IBM Medicare Via Benefits Be Aware of Medicare Advantage Bias in CMS literature

 CMS is the abbreviation for the federal government agency, Centers for Medicare and Medicaid Services,  that oversees Medicare.  This federal agency is responsible for publications, email messages and oversight of Medicare insurance policies and Medicare medical providers.

Over the years, many Medicare advisors have written extensively about the "disadvantage" of Medicare Advantage insurance plans.  I have pointed to some of those articles on this blog and written about the push, particularly in the last 4 years, by the federal government to get Medicare eligible participants to enroll in Medicare Advantage insurance plans.  It makes no sense, because these plans do not reduce the tax payer burden for the cost of Medicare. It would appear it is CMS's way to privatize Medicare and thereby get millions of dollars in campaign donations for the pushers.

A non-profit organization, Center for Medicare Advocacy (CMA), has been trying to hold the federal government accountable and expose it.  There are a huge number of pitfalls associated with Medicare Advantage plans.  Most of these insurance plans, to put it impolitely, suck.  Kaiser Permanente is about the only one worth considering but it is not available in many areas. 

  Here is a link to a recent "alert" document by CMA: 

https://drive.google.com/file/d/1dyJuWaxDOz9DcCKyiuPAT2-8mzYJJ7_K/view?usp=sharing

To access the file, at least when I tested it, I had to download it.

The bottom line - which I feel is sad - I DO NOT recommend you rely on federal government literature as your only source of education about your Medicare choices.  

There are several non-profit groups like CMA and Medicare Rights Center (1-800-333-4114) who offer a balanced approach to Medicare information and in MRC's case, provide Medicare counseling.  The  state health insurance assistance department for your state (which is found at www.shiptacenter.org) also typically provide honest assessments as that is not where insurance industry lobbyists spend a lot of time.  The library might also be a good source of Medicare information. What is not a good source of information?  Insurance agents, and, unfortunately, the federal government because they are both biased.

IBM Medicare Via Benefits Medicare Fall Enrollment for 2021 is Oct 15 - Dec 7, 2020

It's that time of year! Yesterday, I receive an "ANOC" for my stand alone prescription insurance plan. I have that kind of prescription insurance because I use original Medicare.  ANOC stands for "annual notice of change".  This year the thick booklet with all the information about the pharmacy networks and drugs covered by the plan in 2021 that usually are mailed as part of the annual notice of change were not sent.  Unfortunately it is even more likely people will throw out the notice.  Make sure to read your mail!

In the document, my prescription drug insurance said the drug and pharmacy information will be available on their website starting October 1,2020.  The days of quickly flipping through a thick booklet are gone and the likelihood people will go online to look for changes is slim.  My plan shifted the pharmacy information to a "Pharmacy Locator Tool".  That makes me wince.  Yet another thing to learn to figure out how the plan has changed.

More than ever, it is really important to make sure your prescription drug insurance plan is the best plan for you to have in 2021.  Drug insurance plans change from year to year.  Drugs are added.  Drugs are dropped.  Drug costs and deductibles go up (they seem to never go down).   Drugs that did not require "step therapy" - meaning trying a cheaper variety of drug before this one is approved - suddenly have a step therapy requirement.  Drugs that did not have quantity limits get quantity limits. 

YOU MUST CHECK HOW YOUR PLAN WILL CHANGE for 2021!!!!!! 

If you have a Medicare Advantage plan you have more work to do.  You must not only check the changes about prescription drug coverage, but also check the changes in medical coverage copays and medical provider networks.  One way to find out about provider network changes is to ask your current doctors if they will accept your plan in 2021.  Another way is to call your plan to find out the changes but their provider network directories are notorious for being wrong.  Make sure you write down the date you called, who you talked to and take notes on what they tell you.  Do this just in case you get incorrect information because you can use that to dump the plan if you find out they lied to you. 

Via Benefits might also help with some of this.  I am sorry to keep writing this but Via Benefits is an insurance agent.  The more products you buy through them, the more commissions they receive and you do not have to buy all your Medicare coverage from them. If you are on original Medicare and bought a medigap through them then you can change your drug insurance to the best fit policy for you and not have to worry about whether or not they sell the best policy.

Figuring out whether or not you have the best policy is not easy.  If you don't want to use a computer and go to www.medicare.gov to use the planfinder tool (ah, that lovely word again) then call 1-800-MEDICARE to as for help.  If you have a Medicare Advantage plan, then you need to call Via Benefits to pick from the set of Medicare Advantage plans they sell.

Reminder, for people with original Medicare and a medigap plan, this is NOT the time of year when you change your medigap plan.  Depending on the state where you live, you might not be able to change your medigap plan at all or you might be able to change it at specific times.  Check with your State Health Insurance Assistance Agency to find out the rules (their phone number can be found at www.shiptacenter.org).

IBM Medicare Via Benefits Medicare Recipient Insurance Cost Analysis from 2007 - 2020

I have been keeping track of how the cost of Medicare deductibles, coinsurance and copays have increase since 2007.  It is significant!   The current administration has been very aggressive at increasing how much seniors have to pay for Medicare.
   
The way this cost increase is passed along for those using Original Medicare with Medicare Supplement plans (aka medigaps) is the supplement insurance plan premiums increase. It is way too risky to not have a medigap if you use Original Medicare.  People without medigaps are often forced into bankruptcy because Original Medicare does not have an annual cost cap.

The way Medicare Advantage plans pass along the cost is by increasing the cost of things such as premiums, adding deductibles or raising the annual out of pocket maximum cost to the government limit ($6,700).  The other way is to pass along cost increases by cutting services by doing such things as shrinking provider networks, the choices for DME devices decrease or zero copay hospital days coverage decrease.  Then there is always their favorite ways to do it. They increase the denial of claims because they know sick people are often too overwhelmed to appeal a denial and just pay it or they push physical therapy facilities to discharge patients before they are fully recovered.
 
No matter how you get Medicare coverage (Original or Medicare Advantage),  the policy holder always has to pay the part B premiums unless they are really low income ($18,000/year with no cash assets). There is no insurance to cover the part B cost. The part B fee is paid to the government and entitles you to receive insurance coverage for provider services such as office visits or lab tests. It's your choice how you get that insurance coverage. If you stay with Original/Tradition Medicare it becomes an insurance premium for the government insurance pool. If you enroll in a Medicare Advantage plan, the government gives your part B payment to the insurance company issuing your policy.

A picture is worth a whole lot of words so I created the following analysis. To access this file, you may have to download it:

https://drive.google.com/file/d/1pAF75fHqCqLKcFXo0PxRI52NZJA_8PBk/view?usp=sharing

 

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!