmacy.  Don't assume mail order will be cheaper as sometimes it isn't.
5. Call your congressional representative and raise hell - this situation is terrible!

IBM Medicare Via Benefits Extend Health IBM Life Planning Benefit Terminates November 2019

This post has nothing to do with Medicare but I am posting it in case people don't read a recent letter IBM sent out about benefits dated October 11, 2019. 

There was (notice I say "was") a retiree benefit available to some "older" retirees called "Life Planning".  It was a modest program implemented to mostly encourage employees and retirees to stay healthy and also to do financial planning by reimbursing up to $250/year for service fees related to those activities. The recipient had to file a claim every year to get the money.

Buried on page 5 of the October Legal Notice mailing  which is mostly about legal notices related to health benefits is a statement of the Life Planning Program termination.  When they say terminate, they mean terminate!  If you don't file a claim by the end of November 2019 for 2019, you cannot get the $250 benefit.  It is terminated as of January 1, 2020.

It's not a big deal, but a little unnerving because IBM can do the same with the HRA program.  Take full advantage of your HRA money while you can!

IBM Medicare Via Benefits Extend Health Medicare Hospital Days Coverage

Medicare's hospital inpatient coverage is probably the least talked about topic in private insurance marketing campaigns.  That statement is true whether an insurance company is pitching a Medicare Supplement plan (aka medigap) or a Medicare Advantage plan.  Maybe it is not advertised because it is easier to understand copays for a doctor visit.  Mostly, it is too complex to describe in a 30 second ad or a flyer.

Nonetheless, it is the part of Medicare coverage that is the most expensive and if a Medicare consumer doesn't understand the structure it can have both financial and health treatment impacts that are life altering.

The Medicare agency government rules for hospital coverage are straight forward and all Medicare insurance must cover these benefits.  By law, the basic amount of hospital stay coverage is the same irrespective of what type of Medicare insurance:
   

1. There are 90 days of coverage in each benefit period.
         
2. A benefit period begins when the patient is admitted as an inpatient (so "observation" doesn't count as a hospital day).
        
3. A benefit period ends 60 days after the patient leaves the hospital.
         
4. If the patient needs more than 90 days in a hospital in a benefit period, they have an addition 60 "lifetime" days that they can use to extend the 90 day stay.  The "lifetime" number is 190 days if it is a psychiatric hospital.
         
5. If a patient is discharged from a hospital and not readmitted until 61 or more days later, the patient begins a new benefit period.
       

Here is what is not straight forward.  How much do you pay when admitted to the hospital as an inpatient and for hospital days?  What happens if you need more than 150 contiguous days (in the same benefit period) in the hospital because of a dire condition?  What happens if you are hospitalized 3 times in a given year and each time a new benefit period started because you were "out" more than 60 days before being readmitted?

The cost of a hospital stay very much depends on the kind of insurance you have.  It can actually be zero or many thousands of dollars. This is where it gets complicated.  But it's important to understand it. 

The only way to compare original Medicare with Medicare Advantage is to compare costs. To properly compare costs, original Medicare with a Medicare Supplement (aka medigap) are used in the table below.  I used a premium price that is typical for an "N" medigap plan and picked a real Medicare Advantage plan that had a $0 premium. Without a medigap, there is no cap on the annual cost a person can incur in original Medicare.  Medicare Advantage plans do have a cost cap (in 2019 the max can be as much as $6,700 for "in network" services and is the cap for the MA plan I picked).  That $6,700 can buy a very nifty medigap  which is why I am including medigap in this comparison. Also, whether you use original Medicare or a Medicare Advantage plan, you MUST always pay the "part B" fee (currently $135.50/mo). What follows are 2019 numbers:    

Phase	Original Medicare +  Medigap N at $150/mo	Sample MA plan $0 premium
Hospital Benefit period  (Every 60 days if discharged and out of hospital for 60 days)	$1364 deductible Medigap N pays deductible	$0 deductible
Hospital day copay per benefit period	$0 days 1-60  $341 days 61-90  $692 for 60 lifetime days Medigap N pays all the copays	$465 days 1-4 $0 days 5-90 $0 for 60 lifetime days
If exceed 150 days in hospital	All Medigaps provide the extra days benefit of 365 days at $0 copay	No Medicare Advantage plan has extra days benefit, must pay full day cost for days over 150
Maximum hospital  cost in 2019	Medigap premium x 12 (approx. $1800 for 2019)	$6,700 for 2019 (if do not exceed 150 days)

 

    

                                                                                                                            

  

IBM Medicare Via Benefits Extend Health Re-evaluate your part D or MA plan for 2020

Did you get the 2020 brochure for your current part D drug insurance or Medicare Advantage plan?  More importantly, DID YOU READ IT?
 
Actually, all you need to do is glance at it to decide if you need to read more.  I received my part D brochure last week.  Here's what I quickly saw for my plan - wow, the premium when down a few dollars.  But why?  I read on.
 
Let me count the ways:

1. The plan added a deductible.  For me, that's bad news because I would never meet the deductible based on my current drug use.  That means the only benefit I get from the plan is their "negotiated price" for the drug.  I'll have to pay full negotiated price in 2020 for my drugs unless I get new prescriptions.
       
2. The copays, once the deductible is met, increased for brand name drugs.  Again, it's bad news for me because, right now, I don't use generics for the drug I take.
       
3. It looks like the "network pharmacies" have also changed.  A local pharmacy is no longer on the list so I would need to remember to stay away from that pharmacy.
       
4. The brand name drug I take is only covered in the generic version.  I cannot use the generic version.  For some reason, the fillers cause it to work less well for me.
        

So, during open enrollment, I will pick a new plan for 2020.  Since Via Benefits sells a subset of the plans available in my zip code (typically, it is about half of the plans I could buy) I'll look on medicare.gov to pick the new plan and then see if Via Benefits sells it.  If not, just by enrolling in the new plan through medicare.gov, I'll be dis-enrolled from my current part D plan.  Then, I need to remember to file for reimbursement of premiums for that new part D plan in 2020.  

The reason I am easily able to change my part D without engaging Via Benefits is that I buy a Medicare Supplement through them.  Reminder - you only need to buy one medical policy from them to qualify for the HRA/FHA.

Changing a Medicare Advantage plan is more complicated.  If you want to change to a new MA plan for 2020, you have to do it through Via Benefit to continue to have access to your HRA/FHA.  Be sure you check with your doctors before changing to a new MA plan to be sure they will take the plan.